Information
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Conducted on
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Client
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Prepared by
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Location
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Scope of work
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Superintendent
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Foreman
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Crew Members
Site Set-up
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JSA - on site, completed and signed by all members on site.
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Photo/screenshot of JSA
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QEW present (if required)
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Crew knowledge of task at hand
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Crew Attitude
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Knowledge of closest medical center
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Drinking water available at site
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Shade available at site (temps > 80F)
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Competent person identified on JSA and on site
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Traffic control
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Photo of traffic control
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Barricading/pedestrian protection
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Photo of barricading/pedestrian protection
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First aid kit on site and well stocked
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Spill kit on site
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Burn kit on site
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Line of fire / body positioning / pinch points
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Site housekeeping
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Overall site photos
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Fire prevention (tools on site and policy followed)
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First aid and CPR certifications (min. 2 per crew)
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Rigging practices
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Ladder use (Tied off / held in place by anther worker)
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Cooler inspection (clean/appropriate contents)
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Crew member cell phone use (are employees using personal cell phones on the job site?)
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Chemical information (SDS)
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Emergency contact list on site
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A.M. Ortega Policy Manual on site
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General site set up and risk of potential damage claims
Excavation
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Excavation Protective Measures used/install (shoring/benching/sloping)
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Photo of excavation
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Tabulated data on site
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Soil class documented on JSA
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USA mark out completed
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Excavation free of water or pumps installed
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Underground utilities supported
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Excavator/crane swing area clear
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Overhead power lines protected or designated spotter in use
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Designated spotter when moving vehicles and equipment near excavation
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Bridges, rails, toe boards properly installed (when required)
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Photo of bridges, rails and toe boards
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Excavator operator, spotter and foreman walked out USA marks
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Spoils set back at least 2 feet
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Gas detector in use, calibrated and working (if required)
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Gas detector calibration or expiration date
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Ladders in place or ingress/egress ramp installed at least every 25' (excavations deeper than 4')
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Photo of ladders of ingress/egress ramp
Chipping on Encasement
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Is crew member conducting chipping operations trained on the task and on the list of approved employees?
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Is QEW present?
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Is the QEW in direct view of the work being performed?
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Is the QEW wearing appropriate PPE, including FR
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Does the QEW have no test orders (automatic recloser made non-automatic)
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Is the crew member wearing FR outer garments (jumpsuit)
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Is the crew member wearing an FR Balaclava (head sock)?
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Is the employee using a 2" Waffle Gad
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Is the crew using pointed bits or gads
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Is the crew member within 1/2" of the energized cable
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Is the crew member removing encasement from in between conduits
Vehicles
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DVIR completed on all commercial vehicles
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Registration and insurance cards (current)
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Annual DOT inspection
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Fire extinguisher (fully charged and in date)
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Protective pads or matting in use
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Wheel chocks
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Vehicle housekeeping (interior)
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Photo of vehicle housekeeping (interior)
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Vehicle housekeeping (exterior)
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Photo of vehicle housekeeping (exterior)
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Trailer Connections (crossed chains, breakaway cable, battery tested (if equipped)
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Photo of trailer connections
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Load securement
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Photo of load securement
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Circle of safety (walk around) conducted prior to moving vehicles and equipment
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Overall vehicle condition
Personal Protective Equipment
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Head protection
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Eye protection
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Hand Protection
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Traffic vest
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Proper footwear
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Hearing protection
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Toe guards used while jackhammering or tamping
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Arms covered while welding
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appropriate welding hood and shields used (when required)
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Dust mask or respirator
Tools and Equipment
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Condition of rigging equipment
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Storage of rigging equipment
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Condition of hydraulic and air tools (hoses inspected prior to use)
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Condition of power tools
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GFCI in use for power tools
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Condition of welding equipment
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Storage of welding equipment
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Storage of hydraulic and air tools
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Air hoses properly secured (clips, whip checks, leashes, Etc.)
Review
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Notes/comments
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Foreman signature
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Date and time of review with foreman