Goodfellow Trench Inspection and Entry Authorization Form

• Job #

• Conducted on

  Date

• Weather Conditions

• Approximate Temperature

• Competent Person

• Responsible Person

• Location
  Address

Soil Classification

• Soil Type

  Select Type A Wet Type A Dry Type B Wet Type B Dry Type C Wet Type C Dry

  • Type A Wet
  • Type A Dry
  • Type B Wet
  • Type B Dry
  • Type C Wet
  • Type C Dry

• Tested

  Yes

  No

  N/A

• Manual Test Performed

  Select Plasticity Dry Strength Thumb Penetration

  • Plasticity
  • Dry Strength
  • Thumb Penetration

Dimensions

Top

• Width

• Length

Bottom

• Width

• Length

• Depth

ACCESS/EGRESS & PROTECTION METHODS ARE REQUIRED

Ladder locations

• Located in protected area

  Yes

  No

  N/A

• Within 25' of safe travel for employee

  Yes

  No

  N/A

• Secured/Tied Off

  Yes

  No

  N/A

• Extends 36" above landing / top of trench

  Yes

  No

  N/A

Protection Methods

• Are walls vertical, uneven / irregular, or sloped?

  Vertical

  Uneven, Irregular

  Sloped

• Shoring Method

  Timber

  Pneumatic

  Hydraulic

  Screw Jacks

  Trench Shield (not more than 2' above bottom)

• Shoring equipment and materials inspected

  Yes

  No

• Trench Box (Not more than 2' above bottom)

• Shoring equipment and materials inspected

  Yes

  No

• Sloping

  3/4:1

  1:1

  1 1/2:1

  2:1

ENGINEERED PROTECTION METHOD IS REQUIRED

Environmental Conditions

• 4-Gas Detector Used

  Yes

  No

  N/A

• Confined space permit issued

  Yes

  No

  N/A

• Tri-pod used

  Yes

  No

  N/A

• Blower

  Yes

  No

  N/A

Hazardous Conditions

• Saturated soil / standing or seeping water

  Yes

  No

• Cracked or fissured wall(s)

  Yes

  No

• Bulging wall(s)

  Yes

  No

• Traffic control required

  Yes

  No

• Vibration (Traffic or otherwise)

  Yes

  No

• One call locates completed

  Yes

  No

  N/A

• Are utilities protected

  Yes

  No

  N/A

• Frozen soil

  Yes

  No

• Previously disturbed soil

  Yes

  No

Placement of spoils & equipment

• Spoils at least 2' from edge of trench

  Yes

  No

  N/A

• Equipment at least 2' from edge of trench

  Yes

  No

  N/A

• Equipment at end of trench

  Yes

  No

  N/A

• Compressor or other engines at remote locations - no exhaust directed towards trench

  Yes

  No

  N/A

Other

• Is trench safe to enter

  Yes

  No

• AHA / JHA or Safety Meeting discussed prior to start of work?

  Yes

  No

• Take picture of forms.

  Media

• Excavation Entry Authorized By (Competent Person)

  Sign