Information

  • Conducted on

  • Client

  • Prepared by

  • Location
  • Scope of work

  • Superintendent

  • Foreman

  • Crew Members

Site Set-up

  • JSA - on site, completed and signed by all members on site.

  • Photo/screenshot of JSA

  • QEW present (if required)

  • Crew knowledge of task at hand

  • Crew Attitude

  • Knowledge of closest medical center

  • Drinking water available at site

  • Shade available at site (temps > 80F)

  • Competent person identified on JSA and on site

  • Traffic control

  • Photo of traffic control

  • Barricading/pedestrian protection

  • Photo of barricading/pedestrian protection

  • First aid kit on site and well stocked

  • Spill kit on site

  • Burn kit on site

  • Line of fire / body positioning / pinch points

  • Site housekeeping

  • Overall site photos

  • Fire prevention (tools on site and policy followed)

  • First aid and CPR certifications (min. 2 per crew)

  • Rigging practices

  • Ladder use (Tied off / held in place by anther worker)

  • Cooler inspection (clean/appropriate contents)

  • Crew member cell phone use (are employees using personal cell phones on the job site?)

  • Chemical information (SDS)

  • Emergency contact list on site

  • A.M. Ortega Policy Manual on site

  • General site set up and risk of potential damage claims

Excavation

  • Excavation Protective Measures used/install (shoring/benching/sloping)

  • Photo of excavation

  • Tabulated data on site

  • Soil class documented on JSA

  • USA mark out completed

  • Excavation free of water or pumps installed

  • Underground utilities supported

  • Excavator/crane swing area clear

  • Overhead power lines protected or designated spotter in use

  • Designated spotter when moving vehicles and equipment near excavation

  • Bridges, rails, toe boards properly installed (when required)

  • Photo of bridges, rails and toe boards

  • Excavator operator, spotter and foreman walked out USA marks

  • Spoils set back at least 2 feet

  • Gas detector in use, calibrated and working (if required)

  • Gas detector calibration or expiration date

  • Ladders in place or ingress/egress ramp installed at least every 25' (excavations deeper than 4')

  • Photo of ladders of ingress/egress ramp

Chipping on Encasement

  • Is crew member conducting chipping operations trained on the task and on the list of approved employees?

  • Is QEW present?

  • Is the QEW in direct view of the work being performed?

  • Is the QEW wearing appropriate PPE, including FR

  • Does the QEW have no test orders (automatic recloser made non-automatic)

  • Is the crew member wearing FR outer garments (jumpsuit)

  • Is the crew member wearing an FR Balaclava (head sock)?

  • Is the employee using a 2" Waffle Gad

  • Is the crew using pointed bits or gads

  • Is the crew member within 1/2" of the energized cable

  • Is the crew member removing encasement from in between conduits

Vehicles

  • DVIR completed on all commercial vehicles

  • Registration and insurance cards (current)

  • Annual DOT inspection

  • Fire extinguisher (fully charged and in date)

  • Protective pads or matting in use

  • Wheel chocks

  • Vehicle housekeeping (interior)

  • Photo of vehicle housekeeping (interior)

  • Vehicle housekeeping (exterior)

  • Photo of vehicle housekeeping (exterior)

  • Trailer Connections (crossed chains, breakaway cable, battery tested (if equipped)

  • Photo of trailer connections

  • Load securement

  • Photo of load securement

  • Circle of safety (walk around) conducted prior to moving vehicles and equipment

  • Overall vehicle condition

Personal Protective Equipment

  • Head protection

  • Eye protection

  • Hand Protection

  • Traffic vest

  • Proper footwear

  • Hearing protection

  • Toe guards used while jackhammering or tamping

  • Arms covered while welding

  • appropriate welding hood and shields used (when required)

  • Dust mask or respirator

Tools and Equipment

  • Condition of rigging equipment

  • Storage of rigging equipment

  • Condition of hydraulic and air tools (hoses inspected prior to use)

  • Condition of power tools

  • GFCI in use for power tools

  • Condition of welding equipment

  • Storage of welding equipment

  • Storage of hydraulic and air tools

  • Air hoses properly secured (clips, whip checks, leashes, Etc.)

Review

  • Notes/comments

  • Foreman signature

  • Date and time of review with foreman

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.