SAFETY INSPECTION FORM (PAGE 1)

Date: Inspector: Contractor:

Description of Job
Inspected:
Category: Item Description: Yes No N/A Comments
Housekeeping Walkways / egress clear (at least 36”)?
Area free from accumulated trash & debris?
Electrical cords, hoses, & welding leads not
a trip hazard?
No slippery surfaces?
Bone yard & contractor break area in good
order?
Personal Protective Hard hats
Equipment (PPE) Safety glasses
Safety shoes/boots (work/chemical)
Gloves (chemical/leather)
Goggles/face shield
Respirator
Chemical protective suit
Electrical Tasks V-rated gloves and tools being used?
V-rated tools/gloves meet testing reqs?
Is a multi-layer switching hood available for
use?
Conductive articles and jewelry removed
when performing electrical tasks?
Flame retardant clothing being worn when
performing electrical tasks?
Permitting Safe/Hot Work Permit at the job site and all
requirements met?
Line Breaking Permit at the job site and all
requirements met?
Confined Space Entry Permit at the job site
and all requirements met?
Lock-Tag-Try Permit at the job site and all
requirements met?
Electric Power Tools Cords and plugs in good condition?
GFCI or grounding wire continuity inspection
program?
Double insulated or grounded?
Grinder wheels in good condition?
Cords not used for lifting tool?
Electrical cords are not routed through
potential pinch points?
Wheel guarding and tool rest on stand /
mounted grinders? (reference Attachment G)
Pneumatic Tools Hose connections secured by positive
means?
Safety retainer/clips installed/maintained on
pneumatic impact tool attachments
Automatic fasteners (nailer stapler) have
interlock requiring contact with work surface?
Pressure rating of hoses & equipment not
exceeded?
Hoses not used for equipment lifting?
Spill Prevention No equipment fuel/oil or other chemical
leaks?
SAFETY INSPECTION FORM (PAGE 2)
Category: Item Description: Yes No N/A Comments
Hand Tools Wrench (adjustable, pipe, end, socket) jaws
not sprung to the point that slippage occurs?
Impact tools (drift pins, chisels, wedges,
hammers) free of mushroomed heads?
Wooden handles free from splinter and
cracks and tightly attached?
Ladders Ladders were in good repair?
Ladders tied off / spotter used?
Ladders properly stored & no excessive
accumulation?
Not blocking door when in use?
Fall Protection Body harnesses & lanyards worn and in
good repair?
Lanyards securely tied off?
Welding/Cutting Leads and clamps in good condition?
Proper guarding on machine?
Welding hood/cutting goggles used?
Protective clothing, welding gloves used?
Cylinders labeled, stored upright, and
secured? Oxygen 25 ft. from flammables?
Curtains/screens utilized to protect other
personnel?
Fire watch is provided for overhead work?
Fork Lift Safety equipment in good condition?
Seat belt used?
Fire extinguisher w/ inspection?
Labeling legible (load, & class)?
Excavation/Earth Adequate protection systems
Moving (shoring/sloping)?
Rollover protection on equipment?
Back up alarms operational?
Crane / Hoist Slings/chainfalls/come-alongs in good
condition?
Safe rigging techniques used?
Barriers & Signs Floor/ground openings/excavations are
planked or barricaded/tapped off?
Overhead work areas (lifting, welding, etc.)
barricaded/tapped off?
Pressure Cylinders Cylinders adequately secured?
Cylinders properly labeled?
Regulators & hoses in good condition?
Valve protection caps in place?
Vehicles & Mobile Properly maintained?
Equipment Seat belts provided & used?
Lights, horn, and other safety equipment in
good condition?
No excessive use of contractor vehicles in
plant areas?
Scaffolding Constructed to support 4x load w/o tipping?
Railing in place (top 38-45” from platform
mid-rail midway)?
Toe board in place?
Adequate safe access and egress?
Container Labeling Proper Hazcom labeling?
Spill Prevention Equipment fuel/oil or other chemical leaks?
Other Comments:
 SAFETY INSPECTION FORM (PAGE 3)
CONTRACTOR FOLLOW-UP QUESTIONNAIRE

Company:_______________ Employee Interviewed:_________________ Date:___________

Type of Work being conducted:____________ Location:_________________ Interviewed

by:___________________
Correct Answer
Yes No
1) When equipment is locked out, whose lock is always first on & last off? Operating Dept.
2) The only place contractors can consume food & beverages on-site are _____ ? Contractor
break area behind Fire Water Tank.
3) Cell phones cannot be used in the plant because ______ ? may not be properly rated for
the area electrical classification
4) When is fall protection required? greater than 6 ft. or less than 6 ft. if above dangerous
equipment.
5) Extension ladders must be _______ ? tied-off
6) A fire watch is required when _______ ? sparks, slag, etc can fall to a lower level
7) _____ must be used for all power tools plugged into extension cords. GFCI’s
8) If you spot a fire, you should _______. activate pull station if nearby &/or contact BASF

9) When you hear a fire alarm, you should _______. Stop work, turn off all equipment, & go
to designated emergency assembly area.
10) What does the evacuation horn sound like? continuous waling sound

11) Where can trash be disposed? Must be hauled off site and cannot be placed in BASF
dumpsters without permission.
12) What are the 4 Highly Hazardous PSM Chemicals on-site? EO, PO, BO, VA.
13) What are the hazards of EO? Explosion hazard, corrosive to body, CNS depression,
pulmonary edema, vapors heavier than air, exposure threshold below odor threshold.
14) What are the guidelines for work trucks in the area? transport tools/mat’ls. to work site, then
park in contractor parking lot. If essential to have in work area, must be approved by BASF
Project Manager & should be limited to 1 vehicle per contractor.
15) Where would you go to get information about chemicals on site? MSDS for chemicals can
be pulled up and printed out from site PCs, including those in Admin Bldg & Ctrl Room.
16) What personal protective equipment is required for the job you are doing? hard hats, safety
glasses with side shields, steel toed shoes are the minimum plus other job specific PPE.
17) Which of the following are considered hot work – operating a boom truck, jackhammer, or
battery-powered drill, using a manual screwdriver? a boom truck, jack hammer, battery powered
drill- but not a manually operated screw driver
18) If you are not sure an area has been checked by BASF for explosive vapors, what should
you do? Do not start work & contact a BASF rep. From the Operating Dept. to test the area
19) Cylinders of O2 must be stored at least ___ ft. from flammable gas cylinders? 25 feet
20) Face shields are required when _____ ? grinding or removing concrete w/ a jack hammer
21) _______ must be worn when using a torch? cutting goggles
22) What designated smoking area is off-limits to contractors? N. Polyol Warehouse dock
23) What other permits are issued by the Operating Dept. besides Safe/Hot Work permits?
Confined Space, Lock-Tag-Try, Line Breaking
24) Write in a question from Monthly Safety Topic: