Crew Observation Form - Underground

• Document No.

• UPC Crew Observation Form

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Crew Information

• Date

  Date

• Crew Foreman

• Qualified Designated Observer for Job

• 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

  • 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

• 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

• Live Line Tools Used

  Yes

  No

  N/A

• Current Test Date on Live Line Tools

  Yes

  No

  N/A

• All PPE inspected/tested before use?

  Yes

  No

  N/A

Job Preparation

• Job Briefing Documented Prior to Work

  Yes

  No

  N/A

• Lock Out Tag Out Implemented

  Yes

  No

  N/A

Grounding

• 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

• Four Way Flashers

  Yes

  No

  N/A

• Reflective Traffic Vests

  Yes

  No

  N/A

• Cones Adequate

  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

Vehicle and Trailer

• Two Wheel Chocks Available and Used

  Yes

  No

  N/A

• Vehicle has Appropriate Fire Extinguishers

  Yes

  No

  N/A

• Fire extinguishers are checked monthly

  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 Weekly

  Yes

  No

  N/A

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

  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