Title Page

  • Document No.

  • Company Name

  • Supervisor/Foreman

  • Conducted on

  • Location
  • Client / Site

  • Weather conditions

  • Prepared by

General

  • Pre-task cards reviewed by work crew? (At Risk = AUTO FAIL)

  • Safe access to work site?

  • Good house keeping?

  • Fire extinguisher: good condition; current inspection tag?

  • Utilities properly located/identified?

  • Fencing and/or flagging tape in place around pot holes?

Personal protective Equipment

  • Hard Hats in use by all personal? (At Risk = AUTO FAIL)

  • Eye protection in use by all personal?

  • Reflective vest worn by all personal?

  • Hearing protection in use when required?

Tools and Equipment.

  • Tools and equipment in good condition?

  • Strike Alert Operational and pre operational check completed?

  • Machine guards/pinch points identified and protected?

  • Are extension cords in good condition? (no frays, ground prong in place, no holes in outer jacketing)

  • Rigging/ lifting equipment in good condition and inspected?

  • Ladders in good condition? (no cracks, broken parts)

Heavy Equipment

  • Fire extinguisher mounted and in good condition?

  • Seatbelt worn during operation?

Worksite

  • Warning devices (signs and cones) properly placed according to MUTCD?

  • Safety cones in good condition? (Double reflective tape for roadway use, faded, torn)

  • Traffic taper correctly positioned?

  • Sidewalks closed properly to prevent injury to the public?

  • Breaks set on truck/chock on unhitched trailer?

  • Flagger performing duties properly and placed in a safe location?

  • First aid kit/ eye wash available?

Trenching and Excavations

  • Excavations / trenches properly protected? (At Risk = AUTO FAIL)

  • Shoring properly installed/ tabulated data on site? (At Risk = AUTO FAIL)

  • Spoil piles/tools 2 feet or further away from the trench? (At Risk = AUTO FAIL)

  • No standing water in the trench? (At Risk = AUTO FAIL)

  • Are there proper means of egress? (4 feet or more a ladder must be used) (At Risk = AUTO FAIL)

Fall Protection

  • Fall Protection Equipment inspected?

  • Fall Protection equipment in good working order?

  • 100% tie off practices in use?

Personnel Lifting/Aerial Booms

  • 100% Fall Protection in use?

  • Lift device and alarms operational?

  • Any damage to the boom and/or lifting device during the Assessment? (If At Risk operations should stop immediately until inspected by competent person and/or maintenance)

Behaviors

  • Did the crew discuss a Good Catch/Near Miss with you during the Assessment?

  • Enter Good Catch/Near Miss discussed, or enter coaching performed if no Good Catch/Near Miss was discussed.

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