Title Page
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Foreman / Job Number
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Safety Representative
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Date
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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- Inspector
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1.3- Competent Person
2.0 Administrative
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2.1- Documentation of Job Briefing
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2.2- Certifications, Certificates of Fitness, & Training Cards
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2.3- Air monitor in use & calibrated
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2.4- Current HASP on-site
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2.5- Current permits posted & visible
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2.6- Burn Gel in Truck & within Expiration Date
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2.7- First Aid Kit/Blood Bourne Pathogen Kit on-site & current
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2.8- Spill Kit on-site
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2.9- Fire extinguisher visible, current, & immediately available
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2.10- CEHSP 13.00 Excavation Procedures
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2.11- Current RWLB matrix posted
3.00 Work Area Protection
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3.1- Flagger present with advanced warning signs
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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 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- Fall Protection when Required
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3.8- Slings & chains in good condition
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3.9- KV Gloves dated & within expiration
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3.10- Proper PPE in use when required
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3.11- Vehicle’s Engine turned off (Idling regulations)
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3.12- Wheels Chocked when truck on standby
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3.13- Compressor Check Valves / Whip Checks in Place
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3.14- All Tools in Good Shape
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3.15- Housekeeping
4.00 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 and 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 when required
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4.6- Daily excavation Inspection conducted
Sign off
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On- site Representative
