RBI BUILDING PROJECT

< CLIENT LOGO >

EMS LIMITED, NAVI MUMBAI

Electrical Distribution Board

Contractor: Location :

Doc. No : Date:

2 4
3 9
9 1
1
5

O/P 1 8
I/P
cable
cable 12 6
1
3

S No. Description Yes No Remarks

Firm Base with grouting & Easily accessable
1
panel (height of the leg is equal to 1m)
D.B set is weather proof and cover all around To
2
avoid water/ dust
Authorized Operator/Elec. Name/ Photo/ Contact
3
No.on DB panel are available
Visualization of voltage, current and type of tools
4
to be used in the socket & Panel.
I/P and O/P Cable are good in condition and no
5
exposed cable
Confirmation of LOTO(lock out/ tag out) are
6
available.
Double Earthing System of MDB / DB panel with
7
Std earthing pit has been provided.
Separate ELCB with tripping current of 30 mA &
8
in working condition.
 Safety stickers/ signboards / isolate flammable
9
Fire Hazard are display in D.B,
Condition of Cable,Power Socket and Plug are
10
having any damage.
Color coding being followed (RYBWG) for all
11
cables/wires

12 Availibility of rubber mat infornt of the D.B .

13 Plug/ Socket are being used of Industrial type

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT
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EMS LIMITED, NAVI MUMBAI

Diesel Generator
Contractor: Location :

Doc. No : Date:

9 6
7
5 4
2 1
3 1 1
1 0 8
Sr No. Description Yes No Remarks

1 Guard provided for any rotating parts.

2 Hot surface is provided with guard.

Rubber mat is provided in operator standing

3
area.( around the D.G)
No oil leakage from the oil tank & other parts of
4
the m/c.

5 Proper access to the D.G control panel

Exhaust smoke pipe faced upwards & outside of

6
D.G shelter.

7 Adequate ventilation in case of indoor generator

8 Presence of fire extinguisher (ABC type)

 Presence of damage free operating
9 switch,Voltage and temperature meter,circuit
breaker,Oil level indicator, Emergency switch
10 Earthing is provided with standard earthing pit.

Proper foundation done, safety signage's &

11
authorized electrician details displayed.

Remarks

Contractor's EMS Client's

Representative Representative Representative

Signature:

Name:

Date:
 RBI BUILDING PROJECT
< CLIENT LOGO >
EMS LIMITED, NAVI MUMBAI

Tractor
Contractor: Doc. No :

Operator Name & Licence no Date:

S No. Description Yes No Remarks

Protection (canopies, screens) is provided to
1
shield operator from falling objects.
Effective, working horn and reverse alarm.
2 Hydraulic system in working condition during
unloading of materials
Moving parts, shafts, sprockets, belts, etc.are
3
guarded.
Protection against contact with hot surfaces,
4
exhaust, etc.is provided.
Safe means of access (steps, grab bars, non-slip
5
surfaces) to the cab is provided
Damage in tyre(Crack, cut,& air has been
6
checked & tyre pressure is ok.
Leakage of oil from the vehicle parts and vehicle
7
oil tank has been checked & ok.
Vehicle rear view mirror is available & condition is
8
ok
Head light,Tail lamp are fitted & in working
9
condition (for night work)
 Brake, accelerator, clutch are in good & in
10
working condition
Lock of the back door (traile) in good & in working
11
condition
Inter locking system between the tractor and the
12
trailer ok & in working condition..
Visualization of Check sheet and Operator details
13
with photo in the vehicle itslf.
Vehicle having valid insurance paper,Operator
14
having license & other necessary documents

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED, NAVI MUMBAI

Back Hoe Loader

Contractor: Doc. No :

Operator Name & Licence no Date:

2 5 1
5
3

3 4
2
8 9 7
6
S No. Description Yes No Remarks
Front & reverse horn available & in working
1
condition

2 Head & tail lamps(for working at night)

Leakage of oil(in hydraulic & pneumatic systems

3
has been checked)
Loose bolts /connecting pins(In bucket,doser and
4
all innks) has been checked
5 Back view mirror is available & condition is ok.
Roller-crawler / tire condition (check for damaged
6
/ missing idle rollers)
Structure beem condition(damage,cut,crack) has
7
been checked and ok
8 Diesel, oil and grease spillage.

