Title Page
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Document No.
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Crew leader/foreman
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Personnel
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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
Personal protective Equipment
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Hard Hats in use by all personal?
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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?
Tools and Equipment.
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Tools and equipment in good condition?
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Ladders in good condition; tied back; extended 3ft beyond landing?
Worksite
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Warning devices (signs and cones) properly placed according to MUTCD?
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Safety cones in good condition and placed correctly?
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Breaks set on truck/chock on unhitched trailer?
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Engine Idle? ( Truck or Equipment)
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Equipment properly secured on the truck/trailer?
General
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Safe access to work site?
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Good house keeping?
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First aid kit/ eye wash available?
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Pre-task cards reviewed by work crew?
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Fire extinguisher: good condition; current inspection tag; within 50ft?
F. D. O. T.
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Lights/reflectors/bacons operational?
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Truck inspection completed?
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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?
Behaviors
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Push, don't pull?
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Turn, don't twist?
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Squat, don't bend?
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Load close to the body?
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Was the crew open to coaching?
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List any other behaviors you saw on site.
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Signature