Title Page
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Foreman & Job Number
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Safety Representative
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Date (Clock In)
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Date (Clock Out)
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Location
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Weather
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Scope Of Work
1.0 Workplace
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1.1 - Code 753 (Mark Outs)
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1.2 - Competent Person
2.0 Administrative
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2.1 - Documentation of Job Briefing
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2.2 - HASP On-Site & Current
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2.3 - Air Monitor In Use, Calibrated, Current & Readings Documented
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2.4 - Current Permits Posted & Visible
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2.5 - Burn Gel In Truck & Within Expiration
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2.6 - First Aid Kit/Blood Bourne Pathogen Kit On-Site & Current
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2.7 - Spill Kit On-Site
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2.8 - Fire Extinguisher Visible, Current, & Immediately Available
3.0 Work Area Protection /PPE
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3.1 - Flagger Present
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3.2 - Barricades/Cones/Stanchions Complete & In Compliance
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3.3 - MUTCD Signs In Use Where Required
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3.4 - Arrow Board Operating & In Use When Applicable
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3.5 - Pedestrians Provided With a Safe & Clear Path Of Travel
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3.6 - Plates Pinned, Ramped, Flush, Skid Resistant, & In Complete Compliance
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3.7 - Slings & Chains In Good Condition
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3.8 - Rubber Electrical Gloves (KV) Dated With Expiration Date
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3.9 - Proper PPE In Use When Required
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3.10 - Fall Protection Where Required
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3.11 - Wheels Chocked When Truck On Standby (Driver Not In Cab)
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3.12 - All Tools In Good Condition
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3.13 - Compressor Check Valves/Whip Checks In Place
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3.14 - Housekeeping In Place On-Site & In Trucks To Prevent Slips, Trips & Falls
4.0 Excavation
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4.1 - Spoils & Equipment 2' Away From Excavation
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4.2 - Gas Monitoring Where Required
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4.3 - Ladders Used At 4' Depth Or Greater & Extending 3' Above Landing
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4.4 - Ladders In Place Every 25' Of Lateral Travel
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4.5 - Shoring/Sheeting At 4'6" Or Greater Or When Required
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4.6 - Daily Excavation Inspection Conducted
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Notes/Other:
Sign Off
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CP Signature (Clock In/Out)