9 Fire extinguisher in operator cabin is available.

 Swinging horn is available and in working
10
condition
11 Equipment having proper & valid documents

Crawler Excavator having Safe access And

12
Egress for Operator
Operator having license and (heavy duty). With
13
valid date.
Vehicle having valid insurance paper,Operator
14
having license & other necessary documents

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED, NAVI MUMBAI

Concrete Mixer
Contractor: Doc. No :

Operator Name: Date:

S No. Description Yes No Remarks

1 Condition of the base

2 Presence of the hoper stopper

3 Condition of the m/c stand with wheel

4 Presence of guard for rotating parts

Condition of the jack of the feeder/hopper (free from

5
damage, kinks, broken strings)

6 Cover of the starter

7 Hydraulic cylinder leakage

8 Condition of Drum

9 Diesel/Electric leakage from the machine

 10 Condition of Roller

Note: Ensure barricading on both sides of the hooper when the machine is in operation

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED, NAVI MUMBAI

Gas Cutting Set

Contractor: Location :

Doc. No : Date:

4 5
2

6 7
1

8 3

S No. Description Yes No Remarks

Protective valve cap firmly fixed for both

1
cylinder(Check for damage/crack in the valve cap)
Pressure gauges two for each cylinder(in &
2 out)are in working condition(both Oxygen &
Acetylene gas)
Flash back arrestor (FBAs)has been provided for
3
acetylene & oxygen cylinders
Non return valves (NRVs) is provided for both
4 acetylene & oxygen cylinders hose fitted with
cutting torch to avoid back fire.
Tight Crimping of hoses with jubilee clamps are
5
fitted.
Hose free from damage(cut and crack / oil &
6
grease to avoid leakage/ fire.
7 Cylinder secured by chain to the trolley.
 Trolley tyre are free from damage and in working
8
condition.
Availability of industrial type lighter(no match box /
9
commercial lighters) are allowed.
DCP/CO2 Fire extinguisher and fire bucket with
10
sand are available
Gas leak test has been done before starting the
11
job to avoid fire

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED, NAVI MUMBAI

Cherry Picker/Boom Lift

Name of Contractor: Date:

Operator Name: Doc. No :

1
0 3

5 9

1 1
0 2

Sr No Description YES NO NA Remarks

1 No Damage in Tire ( Crack, cut, air pressure etc).

2 Platform is securely fastened to platform support.

Ensure not more than 3 members loaded at a time in the

3
platform.
4 All member in the platform have safety belt

5 Foot pedal in the bucket is in working condition.

6 Outriggers & extendable axles are in smooth working condition.

7 High engine and height drive cutout is in working condition.

 8 Any oil leakage in the Hydraulic systems.

9 LOTO system is available in the ground panel board.

10 Warning lamp is in working condition.

The cherry picker movement/ work area is leveled ,compacted

11
and free from all obstructions
Operator details(Photograph,Licence, Mobile no,Cherry picker
12
details etc) displayed in the cabin.

Remarks

Contractor's Client's
EMS Representative
Representative Representative

Signature:

Name:

Date:
#REF!
 RBI BUILDING PROJECT

EMS LIMITED

Welding Machine
Contractor: Location :

Doc. No : Date:

6 2
2
1

1
0

5
4 3
8

S No. Description Yes No Remarks

ON / OFF knob is provided(Check for damage and
1
uninsulated knob)

2 Regulator with indicator is provided

Welding cables connected to the welding machine

3
with lugs at the joints with proper insulation.

4 Any cuts/ damage in the insulation of welding cables

Electrode rod holder and earthing holder are having

5
any cuts/ damage/ broken and properly insulated.
Industrial type Plug / socket being used for power
6
tapping cable of welding machine.
Any internal live electrical parts of welding machine is
7
exposed
 Trolley being used w/o damaged wheels. Double
8
earthing has been provided to machine.
DCP/CO2 Fire extinguisher and fire bucket with sand
9
are available near m/c.

10 The painting condition of machine is good

The terminal box of machine is in good condition and

11
rain protected

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Grinding Machine
Contractor: Doc. No :

Equipment Number: Date:

2 1
1
4
4
5 5

7 6 8
3 8 6 7
3

S No. Description Yes No Remarks

1 Fibre handle without damage & condition is ok.

whether Wheel guard available & (covering 3/4th

2
area).
whether Grinding wheel having any crack/
damage.And Grinding wheels’ expiry date & its
3
RPM match with the machine RPM” has been
checked.
4 whether Rear handle is having any damage.

whether Presence of Cord strain reliever

5
(glands).are available & ok
 6 whether Trigger switch is having any damage.

whethe Presence of Switch lock is ok. And in

7
working condition.
whether Electric wire having any cuts and joints.
8 Double earthing has been provided in m/c to
avoid shock.

