Title Page
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Job Number
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Job Leader
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Date / Time
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Location
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Safety Goals
1. Zero People Hurt.
2. No disruption to facility or environment. -
Task Name/Plan of Action
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Production Goal/Finish Date
Onsite Supervisor
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Supervisor
Onsite Crew
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Onsite Subcontractors
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Hazard Analysis
Hazard Analysis
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List Steps to Complete Task (List at least 3)
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List Hazards Associated With Each Step (List at least 3)
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Ways to Eliminate or Control Hazards (List at least 3)
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Do you have the information to complete the task?
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What information do you need?
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Do you have to tools to complete the task?
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What tools are needed?
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Do you have the materials to complete the task?
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What materials are missing?
Ways to Eliminate Hazards
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Select All That Apply
General Checklist
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MSDS reviewed for task?
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If no, why?
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Proper safety equipment on site?
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If no, why?
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Guards and handles on power tools?
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If no, why?
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Confined space procedure / rescure plan?
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If no, why?
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Power lines located above/below ground?
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If no, why?
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Rigging and harnesses inspected?
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If no, why?
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Emergency procedure and contacts?
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If no, why?
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Work communicated with others in area?
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If no, Why?
Possible Hazards
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Select all that apply.
Fall Protection Work Plan
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Fall Protection Needed?
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Fall Hazards in the Work Area (select all that apply)
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Other
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Method of Fall Restraints (select all that apply)
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Other
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Overhead Protection (Select all that apply)
Additional Forms
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Rigging / Lifts
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Hot Work
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Site Specific
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Fall Arrest
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Lock Out Tag Out
End of Task Checklist
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All Equipment Shut Down?
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If no, why?
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All tools/materials properly stored?
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If no, why?
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Work area cleaned up?
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If no, why?
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LOTO tags released and signed off/locks removed?
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If no, why?
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Completed task status communicated to customer?
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If no, why?