Title Page
-
Conducted on
-
Project Name
-
Project Number
-
Project Address
Basic Information
-
Area Work Being Performed (e.g. 5th Floor Rooms 101-123, Basement Electrical Room, Rooftop Air Handler #256, etc.)
-
Basic Description of Work Being Performed (e.g. installing pipe rack, mounting electrical panel, pulling wire, etc.)
-
Area Work Being Performed (e.g. 5th Floor Rooms 101-123, Basement Electrical Room, Rooftop Air Handler #256, etc.)
-
Basic Description of Work Being Performed (e.g. installing pipe rack, mounting electrical panel, pulling wire, etc.)
-
Area Work Being Performed (e.g. 5th Floor Rooms 101-123, Basement Electrical Room, Rooftop Air Handler #256, etc.)
-
Basic Description of Work Being Performed (e.g. installing pipe rack, mounting electrical panel, pulling wire, etc.)
How is the Work Being Performed (list detailed step-by-step process to get the work completed)?
-
Describe (in detail) the steps to complete the work task (e.g. step 1 - gather tools and materials, step 2 - identify area to drill anchors, step 3 - drill holes in concrete deck, step 4 - set concrete anchors using set tool, etc.)
Potential Work Hazards
-
Housekeeping issues
-
Fall exposure
-
Ladder work
-
Electrical shock hazard
-
Underground utilities
-
Overhead power lines
-
Potential for particles in the eye/face
-
Working from scaffolding
-
Overhead work
-
Falling/dropped objects
-
Drilling, cutting, grinding concrete
-
Other silica exposure
-
Slip, trip, fall hazard
-
Fire hazard
-
Potential for cuts or lacerations
-
Trench/excavation hazards
-
Heat/cold hazards
-
Insufficient lighting
-
Potential to get caught in or in-between objects/equipment
-
Lead/asbestos exposure
-
Overhead crane hazard
-
Chemical exposure
-
Overexertion
-
Other Hazard (list all additional hazards identified, not on this list)
Steps to Ensure Worker Safety
-
Clean up area prior to work
-
Provide adequate task lighting
-
Have fire extinguisher ready and available
-
Inspect tools and equipment
-
Inspect ladders
-
Inspect PPE
-
Use a scissor lift
-
Use appropriate size ladder for the job
-
Use scaffolding
-
Use man lift/boom lift
-
Utilize fall protection equipment
-
Install/use guard rails
-
Set up cones or barricades
-
Use caution or danger tape
-
Use proper tools for the task
-
Use GFCI cords or devices
-
Use adequate sloping for excavation work
-
Use trench box
-
Utilize lifting aids (chain falls, roustabout, duct lift, etc.)
-
Utilize forklift or pallet jack
-
Get help or assistance
-
Use rope to haul up tools/materials
-
Tether or tie off tools and equipment (dropped object protection)
-
Use personal fall arrest system (harness, lanyard, yo-yo/rope/lanyard, anchor point)
-
Use proper PPE for hazard (hard hat, safety glasses, gloves, face shield, arc-flash suit, hearing protection, etc.)
-
Exercise STOP WORK AUTHORITY
-
Other protective system or device/equipment (describe)
-
Specialized or additional training (describe)
-
Additional resources (e.g. get safety involved, notify GC, ask for assistance, etc.)
Administrative Controls
-
Pre-Job Briefing Completed
-
Energized Electrical Permit Completed
-
Hot Work Permit Completed (for open flames/sparks)
-
Confined Space Permit Completed
-
Utilities Located and Marked
-
Crane Pick Plan Completed
-
SDS Reviewed
-
Fall Protection/Rescue Plan Reviewed
-
Signs Posted
-
Site-Specific Orientation Completed
-
Other Administrative Control
Crew Information
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
-
Employee Name
-
Employee Signature
Additional Information/Notes
-
Permits closed out and turned in?
-
Were there any near misses observed/reported today?
-
Describe the near miss
-
Was it reported to the Safety Manager?
-
Were there any accidents/injuries today?
-
Describe the accident/injury
-
Was it reported to the Safety Manager?
-
List Any Additional Information, Questions, Comments
-
Superintendent Name
-
Superintendent Signature