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Bar Bending Machine

Contractor: Doc. No :

Operator Name: Date:

1
5 9 0
9 1
0

6 5
7
Fron
1 t
8 1
1 side
2 of
3 the
S No. Description m/c
Yes No Remarks

1 Erected in a firm base concrete platform.

Machine is grouted properly/ Base wheel stopper

2
provided

3 Body Earthing is provided

D.B box connected with the machine is equipped

4
with MCB and ELCB.
Emergency switch is available in working
5
condition ( Front side and back side of the m/c)
Power on & off switch with indicator light are
6
available in working condition.
Belt and other internal moving parts are
7
covered/Guarded.

8 No oil leakage

9 Both side hand guard is available.

 Limit switch (Both Side,below the job plate) are in
10
working condition
Availability of standard limit switch pin.(Usage of
11
nail & other material is N.G)

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Flotter Mahine
Contractor: Doc. No :

Operator Name: Date:

S No. Description Yes No Remarks

1 Equipment is equipped with ELCB

2 Maintaince checklist is is available

3 Blade edged aren't burred and concaved

Check centrifugal safety switch on handle is

4
operational

5 Keep untrained people from using the machine

Never leave machine unattended while engine is

6
running

7 Maintain good footing while using the machine

Never allow rotating machine to hit foreign
8 obstacles as this maycause serious damage or
injury
 Do not have throttle above 1/4 when starting
9
machine
Keep hands and machine away from the moving
10
parts

11 Mainting good footing while using the machine

12 All required PPE is in use

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Earth Rammer
Contractor: Doc. No :

Operator Name: Date:

S No. Description Yes No Remarks

1 Fuel tank is full ( Petrol or Diesel )

2 Engine oil is at correct level

3 No oil leakage

4 Fuel line are not damaged & leaked

5 Ramming show condition and retaining bolts

6 Handle for condition and security is OK

7 Stop controls are available for safe operation

8 Starting system and condition of pull cord are OK

9 Double Earthing Provided is OK.

 10 Adequate Guards for all rotating parts.

12 All required PPE is in use

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Batching Plant
Contractor: Doc. No :

Operator Name: Date:

S No. Description Yes No Remarks

Plant boundary are demarked to avoid hazards
1
arising out of unintended operations.
2 Plant supports are as per the design drawing
Demarcation of working area, vehicular
3
movements
4 All rotating parts are adequately guarded.
Emergency stoppers for moving conveyers &
5
plant are provided at accessible areas.

Doors of the moving parts are interlocked to avoid

6
unauthorized operation during plant running.
Adequate accesses are provided to reach all
7
working locations.
8 Safety of the Loading ramps
Protection against entrapping of people in the
9
loading hoppers.
 10 Double Earthing is provided.

11 LOTO system implemented

Effective functioning of pressure relief
12
arrangement in silos.

13 Maintenance register system is followed regularly.

14 Maintenance permit system is followed regularly.

Fire Protection & Fire Fighting arrangement are
15
adequate

Remarks

Contractor's Client's
EMS Representative.
Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Chopsaw Cutting Machine

Contractor: Location :

Doc. No : Date:

S No. Description Yes No Remarks

Cutting wheel having any crack/ damage. And
1 cutting wheels’ expiry date & its RPM match with
the machine RPM” has been checked.
Presence of Cutting plate guard. Double earthing
2
has been provided in m/c to avoid shock.
Presence of locking system for the plate & Guard
3
is available

4 Presence of job clamp and its conditions ok

Presence of fibre body handle and its condition is

5
ok
 Cable condition(Any cut, wear etc.) and presence
6
of wire 03Pin Industrial top plug is ok
7 Presence of cutting dust guard is available

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Check List for Hand Tools

Name of Contractor: Date:

Type of tool Location :

Nicks, cracks, breaks,

Excessive Missing or Other conditions that cause
Defects/ gouges, stretch, bends, Throat opening
S.No ID.No Capacity Wear & Tear pitting or illegible doubt as to continued safe use
Welds discoloration due to of hooks
corrosion identifications of the tool.
excessive heat

Comments

Contractor's HSE EMS Client's

Representative Representative Representative

Signature:

Name:

Date:
9
 RBI BUILDING PROJECT

EMS LIMITED

Check List for Chain Slings(Lifting tools)

Name of Contractor: Date:

Doc. No : Location :

Nicks, cracks, breaks,

Excessive Missing or Other conditions that cause
Defects/ gouges, stretch, bends, Throat opening
S.No ID.No Capacity Wear & Tear pitting or illegible sling doubt as to continued safe use
Welds discoloration due to of hooks
corrosion identifications of the sling.
excessive heat

