Title Page
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Our Safety Goals 1. Zero accidents or injuries 2. No disruption to work environment
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Project Name
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Project Number
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Date and Time
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Location
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Supervisor/Foreman
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Production Goal/Finish Date
Untitled Page
Sign In
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Onsite Supervisor/Foreman
Crew Members
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Add signature
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Add signature
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Add signature
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Add signature
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Add signature
Hazard Analysis
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Steps to Complete Task
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Hazards Associated with Tasks
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Mitigation of Hazards
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Do you have all of the information needed to complete the task?
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What information is needed?
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Do you have the tools needed to complete the task?
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What are you missing?
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Do you have the materials needed?
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What do you need?
General Checklist
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MSDS reviewed for the task?
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If no, why?
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Proper PPE available and in good condition?
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What do you need?
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Guards and handles on power tools?
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Why not?
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Confined space and rescue procedure in place?
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Why not?
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Power lines located above/below ground?
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Rigging and harnesses inspected prior to use?
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Why not?
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Is a copy of the emergency procedure plan and contacts available?
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Why not?
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Work communicated with others in area?
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Why not?
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Suitable supply of water available to crew?
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Why not?
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Is fall protection needed?
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Scope of work that requires protection
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Method of fall protection
Post Task Assessment
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Was anyone injured or did an unplanned incident occur today?
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If yes, explain.
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Was the injury or incident reported to safety?
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Why not?
