Title Page
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Document No.
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Crew leader/foreman
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Conducted on
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Location
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Client / Site
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Weather conditions
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Prepared by
General
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Pre-task cards reviewed by work crew? (At Risk = AUTO FAIL)
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Pre-task card briefed to visitor before entering the work area?
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Good house keeping?(Clean and clear walkways, trash, tools and materials laying around the job site.)
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Utilities properly identified?
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Utilities properly located?
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Utilities potholed according to proposed path?
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Are pot holes covered with plywood and cordoned off with stakes and flagging tape/snow fence while left unattended?
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First aid kit/ eye wash not expired?
Personal protective Equipment
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Hard Hats in use by all personal? (At Risk = AUTO FAIL)
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Eye protection in use by all personal?
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Reflective vest worn by all personal?
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Hearing protection in use when required?
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Proper foot wear?
Structure Entry
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Have Hot Gloves been tested before use? (Not expired, no holes, mud/glue)(AT RISK=AUTOMATIC FAIL)
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Does the crew have proper FR apparel?(AT RISK = AUTOMATIC FAIL)
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Wearing tinted safety glasses while digging on electric lines/structure entry?
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Has the crew verified that they are working on the correct structure?
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Was the structure inspected prior to work beginning?(Add notes and pictures if damage is visible to the structure)
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Has the crew inspected all hot work tools and equipment prior to use?
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Was a visual inspection completed inside the structure? (Add notes if deficiencies were found)
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Are blast mats, secondary covers, dust covers in place prior to work commencing on the structure?
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Is the structure properly closed and secured while left unattended?
Tools and Equipment.
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Do shovels, post hole diggers and rakes have fiberglass handles?
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All other hand tools in proper working order and in good condition?
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All manufactured guards on equipment in good working order and being utilized correctly ?
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Pinch points identified and protected?
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Rigging/ lifting equipment in good condition and inspected?
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Are electrical power tools in good condition and being used properly?
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Have extension cords been inspected?
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Do extension cords have any cuts or abrasions showing the inner insulation?(Cords must be destroyed and replaced)
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Do all extension cords have the ground terminal in place?
Heavy Equipment
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Fire extinguisher mounted and in good condition?
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Seatbelt worn during operation?
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Is the strike alert ground installed?
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Has the strike alert been tested?
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Is the strike alert working properly?
Worksite
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Warning devices (signs) properly placed according to MUTCD?
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Safety cones in good condition?
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Traffic taper correctly positioned?
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Brakes set on truck?
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Wheels chocked on truck and on unhitched trailer?
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Has the homeowner been contacted?
Trenching and Excavations
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Spoil piles/tools 2 feet or further away from the trench? (At Risk = AUTO FAIL)
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Less than 5' has the competent person evaluated the safety of the excavation/trench?
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Are there proper means of egress? (4 feet or more a ladder must be used) (At Risk = AUTO FAIL)
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Does the ladder extend 3' above the top surface? Ladder secured? Ladder in proper working order?(No cracks, broken rungs, etc.)
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Excavations / trenches properly protected at 5' or deeper? (At Risk = AUTO FAIL)a
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Shoring properly installed/ tabulated data on site? (At Risk = AUTO FAIL)
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No standing water in the trench? (At Risk = AUTO FAIL)
D. O. T.
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Is ZONAR completed daily?
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Equipment properly secured on the truck/trailer?
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Lights/reflectors/bacons operational?
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Truck cab neat/vehicle clean?
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Trailer properly mounted and free of debris?
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Tires within acceptable depth?
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Is the Incident Report Card in the truck ?
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Does the driver have a valid drivers license for the vehicle they are driving?(Class, expiration)
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Does the driver have a medical card?(Expired)
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Vehicle insurance card current?