Comments

Contractor's HSE EMS Client's

Representative Representative Representative

Signature:

Name:

Date:
9
 RBI BUILDING PROJECT

EMS LIMITED

EARTH LEAKAGE CIRCUIT BREAKER ( ELCB )

Name of Contractor: Doc.No

Rating(mA) /
Location of ELCB Defects/
S.No ELCB S.No Type( 2pole/ Sensitivity Test Date of Test Status Corrective Action Taken
Installed Welds
4pole )

R Y B N

Comments

Contractor's HSE EMS Client's

Representative Representative Representative

Signature:

Name:

Date:
9
 RBI BUILDING PROJECT

EMS LIMITED

Check List for Web Slings(Lifting tools)

Name of Contractor: Doc. No :

Type of lifting tool Date of Insp.
Work Description: Location :
Abrasion/B
Acid or Melting Snags/ roken or Evidence of Remarks
Caustic or Tear Cut/ Broken or Damage Knot in any Heat Overall
S.No Location Capacity Burns Charring Punctures Worn Stitches Corn Yarn Part damage Condition

Contractor's HSE EMS Client's

Representative Representative Representative
Signature:
Name:
Date:
9
 RBI BUILDING PROJECT

EMS LIMITED

Register for Fire Extinguisher

Name of Contractor: Location :

Doc. No : Date:
Year of Annual Pressure Date of Due for Monthly
S No. Type Capacity Location Refilled on Remarks
Manfacture Insp. Dt. tested on Discharge Refilling Inspection Dt.

Remarks

Contractor's Representative EMS Representative Client's Representative

Signature:

Name:

Date:
 RBI BUILDING PROJECT
< CLIENT LOGO >
EMS LIMITED, NAVI MUMBAI

SCAFFOLDING & LADDER

Name of Contractor: Location :
Doc. No : Date:
The following points shall be checked before starting the work
S.No POINT OBSERVATION YES NO N/A Remarks
Is the ground level firm, or have proper support been placed
1
under the structure?
2 Is the base away from all excavation, drain covers, manholes etc.

3 Whether area below the work place barricaded.

Whether proper base plate provided to S/F for maintaining equally
4
balance.
Are all the scaffold pipes and clamps in good condition, i.e. No
5
bends or cuts, etc?
6 Are adequate bracings provided?

7 Whether proper hand rail, mid rail and toe board provided in S/F.
Whether all work platforms ensured to be of adequate strength
8
and suitable for work.
Whether all the metallic planks, gratings tightened with binding
9
wires.
10 Whether proper supporting has been fixed to avoid S/F topple.
Whether common lifeline provided in critical work place to secure
11
safety belt/ harness
Whether Scaffolding has been inspected by S/F supervisor/safety
12
officer and Scaff Tag provided.
LADDER CHECKLIST:
Whether ladders are provided at the working site & in good
1
condition.
Whether ladders are properly secured to prevent slipping, sliding
2
and falling
Whether Aluminum ladder has been used to avoid electrical
3
hazards.
 4 Whether ladder placed at right angle(65 to 75 degree)

5 Whether 1 meter landing has been provided for landing on S/F.

6 Are existing access ways (Stair, walkway, ladders) etc. left clear?

Scaffold Contractor's EMS Client's

Supervisor Representative Representative Representative

Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Tough Rider
Contractor: Doc. No :

Operator Name & Licence no Date:

S No. Description Yes No Remarks

Physical damage in body of the vehicle and in the
1
bucket

Working condition of the vehicle forward, reverse

2
gears & horns.

Working condition of the hydraulic brakes (4

3
wheels)
Oil leakage from the hydraulic cylinder and from
4
the diesel tank.

5 Starter shaft covered by guard

6 No Damage in Tire ( Crack, cut, air pressure etc).

Driver seat belt & hood is available and no

7
damage

8 Head and tail lamps (for night working).

 Exhaust pipe is bended outside(Not faced on
9
operator)

10 Operator & Vehicle with license and valid docs.

Remarks

Contractor's JLL Client's

Representative Representative Representative
Signature:

Name:

Date:
 1
<Project Name>

Dumpers
Name of Contractor: Date:

Dumper's Driver Name Vehicle No:

Trailer Capacity Doc. No :

Check List for Non Compliances

S.No Description of Items to be check Yes No NA

1 Is driver licenses available. HMV/HTV

2 Is the RC book available?

3 Are tyres in good condition?

4 Is the chassis in good condition?

5 Is there a Fitness certificate of the chassis (Approved by RTO)

6 Is cabin clean and free from oil/grease?

7 Is seating in good order?

8 An adequate rear-view mirror?

Are service brakes on trailers and semi trailers controlled from the driver’s
9
seat of the prime mover?
Are dead-man levers and foot pedals returning to the neutral position
10
automatically upon release by the driver?

