Field safety assessment

• Date

  Date

• Cost center

• District

• Region

  ACE

  DPL

  PEPCO

  GAS

• Shift

  Day - B

  Night - A

  Middle - C

  Overtime

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

• Department

  Select overhead / URD underground substation F O & R relay / Testing communications meter services Gas VRM / Stores / Facilities Other. list below

  • overhead / URD
  • underground
  • substation
  • F O & R
  • relay / Testing
  • communications
  • meter services
  • Gas
  • VRM / Stores / Facilities
  • Other. list below

• Other department

• Division

  electric Utility Operations

  Gas Construction/Service/Operations

  Shared Services

  Customer Care - Meter Technician

• Planning

  Scheduled Work

  Unscheduled Work

  Emergency Work

  Storm Work

• Work type

  Repair

  Maintenance

  Inspection

  New Construction

• Work hazard

  Energized Primary

  Energized Secondary

  De-energized Grounded

  Enclosed Space / Confined Space

  Combustable Atmosphere

• Work task

  Select Install / Repair Equip. Pulling Wire Switching Wire / Cable Climbing / Tower Digging / Trenching Shop / Yard Work Leak Repair Sample / Test / Service Other, list below

  • Install / Repair Equip.
  • Pulling Wire
  • Switching Wire / Cable
  • Climbing / Tower
  • Digging / Trenching
  • Shop / Yard Work
  • Leak Repair
  • Sample / Test / Service
  • Other, list below

• Other work task

Cardinal Rule

• Unacceptable

• Permitting / Clearing / Lockout & Tagout

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Grounding / Barricading

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Rubber Gloves and Sleeves

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Rubber Cover-Up

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Fire Retardant Clothing

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Enclosed / Confined Space Entry

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Sheeting, Shoring, Trenching

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Fall Protection

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Gas Control Device Tag

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Static Reduction / Venting & Purging

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

Personal Protective Equipment

• Head, Eye, Face, Footwear, Hand

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Flame. retardant Clothing

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Hi - Viz Traffic Vest

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Rubber Protective Equipment

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Fall Protection

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Repertory Protection

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Hearing Protection

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Rescue Equipment

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Personal Flotation Device

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• O2 meter / Combustible Gas Indicator

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

Safe Work Practices and Safe Behavior

• Tailgate completed and signed by Crew

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Job site set up - signs / barricades

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• General vehicle set up - chocks

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Work zone set up - signs / flaggers

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Proper use of tools / equipment

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Slip / trip / fall prevention

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Climbing - ascending / descending

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Safety procedure competence

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Work procedure competence

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Focused - safe work attitude

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Awareness to line of fire

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Awareness if pitch points

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Eye on path / eyes on task

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Body mechanics

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Lifting / carrying

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Pushing / pulling

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Bending / reaching

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• 3 point contact

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

Vehicle inspection

• DOT log / registration / insurance card

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Drives license / medical card

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Lights / mirrors / boom / back up alarm

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Fire extinguisher

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• First aid kit - inspected semi annually

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Fire blanket

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Protective rubber goods

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Compressed gas bottles

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Housekeeping

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

Tools and equipment

• Ladders

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Slings / hoisting equipment

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Portable tools

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Hydraulic and pneumatic tools

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Hot stick / live line tools

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Portable grounds

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Rescue equipment / bucket escape

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Climbing equipment

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Hazardous material storage / labeling

  Select A 1 2 3 4 5 N/A

  • A
  • 1
  • 2
  • 3
  • 4
  • 5
  • N/A

• Acceptable

• Unacceptable

• Remarks

• Manager name

• Date

  Date