2013 Encore Excavating Hazard Assessment

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Assessment (if Yes to a question describe corrective action)

• Select for general assessment

Assessment

• Are permits in place?

  Yes

  No

  N/A

• Are locates completed? If No, do not proceed with excavation

  Yes

  No

  N/A

• Are private locates completed?

  Yes

  No

  N/A

• Is your proper PPE in place? (Steel toe boots, gloves, eye protection)

  Yes

  No

  N/A

• Are there any other obstruction such as trees, light poles, etc in work area?

  Safe

  At Risk

  N/A

• Will you be working on the street? Use of signage is needed

  Yes

  No

  N/A

• Are there any hazardous materials on site?

  Safe

  At Risk

  N/A

• House keeping status?

  Safe

  At Risk

  N/A

General Excavation Hazards (if answered "at risk" describe corrective action)

• Select to preform a general excavation assessment

Assessment

• Are other working in the work area?

  Safe

  At Risk

  N/A

• Over head obstruction?

  Safe

  At Risk

  N/A

• Any signs of undergrounds unmarked? (Ie power poles, gas meter, water valves, power meters, auxiliary building)

  Safe

  At Risk

  N/A

• Underground hazards?

  Safe

  At Risk

  N/A

• Overhead hazards present?

  Safe

  At Risk

  N/A

• Material storage

  Safe

  At Risk

  N/A

• Confirmed space needed?

  Safe

  At Risk

  N/A

Trench Excavations

• Is there a trench present in work area?

Trench hazard

• Is edge protection in place?

  Yes

  No

  N/A

• Are services clear and protected?

  Safe

  At Risk

  N/A

• Excavations off 1.2 m is trench box or proper slope backs in place?

  Safe

  At Risk

  N/A

• Is a ladder in place for secondary egress?

  Yes

  No

  N/A

Description of Additional Hazards (ex. Trip, fall, equipment, hazardous materials, etc)

• Identify Additional Hazards

Add hazard risk

• Identify hazard and describe potential RISK

• Hazard risk level. (1= minimum, 4= maximum)

  1

  2

  3

  4

• Identify corrective action taken

• Add media

  Media

Send report to EHS Manager, Production Superintendent, and Supervisor of the Department. If it requires a maintenance copy report to Maintenance Manager.

• Select date

  Date

• Person completing the report

  Sign