Crew Observation Form

• Job Type

  Construction

  Maintenance

  Outage

  General

• Conducted on

  Date

• Prepared by

• Location
  Address

• John Coleman

• Andy Barnett

• Andy Hudson

• Jimmy Sutter

• Kyle Schneider

• Tanner Gordon

• Cole Kizer

• Andy Augspurg

• Ross Hein

• Josh Hirner

• Jacob Kumm

• Rob Bush

• Dale Peter

Inspection

• Work Performed

• Is work being performed on energized lines

  Yes

  No

  N/A

• Minimum approach distances observed

  Yes

  No

  N/A

• Vehicles grounded

  Yes

  No

  N/A

• Proper PPE in use

  Yes

  No

  N/A

• Hotline Tag

  Yes

  No

  N/A

• Proper Coverup Installed

  Yes

  No

  N/A

• Qualified Observer in Place

  Yes

  No

  N/A

• Was proper lock out/tag out procedure completed

  Pass

  Fail

  N/A

• Are proper grounds in place

  Pass

  Fail

  N/A

• Job briefing completed and hazards reviewed

  Yes

  No

  N/A

• Work zone and traffic control

  Pass

  Fail

  N/A

• Trenching and excavation meets guidelines

  Yes

  No

  N/A

• Chocks, outrigger pads, cones, lights for safety

  Yes

  No

  N/A

• Employees are clear of equipment when in the vicinity of energized lines

  Yes

  No

  N/A

• Are loads properly secured

  Yes

  No

  N/A

PPE Checklist

• Hard Hats

  Pass

  Fail

  N/A

• Eye Protection

  Pass

  Fail

  N/A

• Hearing Protection

  Pass

  Fail

  N/A

• Rubber Gloves

  Pass

  Fail

  N/A

• Rubber Sleeves

  Pass

  Fail

  N/A

• Fall Protection

  Pass

  Fail

  N/A

• Leather Gloves

  Pass

  Fail

  N/A

Additional Information and Pictures

• Additional Information

• Picture 1

  Media

• Picture 2

  Media

• Picture 3

  Media

• Picture 4

  Media