Contractor Underground Crew Observation

• Document No.

• UPC Crew Observation Form

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Crew Information

• Date

  Date

• Name of Contractor

• Crew Foreman

• Job Number

• Location Number

• Job

  Select Energized De-energized Secondary Primary

  • Energized
  • De-energized
  • Secondary
  • Primary

• Equipment

  Select Underground Trencher Excavator Pick-up Compressor Other Plow

  • Underground
  • Trencher
  • Excavator
  • Pick-up
  • Compressor
  • Other
  • Plow

• Details of Job

PPE

• Hard Hat(s)

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Rubber Gloves

  Yes

  No

  N/A

• Rubber Sleeves

  Yes

  No

  N/A

• Appropriate Cover Up

  Yes

  No

  N/A

Job Preparation

• Lock Out Tag Out/Hot Line Tag?

  Yes

  No

  N/A

Grounding

• Personal Grounds Used

  Yes

  No

  N/A

Traffic Control

• Four Way Flashers

  Yes

  No

  N/A

• Reflective Traffic Vests

  Yes

  No

  N/A

• Cones Adequate

  Yes

  No

  N/A

Risk/Hazard Recognition

• Are there any unrecognized hazards at the jobsite

  Safe

  At Risk

  N/A

• Are there any unsafe work behaviors being demonstrated by employees

  Safe

  At Risk

  N/A

• Is there any unsafe equipment being used at the job

  Safe

  At Risk

  N/A

Signatures

• Comments

• Picture of job

  Media

• Inspected By