11 Is there a legible copy of the operators manual with the Trailer (English)
 Is the Trailer crew wearing appropriate PPE (e.g.: visibility vests, hard hats,
12
safety boots etc.)?

13 Is there a driver assistant for directing the trailer?

Remarks:

Contractor's EMS Client's

Representative Representative Representative

Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

First Aid Box

Contractor: Location :

Doc. No : Date:

S No. Description Yes No Remarks

A sufficient number of but not less than 12, sterile, small-size finger
1
dressings
A sufficient number of but not less than 6 sterile medium-size hand
2
dressings?
A sufficient number of but not less than 6 sterile large-size hand
3
dressings?
A sufficient supply of absorbent cotton wool for packing and
4
firming up splints.
A sufficient number of but not less than 12 gauze bandages 7 cm.
5
In width.
A sufficient number of but not less than 12 gauze bandages 11
6
cm. In width.
Greaseless Ointment for burns containing a disinfectant and an
7
analgesic.
100 grams of aromatic ammonia solution in a glass bottle with a
8
glass stopper.
9 Not less than 4 yards of adhesive tape in rolls, 1 cm. In width.
10 Not less than 100 grams of Mercurochrome in aqueous solution
11 Two 10-gram shakers of sulfa powder for sterilization of wounds.
12 A medium-sized Thomas Thigh Splint,
 13 a wooden posterior leg splint,
14 a wooden elbow splint,.
15 a wooden Carr splint for the forearm,
16 a wooden palm splint, and other types of ready-to-use splints
17 A minimum of 6 triangle bandages
18 A quantity of safety pins
19 An assortment of elastic bandages, 2” to 6” in width.
20 A minimum of ten 70 x 70 sterile bandages for burns.
21 A pair of scissors with blunt ends.
22 Sterile water for irrigation and burn treatment.
23 A sufficient number of stretchers for moving injured persons.

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Full body Harness.

Name of Contractor: Date:

Type of Harness Doc. No :

Identification No. of full body Harness
Description Of Check Points Remark.
S.No 1 2 3 4 5 6 7
Hard wares - (D-Rings, Buckles, Back Pad) Any damage, distortion, sharp
1 edges, burrs, cracks and corrosion
Webbings – Any cuts, burns, tears, abrasion, frays, excessive soiling and
2 discoloration.
3 Stitching – Any pulled or cut stitches.
Lanyards (Double)
a) Hard wares - (D-Rings) Any damage, distortion, sharp edges, burrs,
1 cracks and corrosion
2 c) Stitching – Any pulled or cut stitches
d) Synthetic rope – Any pulled or cut yarns, burns, abrasion, knots, excessive
3 soiling and discoloration
Anchoring Hook
a) Hard wares – (D-Rings) Any damage, distortion, sharp edges, burrs,
1 cracks and corrosion
b) Physical damage – Any cracks, sharp edges, deformities and locking
2 operation
3 c) Excessive corrosion – Any corrosion which effects the operation
4 d) Fasteners – Any corrosion, tightness, damage or distortion.
5 RESULT (A: ACCEPTED ,R : REJECTED )
Contractor's EMS Client's
Representative Representative Representative

Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Road Compactor
Contractor: Doc. No :

Operator Name: Date:

S No. Description Yes No Remarks

Protection (Canopie) is provided to Shield
1
Operator from falling objects
Effective working front horn and reverse horn /
2
signal man
Moving parts, shafts, sprockets, belts, etc.., are
3
gaurded
Protection against contact with hot surfaces,
4
exhaust, etc.., is provided
Safe means of access (steps, grab bars, non-slip
5
surfaces) to the cap is provided
No damage in tyre and roller (crack, cut, air
6
pressure, etc..,)
No leakage of oil from the vehicle parts and
7
vehicle oil tank
Vehicle rear view mirror is available and in good
8
condition

Head light, Tail lamp are in working condition (For

9
night work)
 Brake, Accelerator, Clutch are in good working
10
condition
11 Condition of the hydraulic tank and pipes

12 Operator having proper Valid license & I.D. card

Vehicle having Valid Insurance, R.C, PUC and

13
Road Tax Certificate
Whether Check Sheet (Vehicle Information
14
Sheet) is displayed in Vehicle itself

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Excavations
Contractor: Date:
Excavation
Location :
Depth:

Excavation Depth: Doc. No :

