3CIX-Risk Assessment Pole Survey

• RA Pole Survey

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Have all team members attended the pre-survey briefing (toolbox talk)?

  Yes

  No

  N/A

• Have weather conditions been checked for suitability (no high winds, storms, etc.)?

  Yes

  No

  N/A

Equipment Checklist

• Are all survey tools (e.g., binoculars, pole cameras, laser measures) in good working condition?

  Yes

  No

  N/A

• Is all electrical equipment safe and insulated for use near overhead lines (if necessary)?

  Yes

  No

  N/A

• Have tools been calibrated or tested (if applicable)?

  Yes

  No

  N/A

• Are there enough safety measures in place to perform activity safely Without being exposed to harmful/hazardous substances)

  Yes

  No

  N/A

• Is all equipment stored securely when not in use to prevent tripping hazards?

  Yes

  No

  N/A

• Is vehicle in use having proper Chevron marking and beacon lights?

  Yes

  No

  N/A

Personal Protective Equipment (PPE) Checklist

• Are all team members wearing the required PPE (hard hats, high-visibility vests, safety boots)?

  Yes

  No

  N/A

• Is weather-appropriate clothing available (waterproofs, sun protection)?

  Yes

  No

  N/A

• Are gloves and protective eyewear available (if necessary)?

  Yes

  No

  N/A

Site Setup Checklist

• Is the worksite free from visible hazards (e.g., debris, loose cables, uneven ground)?

  Yes

  No

  N/A

• Are cones, barriers, and signage set up to demarcate the work area and restrict public access?

  Yes

  No

  N/A

• Are traffic control measures in place (if working near roads or footpaths)?

  Yes

  No

  N/A

• Is a clear path established for safe access to and from the work area?

  Yes

  No

  N/A

• Have public safety precautions been set up (e.g., warning signs, cones)?

  Yes

  No

  N/A

Work Checklist

• Are any defects, such as cracks, leaning, or damaged components, being documented accurately (with photos if necessary)?

  Yes

  No

  N/A

• Is any data regarding the condition of overhead wires and attachments being recorded accurately?

  Yes

  No

  N/A

• Are no surveyors making physical contact with the poles, wires, or electrical attachments?

  Yes

  No

  N/A

• Are team members using proper lifting techniques for any equipment?

  Yes

  No

  N/A

• Is overreaching, twisting, or unsafe postures being avoided during the survey?

  Yes

  No

  N/A

• Are all team members aware of the emergency contact numbers and procedures?

  Yes

  No

  N/A

• Is a first aid kit available on-site and a trained first aider present?

  Yes

  No

  N/A

• Is Fire extinguisher available on site?

  Yes

  No

  N/A

• Are all materials and equipment being stored in a way that does not harm the environment?

  Yes

  No

  N/A

Signature

• Team Lead Name

• Signed by

  Sign