Title Page
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Conducted on
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Prepared by
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Location
Jobsite/Saftey assestment
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Project Name:
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Task Overview:
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Crew Members on this Task:
- Kevin Williams
- Chris Arsenault
- Nathan Shackelton
- Jesse Cooper
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Date and Time:
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Weather:
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Did your crew bring up any hazards they have found?
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If yes, please explain
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Have you consulted with workers about the task and the safe way to do it?
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Have you got a safe way of getting in and out of your work area?
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Pre-Task Checklist (Check All That Apply):
- PPE
- Proper safety equipment
- Proper tooling
- Stretch/Warm up
- Action Plan discussed
- Jobs Assigned discussed
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Special traffic needed?
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If yes, (what traffic set up is needed)
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Recognized Hazards (Check All That Apply)
- Chemicals
- Material Handling
- Customer Equipment
- Energized Electric
- Fire Explosion
- Struck By
- Slip/Trip/Fall Hazard
- Pinch Point/Caught Between
- Excessive Nosie
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If hazard, (please explain hazard)
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Hazard Protection (Check All That Apply)
- Ladder Safety
- Fall Protection
- Hearing Protection
- MSD Sheet
- Equipment Inspection
- Tool Inspection
- Vehicle Inspection
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List other hazard protection
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Post Task Checklist (Check All That Apply)
- Site cleaned up for access
- Tools put away and stored
- Stored equipment in designated area
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Team Supervisor
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Team reviewer
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Team reviewer
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Team reviewer
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Team reviewer