S No. Description YES NO Remarks

General Inspection of Jobsite:
Excavations, adjacent areas, and protective systems inspected by
1
a competent person daily before the start of work.
Competent person has the authority to remove employees from
2
the excavation immediately.
3 Surface encumbrances removed or supported.
Employees protected from loose rock or soil that could pose a
4
hazard by falling or rolling into the excavation.
5 Hard hats worn by all employees.
Spoils, materials, and equipment set back at least two feet from
6
the edge of the excavation.
Barriers provided at all remotely located excavations, wells, pits,
7
shafts, etc.
Walkways and bridges over excavations four feet or more in depth
8
are equipped with standard guardrails and toeboards.
Warning vests or other highly visible clothing provided and worn
9
by all employees exposed to public vehicular traffic.
Employees required to stand away from vehicles being loaded or
10
unloaded.
Warning system established and utilized when mobile equipment
11
is operating near the edge of the excavation.
12 Employees prohibited from going under suspended loads.
 Employees prohibited from working on the faces of slopes or
13
benched excavations above other employees
Utilities:

1 Utility companies contacted and/or utilities located.

2 Exact location of utilities marked.

Underground installations protected, supported, or removed when
3
excavation is open.
Means of Access and Egress:
Lateral travel to means of egress no greater than 25 feet in
1
excavations four feet or more in depth.
Ladders used in excavations secured and extended three feet
2
above the edge of the trench.
Structural ramps used by employees designed by a competent
3
person.
Structural ramps used for equipment designed by a registered
4
professional engineer (RPE)
Ramps constructed of materials of uniform thickness, cleated
5
together on the bottom, equipped with no-slip surface.
Employees protected from cave-ins when entering or exiting the
6
excavation.
Wet Conditions:
Precautions take to protect employees from the accumulation of
water.
Water removal equipment monitored by a competent person.
Surface water or runoff diverted or controlled to prevent
accumulation in the excavation.
Inspections made after every rainstorm or other hazard-increasing
occurrence.
Hazardous Atmosphere
Atmosphere within the excavation tested where there is a
reasonable possibility of an oxygen deficiency, combustible or
Adequate precautions taken to protect employees from exposure
to an atmosphere containing less than 19.5% oxygen and/or to
Ventilation provided to prevent employee exposure to an
atmosphere containing flammable gas in excess of 10% of the
 Testing conducted often to ensure that the atmosphere remains
safe.
Emergency equipment, such as breathing apparatus, safety
harness and lifeline, and/or basket stretcher readily available
Safety harness and lifeline used and individually attended when
entering bell bottom or other deep confined excavations.
Employees trained to use personal protective and other rescue
equipment.
Support Systems:
Materials and/or equipment for support systems selected based
on soil analysis, trench depth, and expected loads.
Materials and equipment used for protective systems inspected
and in good condition.
Materials and equipment not in good condition have been
removed from service.
Damaged materials and equipment used for protective systems
inspected by a registered professional engineer (RPE) after repairs
Protective systems installed without exposing employees to the
hazards of cave-ins, collapses, or threat of being struck by
Members of support system securely fastened to prevent failure.
Support systems provided in ensure stability of adjacent
structures, buildings, roadways, sidewalks, walls, etc.
Excavations below the level of the base or footing supported,
approved by an RPE.
Removal of support systems progresses from the bottom and
members are released lowly as to note any indication of possible
Backfilling progresses with removal of support system.
Excavation of material to a level no greater than two feet below
the bottom of the support system and only if the system is
Shield system placed to prevent lateral movement.
Employees are prohibited from remaining in shield system during
vertical movement.
Contractor's EMS Client's
Representative Representative Representative
Signature:
Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Ambulance
Contractor: Doc. No :

Driver Name: Date:

S No. Description Yes No Remarks

1 Licensed driver deployed
2 Contact number displayed on the vehicle
3 Oxygen Cylinder available
4 Mask In Good Condition
5 Stretcher With Belt
6 Function Test
7 Folding Stretcher
8 Basic First Aid Kit
9 Torniquet
10 Splints
11 Neck Brace
12 Back Door Opens Easily From Inside
 13 Back & Side Doors Locking System Good Condition
14 Good Mechanical Condition/Tires
15 Revolving Lights/Headlights/Signal Lights
16 Service Horn/Siren

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Motor Vehicle( Car )

Contractor: Doc. No :

Driver Name: Date:

