Gerstner Electric, Inc.

• GEI Job Number

• Conducted on

  Date

• Prepared by

• Location
  Address

• Project Manager

• Job Foreman

Pre Task Planning/JSA/Delineation of Jobsite

• Is the Daily JSA Filled Out or signed if weekly?

  Yes

  No

  N/A

• Job steps, hazards and controls identified

  Yes

  No

  N/A

• Is the excavation permit signed ?

  Yes

  No

  N/A

• Are the Controls Listed on the JSA being Adhered to?

  Yes

  No

  N/A

Tools and Equipment

• Tools and equipment in good condition

  Good

  Fair

  Poor

  N/A

• Whip checks in place on air hoses

  Yes

  No

  N/A

• Pins in place on air hoses

  Yes

  No

  N/A

Material Handling/Rigging

• Workers know and use proper crane signals?

  Yes

  No

  N/A

• Rigging/Lifting equipment in good condition and inspected

  Safe

  At Risk

  N/A

• Workers attach tag lines to loads?

  Safe

  At Risk

  N/A

Electric tools and extension cords

• Are electric tools and extension cords double insulated and has no visible signs of damage?

  Safe

  At Risk

  N/A

• Do electric tools and extension cords have a grounding conductor?

  Safe

  At Risk

  N/A

• Electrical equipment connected properly and use of GFCI?

  Safe

  At Risk

  N/A

• Are hand drills equipped with side handle?

  Yes

  No

  N/A

Heavy Equipment

• Fire extinguisher secure and in working order?

  Safe

  At Risk

  N/A

• Seatbelt worn during operation

  Safe

  At Risk

  N/A

• Backup alarm operable & can be heard over surrounding noise?

  Yes

  No

  N/A

• Ground guide/spotter being used if needed?

  Yes

  No

  N/A

• Any visible damage to equipment?

  Safe

  At Risk

  N/A

• Is cargo secure and tie-down components in good condition?

  Yes

  No

  N/A

Personal Protective Equipment

• Hard Hats in use by all personnel

  Yes

  No

  N/A

• Proper eye protection in use by all personnel

  Yes

  No

  N/A

• Hearing protection in use. Rule of thumb: If standing 5' or more apart and you have to raise your voice to communicate hearing protection is needed

  Yes

  No

  N/A

• Proper footwear (Safety Toed Work Boots)

  Yes

  No

  N/A

• Class II reflective vest/shirts worn by all employees

  Yes

  No

  N/A

• Respirators/face masks used as required (Medical evaluation and fit test)

  Yes

  No

  N/A

Hazardous Chemicals/Air Contaminants

• OSHA Table 1/or GEI Silica Controls in place?

  Safe

  At Risk

  N/A

• Safety Data Sheets onsite

  Safe

  At Risk

  N/A

• Proper containers in use with correct SDS/GHS labels

  Safe

  At Risk

  N/A

General Safety/ Behavioral Factors

• Hands/ body safe from line of fire/pinch points?

  Safe

  At Risk

  N/A

• Not lifting over 50 lbs. without help

  Yes

  No

  N/A

• Entering/Exiting vehicles using 3 points of contact

  Safe

  At Risk

  N/A

• Good housekeeping and material storage

  Good

  Fair

  Poor

  N/A

• Barricades/debris protection/ warning signs in place

  Good

  Fair

  Poor

  N/A

• Excavation, manhole, pull box covered or barricaded?

  Safe

  At Risk

  N/A

• Is the work area properly demarcated/blocked off to prevent injury/entry of the public?

  Yes

  No

  N/A

• Fire extinguisher; Good condition; current inspection tag; within 50'

  Yes

  No

  N/A

• Flammables stored and handled in approved containers?

  Safe

  At Risk

  N/A

• Are ladders used for the manufacturers intended purpose?

  Safe

  At Risk

  N/A

Temporary Traffic Control

• Are advance warning signs in place and at proper spacing?

  Yes

  No

  N/A

• Correct TTC device spacing along taper and tangent?

  Good

  Fair

  Poor

  N/A

• Condition and uniformity of channelizing devices

  Good

  Fair

  Poor

  N/A

• Condition of signs, cones, channelizers, etc

  Good

  Fair

  Poor

  N/A

• Traffic moves smoothly around TTC zone?

  Safe

  At Risk

  N/A

• Pedestrians have a safe route to walk?

  Safe

  At Risk

  N/A

• Are SIDEWALK CLOSED signs in place?

  Yes

  No

  N/A

• Are flagging operations being conducted per MUTCD standards?

  Good

  Fair

  Poor

  N/A

Fall Protection

• Are employees protected from falls 6' or greater?

  Yes

  No

  N/A

• Are employees properly wearing fall protection devices?

  Safe

  At Risk

  N/A

• Are employees properly tied off? No 6 ft. lanyards in bucket truck?

  Safe

  At Risk

  N/A

• Fall protection equipment in proper working order?

  Safe

  At Risk

  N/A

Trenching and Excavation

• Was the soil classification determined and is the classification correct?

  Safe

  At Risk

  N/A

• Are soil piles, tools, and equipment stored 2' or more from the edge of the excavation?

  Safe

  At Risk

  N/A

• Are ladder rungs 3' above the landing surface?

  Safe

  At Risk

  N/A

• Is access and egress provided every 25' of lateral movement when the excavation/trench reaches 4' in depth?

  Safe

  At Risk

  N/A

• Is the excavation/trench properly protected at 5' in depth?

  Safe

  At Risk

  N/A

Confined Space Operations

• Are the proper permits in place?

  Yes

  No

  N/A

• Are barricades up to protect the workers and public?

  Yes

  No

  N/A

• Are these items at the site-Tripod with rescue winch, Air Blower, 4 Gas Monitor, Barricade with signage?

  Yes

  No

  N/A

Paperwork and other Postings

• Signature

  Sign

• Additional Notes