Crew Observation Form

• Document No.

• UPC Crew Observation Form

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Crew Information

• Date

  Date

• Crew Foreman

• Crew Members

• Job Number

• Location Number

• Vehicles at Job

• Inspection Type

  Select Regular Outage/Emergency

  • Regular
  • Outage/Emergency

• Job

  Select Energized De-energized Secondary Primary Overhead Underground

  • Energized
  • De-energized
  • Secondary
  • Primary
  • Overhead
  • Underground

• Equipment

  Select Bucket Derrick Underground Trencher Excavator Backhoe Pick-up Compressor Puller/Tensioner Other

  • Bucket
  • Derrick
  • Underground
  • Trencher
  • Excavator
  • Backhoe
  • Pick-up
  • Compressor
  • Puller/Tensioner
  • Other

• Details of Job

PPE

• Hard Hat(s)

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Protective Footwear

  Yes

  No

  N/A

• Hand Protection

  Yes

  No

  N/A

• Rubber Gloves

  Yes

  No

  N/A

• Rubber Sleeves

  Yes

  No

  N/A

• Gloves and Sleeves have Current Test Date

  Yes

  No

  N/A

• Appropriate Cover Up

  Yes

  No

  N/A

• Fall Protection

  Yes

  No

  N/A

• Live Line Tools Used

  Yes

  No

  N/A

• Current Test Date on Live Line Tools

  Yes

  No

  N/A

• Hand Line is in Good Condition

  Yes

  No

  N/A

• Chaps used when running chainsaw?

  Yes

  No

  N/A

Job Preparation

• Job Briefing Documented Prior to Work

  Yes

  No

  N/A

• Breaker on One Shot

  Yes

  No

  N/A

• Lock Out Tag Out

  Yes

  No

  N/A

Grounding

• Truck Grounded to Main Line Neutral

  Yes

  No

  N/A

• Personal Grounds Used

  Yes

  No

  N/A

• Current Test Dates on Grounds

  Yes

  No

  N/A

• Grounds are Properly Stored

  Yes

  No

  N/A

Traffic Control

• Beacon/Strobe

  Yes

  No

  N/A

• Four Way Flashers

  Yes

  No

  N/A

• Reflective Traffic Vests

  Yes

  No

  N/A

• Cones Adequate

  Yes

  No

  N/A

• Signs Adequate

  Yes

  No

  N/A

• Flagger(s)

  Yes

  No

  N/A

• Paddles

  Yes

  No

  N/A

• Proper Communication Means for Flaggers

  Yes

  No

  N/A

Hand Tools

• Tools in Good Condition

  Yes

  No

  N/A

• Appropriate Guards/Covers on Tools

  Yes

  No

  N/A

• Tools Properly Stored

  Yes

  No

  N/A

• Chainsaw is Properly Stored

  Yes

  No

  N/A

• Chainsaw Bar is Completely Covered

  Yes

  No

  N/A

• Chainsaw Fuel Properly Labeled

  Yes

  No

  N/A

Vehicle and Trailer

• Daily Pre and Post Trip

  Yes

  No

  N/A

• Two Wheel Chocks Available and Used

  Yes

  No

  N/A

• Outrigger Pads Available and Used

  Yes

  No

  N/A

• Vehicle has Appropriate Fire Extinguishers

  Yes

  No

  N/A

• First Aid Kit is Properly Stocked and Checked Weekly

  Yes

  No

  N/A

• AED is in Proper Working Condition and is Checked Monthly

  Yes

  No

  N/A

• Chain and Binders on Trailer are Correct Grade and in Good Condition

  Yes

  No

  N/A

• Winch Lines are not Damaged or Frayed

  Yes

  No

  N/A

Signatures

• Comments

• Inspected By

• Crew Supervisor Signature

  Sign