Title Page

  • Company Name

  • Location
  • Date

  • Project #

  • Prepared by

  • Project Manager

On Site Contact

  • On site contact name

  • Is worker working alone?

  • Form of contact

  • Duration of contact is every 30 minutes from arrival on-site to leaving site.

Personal Injury Hazards

  • Identify the tasks and hazards below, and plans to eliminate/control these hazards

  • Hazards

  • Other Hazards

  • Controls for Hazards

  • PPE Required

Room Assessment

  • Identify any hazards that can damage client's property.

  • Is the room clean and clear of hazards when you first entered to room?

  • Hazards

  • Other Hazards

  • Controls for Hazards

  • Asset protection requirements

Incident Report

  • Was there any incidents/injuries?

  • Was the incident report filled out?

  • Explain

  • Date incident report was filled out

  • Incident report submitted to

  • Photos of the incident

  • Upload or photo of incident report.

Worksite Cleanup

  • Is the job complete?

  • Is the worksite cleaned?

  • Explain

  • Garbage/Recycling removed

  • Displays cleaned

  • Touched surfaces cleaned/disinfected

  • Tools removed

  • Equipment List updated

  • Pictures uploaded to Trello


  • Please print and Sign Below (All members of the crew) prior to commencing work.

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.