CIVIL SAFETY INSPECTION

• Site conducted

  Date

• Site Name

• Contractor

• Carrier

• Location
  Address

• Competent Person Onsite

• Crewmembers onsite

Paperwork and Training

• JSA is thorough and Complete?

  Good

  Fair

  Poor

  N/A

• Crew is taking appropriate hazard mitigation steps identified in JSA?

  Good

  Fair

  Poor

  N/A

• All Crewmembers have documented training certifications for tasks being performed? EX: Authoroized/Competent<br>Climber, Rigging, First-Aid/CPR, RF, Crane, Aerial Lift, etc.

  Good

  Fair

  Poor

  N/A

• Crew logged in with tower owner?

  Yes

  No

  N/A

• Crew logged in with carrier?

  Yes

  No

  N/A

PPE

• Hard Hats

  Safe

  At Risk

  N/A

• High Vis

  Safe

  At Risk

  N/A

• Safety Glasses

  Safe

  At Risk

  N/A

• Gloves

  Safe

  At Risk

  N/A

• Work Attire

  Safe

  At Risk

  N/A

Equipment

• First Aid Kit Readily Accessible?

  Compliant

  Non-Compliant

  N/A

• First Aid Kit Fully Stocked

  Compliant

  Non-Compliant

  N/A

• Fire Extinguisher Readily Accessible?

  Compliant

  Non-Compliant

  N/A

• Fire Extinguisher Has Annual Inspection Tag?

  Compliant

  Non-Compliant

  N/A

• Fire Extinguisher Has Monthly Inspection Logged?

  Compliant

  Non-Compliant

  N/A

• GFCI Being Utilized?

  Compliant

  Non-Compliant

  N/A

• Extension Cords Are Free From Trip Hazards or Properly Marked?

  Compliant

  Non-Compliant

  N/A

• Proper LOTO Utilized When Necessary?

  Compliant

  Non-Compliant

  N/A

• Task Specific PPE Available and In Use?

  Compliant

  Non-Compliant

  N/A

Enviornmental

• Warning/Safety Banner in Use?

  Compliant

  Non-Compliant

  N/A

• Adequate Warmth or Shade Accessible?

  Compliant

  Non-Compliant

  N/A

• Water Available for Entire Crew?

  Compliant

  Non-Compliant

  N/A

• Traffic Cones or Barricades Used When Necessary?

  Compliant

  Non-Compliant

  N/A

• Trenches/Holes Covered & Secured?

  Compliant

  Non-Compliant

  N/A

• Housekeeping, Site is free from excessive trash/debis?

  Compliant

  Non-Compliant

  N/A