Title Page

  • Conducted on

  • Project #

  • Location
  • Personnel

  • Prepared by and Title

  • Has the lane closure supervisor observed the sight location before beginning work, lane closures, sign placement, flagger placement, and positioning the equipment.

What did you discuss in your daily huddle? Warnings, job to be done etc.

Is the truck loaded so there is NO chance of material falling in the highway? This means NOTHING. Loaded above the work bins. Is the back of the truck free of trash that could blow off the truck?

Have you done a JSA “ Job Safety Analysis” for this job?

Before work begins, have you completed, and sent Lindy your daily Huddle ?

  • Do you have your encroachment agreement with you ?

REMEMBER...AS OF JULY 2018, SPEED LIMIT 55 AND ABOVE “ REQUIRES “ EVERYONE HELPING SET THE LANE CLOSURE MUST BE CERTIFIED.THIS IS A TOTALY DIFFERENT CLASS FROM FLAGGER CERTIFICATION. NO EXCEPTIONS...EVERYONE, EVEN GREEN HATS !

AS OF 2018..ALL STOP✋ 🛑 SLOW FLAGGER SIGNS MUST BE 24 NOT 18 ! Are yours?

Do we have proper taper, warning signs out, and proper lane closure.

Do employees have the proper training, and certification to operate any machinery to be used today?

We're drivers told to never back up without a spotter?

Do you understand, ALL cutting must be wet cuts?

Are the flaggers to be used today trained, and certified?

Is the Federal inspection current on the truck. This is the sticker on the vent window of the drivers door.

Is the federal inspection current on the pole trailer ?

Are wheels chocked, and proper padding under outriggers?

Did you make it clear employees are NOT allowed to ride in the bucket while the truck is moving?

Do we have a experienced spotter in a safe position to spot for our man in the bucket. Especially at busy intersections with truck traffic.

Did you tell the crew to tape off, covering up, or remove anything that could in anyway be a potential hazard to the public while on the job, or between shifts?

Have we checked all equipment we are using today to make sure it is safe, and ready to use?

Potential hazards associated with the work to be done). Write in your own specific hazard if it is not listed below. Check all that apply for the task to be completed today. Check marking the potential hazard below means you have discussed all safety measures to be taken that will eliminate, or control the potential hazard.

  • Falls

  • Lockout Tagout

  • Electrical hot work

  • Electrical Hazards

  • Manual Lifting

  • Ladders

  • Cadweld

  • Aerial/Scissor Lifts

  • Dust/Fumes

  • Forklift

  • Power Tools

  • Chemical Hazards (SDS)

  • Cranes

  • Rigging

  • Powder Actuated Tools

  • Excavation/Trenching

  • Underground Utilities

  • New or Temporary Employees

Personal Protective Equipment (PPE) and safety measures necessary to eliminate or protect employees

  • Hard Hat

  • Safety Glasses

  • Safety Goggles

  • Face Shield

  • Cut Resistant Gloves

  • Hard Toe Work Boots

  • Proper class 2 or class 3 Hi-Visibility Vest

  • Confined Space Permits

  • Excavation Permit

  • Electrical Hot Work Permit

  • Equipment Inspection Sheet

  • Fall Protection

  • Tool Inspection

  • Monthly/Quarterly Color Code

  • Work Permits

  • Hearing Protection

List additional safety concerns within our work areas (Ex. Other trades, equipment operation, material storage, accessing work location, permit requirements, utility locates, etc)

List any unusual conditions or hazards that could affect today's work ( Ex. Heat, high winds, rain, crane operation, etc)

All PPE (gloves, hard hats, safety glasses, ear plugs, safety harnesses etc.) are in good repair and being utilized by everyone on site. It is understood that all fall protection measures are in place and this certifies that I understand and agree to follow Watson Electrical guidelines which state Conventional Fall Arrest and Fall Restraint Systems shall be utilized where the exposure to falls greater than 6 foot is reasonably foreseen.

Print everyone’s name below on your crew and have them sign it.

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.