S No. Description Yes No Remarks

1 Tyre condition
2 Wiper
3 Left indicator
4 Right indicator
5 Headlight
6 Brake light
7 Parking light
8 Brake condition
9 Reverse horn
10 Rear view mirrors
11 Speedometer
12 Self starting
13 First aid box
14 Fire extinguisher
15 Spare bulbs
 16 Stepney
17 Tools kit / lifting jack
18 Cleanliness
19 Oil leakage
20 Periodic Vehicle Servicing
21 Driver licence
22 First aid training
23 Fire Training
24 Pneumatic Door condition
25 Other Points

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Housekeeping
Contractor: Doc. No :

Date: Location :

S No. Description Yes No Remarks

Plant operations area :
1 Floor clean, no pools/spillage of condensate/ oil/chemicals/water
2 Platform/Grating ok
3 Tag Nos. painted as per standard on equip./machines
4 Plant area free of superfluous material
5 Escape routes marked
Access to fire extinguishers/MCP/Emergency exit etc. unobstructed.
6

7 Scrape and refuse bins provided & cleaned.

8 Solid/liquid disposal area marked drums labeled
9 All columns & chimneys skirts are kept clean
10 Torn/No wind sock
Temporary floor opening without barrication caution/sign boards "Do
11
not enter without permit".
12 High noise area properly marked
13 Drains and vents are plugged/capped/blinded
14 Is insulation in good condition
15 Guards- Machine/Railing/Ladders/platforms ok
Colour Coding and Sign Boards
16 Colour coding of pipelines done & displayed conspicuously
Adequate Nos. of caution /hazard boards & displayed conspicuously
17
-appropriateness of display locations
18 Tanks identification as per standards
Personal protective Equipments :
 19 Designated space for PPE & kept properly
20 PPEs are kept clean & maintained
21 SCBA sets are maintained in working condition
Storage Area ;
22 Aisles and storage marked
23 No over stacking. No spillage/over flow
Chemical drums labeled/stored properly & separate storage for in
24
compatible chemicals/Material
Illumination and Ventilation
25 Lighting fixtures Lighting fixtures working and cleaned
26 A/C, Exhaust fan working. Lighting sufficient.
Road
27 Swept , No dust , No debris ,Road in good condition
Drains :
Plant drains having proper cover and surrounding area of OWS pit
28
clean. Pits not over flowing
Storm water channels -free from hydrocarbon and debris. No
29
vegetation growth. Pass ways over channels.
Fire Equipments
30 Identification Nos. painted properly & in good condition
31 Extinguishers & hose boxes at their proper location
32 Not obstructed
33 Hydrants/Monitors/Deluge not leaking
Work shop
34 Tools/spares stacked properly at designated places
35 Properly identified
36 Floors clean
Sub-station/PIB
37 properly locked
38 Fire/safety equipment in position/FM-200 procedure followed
39 Floor clean /No loose material
Garden and Beautification :
40 Condition of lawn & shrubs
41 Trimmed & lively plants
42 Overview of whole plant
Electrical :
43 Portable electrical connection with plug top/with earthing/
44 Proper insulation. Electrical cables in good condition.
45 Condition of flame proof fittings
Gas Cylinders :
46 Cylinders in stand/chained/stacked vertically
47 Empty and filled cylinders are segregated
First Aid Box
48 Proper location , Properly maintained
Hoses
All the types of hoses in use specified for the service/properly
49
clamped.
50 Damaged/scattered in the area
51 Rolled/kept at designated places
Hygiene
52 Mirrors/sink/urinals/WC clean
53 Taps not leaking
54 Exhaust fan in operation and clean also not making noise
55 Domestic sewer not over flowing
56 Water cooler/Vending m/c and area cleaned. Dining facilities clean - No flies
Contractor's EMS Client's
Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

Vehicle Inspection Tag

Name of Contractor: Report No:

Doc. No : Date:

Work Description: Location :

S.N.
Vehicle Type
Registration No
Operator Name
Training date
Company
License No
EMS Engineer Safety Manager Security
Authorised by

Date

Do not use
mobile while
driving

SPEED LIMIT AT SITE

SPEED LIMIT AT SITE
10KM/H
 RBI BUILDING PROJECT

EMS LIMITED

Doc No Bar Cutting Machine

Contractor: Doc. No :

Job No: Location :

Work Description Date:

S No. Description Yes No Remarks

1 Condition of the machine base (Floor levelled )

2 Presence of the cutting machine emergency stopper

Provided body earthing (System earthing and body

3
earthing)

