Information
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Supervisor
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Foreman
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Date
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Job No.
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Location
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Prepared by
Daily Safety & Pre-Task Planning
Daily Safety & Pre-Task Planning
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Are Daily Safety & Pre-Task Planning forms being completed?
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Is the work being done matching the form?
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Why is not being completed?
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Daily huddle completed?
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Employee Comments
Comments
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Name
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Comments
Emergency
Emergency Plan
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Do employees know of the emergency plan?
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911 Confirmation
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Clinic/Hospital Location
New Employees
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Jobsite Orientation
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Integration
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New Employee Concerns
Concerns
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Name
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Concern
New Employee
New Employee
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Have you completed job site orientation?
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Are you being welcomed in/how are you fitting in?
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Do you have any concerns?
New Employee
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Have you completed job site orientation?
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Are you being welcomed in/how are you fitting in?
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Do you have any concerns?
New Employee
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Have you completed job site orientation?
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Are you being welcomed in/how are you fitting in?
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Do you have any concerns?
TPR
TPR (Open Ended Questions)
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Issues and Concerns?
Comment
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Describe
Machinery
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Lubricated?
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Clean?
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Seat belt?
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Safety equipment?
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Any issues with One Call or Operator Care?
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Explain
Locates
Overhead
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Power Lines
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How far away (in ft.)?
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Phone Lines?
Underground
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Power Lines
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How far away (in ft.)?
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Phone Lines?
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Fiber-optics?
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Gas lines?
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Water Lines?
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Sewer Lines?
Traffic Control
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Designated employee parking?
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Picture
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Suggestions for parking spots
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Picture
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Pedestrian Traffic Areas designated and guarded?
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Picture
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Haul Routes and/or Traffic Pattern in place?
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Work zone signing/traffic control manual in place?
Trench Safety
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Type of Soil Present
Which types? (check all that apply)
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A
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B
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C
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Is the trench safe?
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Picture
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Ladders within 25ft of employees?
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Are employees aware of the rescue plan?
Control of Hazardous Energy
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Lock-out/tag-out procedures in place?
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Add media
Wiring, Hoses, Jacks, Vessels
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Problems
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Describe any problems, if applicable
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Photos, if applicable
Chains and Slings
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Chains and Slings
Equipment
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What is the condition of the chains/slings?
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Photos
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Have the chains/slings been inspected and certified within the last year?
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Date of last inspection
Employees
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Are employees operating within the danger zone/swing zone of equipment?
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Are employees aware of danger zone/swing zone?
Fire Safety
Extinguishers
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Extinguisher
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Serial #
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Date of last inspection
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Are extinguishers clearly marked?
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Are extinguishers free from material in front and around of them?
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Do employees know how to use extinguishers? (P.A.S.S. method)
Gas cylinders
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Are cylinders stored properly?
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Photo
Sprinklers
Security
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Is equipment being locked when not in use?
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Are keys being left in equipment?
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Are security systems online?
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Is the address from the security system current?
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Are job trailers (QC, main trailer, parts trailer) being locked when not in use and/or occupied?
Select all that apply
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QC
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Parts trailer
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Main trailer
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Generator trailer
PPE
Are employees wearing....?
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Safety Vests?
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Are the vests in good condition (clean, reflective material visible, etc.)?
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Safety glasses?
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If grinding/cutting, are face shields also being worn?
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Hearing protection (if required)?
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Hard hats?
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Are hard hats free from nicks, gouges, and is suspension inside hard hat adjusted properly?
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Sun protection? (sunscreen, UV protective clothing)?
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Seat belts on equipment being worn?
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Fall protection (if required)?
Chain Saw Safety (if applicable)
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Chaps being worn and fitted properly?
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Hard hat?
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Face shield and safety glasses being worn?
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Hearing protection?
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Gloves being worn?
Power/Hand Tools
Tool
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Tool
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Name of Tool
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Proper Guarding on Tool?
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Exterior Damage?
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Describe
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Picture
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Are cord(s) cut, frayed, damaged?
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Describe
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Picture
PPE
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Proper PPE worn? (select all that apply)
- Respirator
- Safety Glasses
- Face Shield
- Gloves
- Chaps
- Hearing Protection
- Safety toed shoes
Erosion Control
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Erosion control measures in place?
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Following SWPPP?
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Photos
Previous Job Site Inspection
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Date of Last Job Site Inspection
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Name of Supervisor
Cell Phone usage
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Do employees have cell phones on their person?
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Are cell phones being used during work hours?
Finalization
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Executive Safety Committee Member
- Trevor Duininck
- Chris Duininck
- Jason Duininck
- Judd Duininck
- Rick Maursetter
- Jeff Rettig
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Select date
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Add signature
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Supervisor
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Select date
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Received copy?
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Add signature