Crew

Assessor

First name

Last name

Payroll ID number

Co-assessor
Co-assessor

First name

Last name

Payroll ID number

Crew lead
Crew lead

First name

Last name

Payroll ID number

Crew
crew

First name

Last name

Payroll ID number

Work specifications

Department

Other department

Division

Planning

Work type

Work hazard

Work task

Other work task

Field assessment

Cardinal Rule

Unacceptable

Permitting / Clearing / Lockout & Tagout
Grounding / Barricading
Rubber Gloves and Sleeves
Rubber Cover-Up
Fire Retardant Clothing
Enclosed / Confined Space Entry
Sheeting, Shoring, Trenching
Fall Protection
Gas Control Device Tag
Static Reduction / Venting & Purging
Personal Protective Equipment
Head, Eye, Face, Footwear, Hand
Flame. retardant Clothing
Hi - Viz Traffic Vest
Rubber Protective Equipment
Fall Protection
Repertory Protection
Hearing Protection
Rescue Equipment
Personal Flotation Device
O2 meter / Combustible Gas Indicator
Safe Work Practices and Safe Behavior
Tailgate completed and signed by Crew
Job site set up - signs / barricades
General vehicle set up - chocks
Work zone set up - signs / flaggers
Proper use of tools / equipment
Slip / trip / fall prevention
Climbing - ascending / descending
Safety procedure competence
Work procedure competence
Focused - safe work attitude
Awareness to line of fire
Awareness if pitch points
Eye on path / eyes on task
Body mechanics
Lifting / carrying
Pushing / pulling
Bending / reaching
3 point contact

Extended field assessment

Vehicle inspection
DOT log / registration / insurance card
Drives license / medical card
Lights / mirrors / boom / back up alarm
Fire extinguisher
First aid kit - inspected semi annually
Fire blanket
Protective rubber goods
Compressed gas bottles
Housekeeping
Tools and equipment
Ladders
Slings / hoisting equipment
Portable tools
Hydraulic and pneumatic tools
Hot stick / live line tools
Portable grounds
Rescue equipment / bucket escape
Climbing equipment
Hazardous material storage / labeling

Review questions

Acceptable

Unacceptable

Remarks

Manager name

Date
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.