Title Page
-
Conducted on
-
Prepared by
-
Location
General Work Zone
-
Equipment Wheels Chocked
-
Keys Out of Vehicle Ignitions
-
Housekeeping, Trip Hazards
-
Excavation Protected by Cones and/or Barriers
-
All Utility Companies Within Work Zone Contacted and Utilities Located
-
Exact Location of Utilities Marked When Near Excavation
-
Crew Leader Offered JSA
-
Work Area Marked with Proper Signs
Excavation Safety
-
No Mechanical Equipment in Tolerance Zone
-
Trench Boxes being used when 5+ feet of depth
-
Hand Dig Around Facilities
-
Atmospheric Monitoring CGI Calibrated
-
Egress Provided for 4+ Feet Deep
-
Means Of Egress Within 25 Feet of Employees
-
Ladder Extends 3+ Feet Out Of Excavation
-
Trench is Not Greater Than 20 Feet Unless PE Designed Protective Systems
-
Shoring Extends 18 inches above edge of excavation when required
-
Spoil Pile and tools placed more than 2 feet from excavation
-
Shoring space/sloping greater than 5 feet depth
-
Precautions taken to protect workers from accumulation of water
Personal Protective Equipment
-
All PPE in Clean and Serviceable Condition
-
Eye Protection
-
Side Impact Hard Hat
-
Foot Protection
-
Face Protection
-
Hand Protection
-
Respiratory Protection
-
Fall Protection
-
Hearing Protection
-
FR Clothing
-
High Visibility Clothing
-
Helmets used when operating UTV/ATV
Tools and Equipment
-
Mechanized Equipment used correctly
-
Pre-Use inspection checklist for equipment
-
Air Hoses and Fittings in Good condition and properly restrained
-
Ladder available and secured properly
-
Equipment Calibrated
-
Guards on all portable tools
-
Spotters being used for movement of equipment
Ergonomics
-
Employees away from pinch points
-
Proper lifting technique
-
Employee positioned away from moving parts and equipment
-
Proper body mechanics
-
Suspended Load Operations
-
Workers prohibited from working or walking under suspended loads
-
Lifting Devices in safe conditions
-
Proper rigging
-
Properly load rated
-
Chemical Safety
-
Chemical information available (SDS)
-
Containers in good condition
-
Containers and secondary containers properly labeled
-
Containers closed and sealed
-
Flammables in Safety approved cans
-
Electrical Equipment
-
Cords free of cuts and damages
-
Field Goals Posts for overhead power lines used and positioned properly
-
GFCIs used on all power equipment
-
Grounding pins on extension cords and power tools in place
-
Lock Out Tag Out locks used properly
Fire Protection/First Aid
-
Fire extinguishers positioned properly
-
Fire extinguisher inspected monthly
-
Fire extinguisher tag current
-
First aid kit complete and sanitary
-
First aid kit inspected monthly