4 Machine weather protection (Shed)

5 Condition of machine operating lever and cutting blade.

6 Presence of all rotating guards (Belt, pulley and motor)

7 Condition of terminal box and doors.

8 Condition of the warning devices &gauges.

9 Condition of the Limit cut off switch.

 10 Any oil leakage from the oil tank & pipes

11 Display the SOP (safe Operating Procedure).

12 Operator fitness with trained

13 Machine base rest *(provided solid foundation)

NOTE:- Ensure barricading on both sides of the when the machine is in operation

Remarks

Contractor's EMS Client's

Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Doc No Vibrator Soil Compactor

Contractor: Report No

Doc. No : Location :

Work Description Date:

S No. Description Yes No Remarks

From the ground:

1 Tires, Wheels, Lug Nuts, Stem CapsInflation, Leaks, Damage, Wear

2 Leveling BladeExcessive Wear, Damage, Leaks

3 Cutting Edges (Leveling Blade)Excessive Wear, Damage
4 Drum ScrapersExcessive Wear, Damage
5 Drum Cooling OilLeaks
6 Vibratory SupportLeaks
7 Eccentric Weight HousingLeaks
8 Isolation MountsDamage, Cracking, Splitting
9 Steering Cylinders / EndsDamage, Wear / Leaks
10 Steps and HandholdsCondition, Cleanliness
 11 Underneath MachineLeaks, Damage
12 Axles – Final Drives (Axle / Drum)Leaks, Damage, Wear
13 Hydraulic Tank & FiltersFluid Level, Damage, Leaks
14 Fuel TankFuel Level, Damage, Leaks
15 All Covers and GuardsDamage, Securely Attached
Lights, Front and Rear, BeaconFunction, Damage to Lens, Housing,
16
or Wiring
17 Battery CompartmentCleanliness, Loose Nuts & Bolts
Engine Compartment:
18 Engine Oil (Fluid level)
19 Engine Coolant (Fluid level)
20 Radiator /AC Condenser/Oil Cooler ( Fin, Blockage, Leaks)
21 All Hoses (Cracks, wear spots, Leaks)
22 Fuel Filters / Water Separator ( Leaks, Drain water)
23 All Belts (Tension, Wear, Cracks)
24 Air Filter ( Service Indicator)
25 Overall Engine Compartment ( Trashor dirt build up leaks)
On the Machine outside the Cab:
26 Handholds (Condition and Cleanliness)
27 ROPS (Damage, Loose Mounting Bolts)
28 Fire Extinguisher (Charge, Damage)
29 Windshield, Windows (Broken Glass, Cleanliness)
30 Windshield Wipers / Washers (Wear, Damage / Fluid Level)
31 Doors (Open properly, broken glass)
Inside the Cab:
32 Seat (Adjustment-Height, Weight, Able to Reach Pedals)
33 Seat Belt & Mounting (Damage, Wear, Adjustment, Age)
34 Horn, Backup Alarm, Lights (Proper Function)
35 Mirrors (Damage, Adjust for Best Visibility)
36 Gauges, Indicators, Switches, Controls (Damage, function)
37 Overall Cab Interior (Cleanliness)
Contractor's EMS Client's
Representative Representative Representative
Signature:

Name:

Date:
 RBI BUILDING PROJECT

EMS LIMITED

Safety Checklist for Crane

Contractor: Doc. No :

Operator Name & Licence no: Date:

S No. Description Yes No Remarks

1 Hook and Hook Latch
2 Over-Hoist Limit Switch
3 Boom-Limit Switch
4 Boom Angle indicator
5 Boom-Limit cut-off switch
6 Condition of boom
7 Condition of Ropes
8 No. of load lines
9 Size and condition of the sling
10 Stability of crane
11 Soil Condition
12 Swing Brake & Lock
13 Propel Brake & Lock
14 Hoist Brake & Lock
15 Boom Brake & Lock
16 Main clutch
17 Leakage in hydraulic cylinders
18 Out riggers fully extendable
19 Tyre pressure
20 Condition of Battery and Lamps
21 Guards of moving and rotating parts
22 Load chart provided
23 No. and position of pendant ropes
24 Reverse horn
25 Load test details
26 Operators Fitness
27 Fire Extinguisher in operators cabin
28 identification / Registration Number
29 Make / Model
 30 Unsafe Conditions/ Deficiencies observed
31 Engine condition
32 Clutch / brake
33 Hydraulic System
34 Guards / Covers / Doors
35 Fastener locks pins / Keys.
36 Horn / Reverse horn / Lights/
37 Indicators / Wiper Blades
38 Operators fitness
39 Tyre pressure
40 Condition of Battery and Lamps
41 Operating levers / steering
42 Gauges & warning devices
43 Fire extinguisher Provided
Contractor's EMS Client's
Representative Representative Representative
Signature:

Name:

Date: