Title Page
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Company Name
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Location
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Date
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Project #
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Prepared by
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Project Manager
On Site Contact
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On site contact name
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Is worker working alone?
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Form of contact
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Duration of contact is every 30 minutes from arrival on-site to leaving site.
Personal Injury Hazards
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Identify the tasks and hazards below, and plans to eliminate/control these hazards
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Hazards
- Heavy Lifting/Mounting
- Drilling/Cutting (into wall/table/etc)
- Working on Ladder
- In Ceiling Obstructions/Work
- Working at Heights (Scissor Lift, Scaffold)
- Running Cables/Cable Management
- Tripping Hazards
- Hot Work (Solder)
- Confined Space
- Dust/Air Particles
- Hazardous Substances (Asbestos)
- Noise
- Electrical
- Weather (Hot/Cold)
- Heavy Machinery
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Other Hazards
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Controls for Hazards
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PPE Required
- None
- Steel Toe Boots
- Hard Hat
- Safety Glasses
- Safety Vest
- Gloves
- Fall Protection
- Other (Note Below)
Room Assessment
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Identify any hazards that can damage client's property.
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Is the room clean and clear of hazards when you first entered to room?
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Hazards
- Falling objects (ex/ Ladder, chairs, items on table/shelf...)
- Tools/hardware on table.
- Mutiple chairs in room.
- Small space. Limited room to stage tools/new hardware.
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Other Hazards
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Controls for Hazards
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Asset protection requirements
- None
- Furniture Blankets
- Removal of furniture from room
- Bubble wrap/shrink wrap
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Any existing damage to room or client's property? Check walls, furniture and existing equipment.
Incident Report
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Was there any incidents/injuries?
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Was the incident report filled out?
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Explain
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Date incident report was filled out
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Incident report submitted to
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Photos of the incident
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Upload or photo of incident report.
Worksite Cleanup
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Is the job complete?
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Is the worksite cleaned?
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Explain
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Garbage/Recycling removed
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Displays cleaned
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Touched surfaces cleaned/disinfected
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Tools removed
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Equipment List updated
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Pictures uploaded to Trello
Signatures
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Please print and Sign Below (All members of the crew) prior to commencing work.
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Add signature
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Add signature
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Add signature
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Add signature
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Add signature
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Add signature
