Contents

H&S Self-Assessment Checklist - EARTHMOVING EQUIPMENT Page 1 of 2
This checklist shall be used by CH2M HILL personnel only and shall be completed at the frequency specified in the project’s
Field Safety Instructions (FSI). This checklist is to be used at locations where CH2M HILL employees are potentially exposed
to hazards associated with earthmoving equipment.
Designated Safety Coordinator (DSC) may consult with earthmoving equipment contractors when completing this checklist, but
shall not direct the means and methods of equipment operations nor direct the details of corrective actions. Earthmoving
equipment contractors shall determine how to correct deficiencies and we must carefully rely on their expertise. Items
considered to be imminently dangerous (possibility of serious injury or death) shall be corrected immediately or all exposed
personnel shall be removed from the hazard until corrected.
Project Name: ______________________________________________________
Project No.: ______________________
Location: ______________________________________________________ PM: __________________________________
Auditor: ____________________________________ Title: _________________________________ Date: _____________
This specific checklist has been completed to:
Evaluate CH2M HILL employee exposures to earthmoving equipment hazards
Evaluate a CH2M HILL subcontractor’s compliance with earthmoving equipment H&S requirements
Subcontractors Name: ________________________________________________________
• Check “Yes” if an assessment item is complete/correct.
• Check “No” if an item is incomplete/deficient. Deficiencies shall be brought to the immediate attention of the earthmoving
equipment subcontractor. Section 3 must be completed for all items checked “No.”
• Check “N/A” if an item is not applicable.
• Check “N/O” if an item is applicable but was not observed during the assessment.
Numbers in parentheses indicate where a description of this assessment item can be found in Standard of Practice HS-27.
SECTION 1 Yes No N/A N/O
PERSONNEL SAFE WORK PRACTICES (3.1)
1. Only authorized personnel operating earthmoving equipment
2. Personnel maintaining safe distance from operating equipment
3. Personnel and equipment operator in close communication when personnel must
be in proximity of operating equipment
4. Personnel approach operating equipment safely
5. Personnel wearing high-visibility and/or reflective vests when close to
operating equipment
6. Personnel riding only in seats of equipment cab and using seat belts
7. Personnel not positioned under hoisted loads
8. Personnel not hoisted by equipment
1. Personnel instructed not to approach equipment that has become
electrically energized
10. Personnel wearing appropriate PPE, per HSP/FSI
Rev.0
GNV310133632156.DOC/090840008 A-87