• Cooperative name:

  • Auditor(s) name:

  • Date/Time:


  • Jobsite location:

  • Name of foreman in charge:

  • Crew members:

  • Describe type of work being performed:

  • Are lines energized or de-energized (or both):

  • Secondary or Distribution (or both):

  • Overhead or Underground (or both):


  • Was tailgate/job briefing conducted and documented:

  • Radio operation check was performed:

  • Daily vehicle inspection was performed on CMV(s):

  • Pre-flight of aerial unit was performed:

  • Aerial lift properly set up for the task as required by manufacturer:

  • Energy source controls (Energy Control/LOTO) have been identified:


  • Hard hat(s) properly worn and in good condition:

  • Eye protection in ANSI approved and worn:

  • Proper hand protection is being used:

  • Safety toe boots are being used:

  • Hearing protection is available:

  • FR clothing is in good condition:

  • Rubber gloves worn and inspected prior to use:

  • Rubber sleeves worn and inspected prior to use:

  • Fall protection used where appropriate and all components inspected prior to use:


  • Truck grounds are being used and in good condition:

  • Personal grounds are being used and in good condition:

  • Conductor was tested (digital voltage indicator) prior to grounds being installed:

  • Crew members can explain proper grounding techniques:

  • Grounds are properly stored:


  • Digger/bucket trucks are properly set up:

  • Wheel chocks are being used:

  • All material on the vehicle is properly stowed:

  • Outrigger pads are being used:

  • Reverse alarm is in working order:

  • Fire extinguishers are properly charged and stored:

  • First-aid kit is stocked and location is properly marked:

  • AED is available and location is properly marked:


  • Beacon/strobe lights are in working order and being used:

  • Traffic cones are used and properly placed:

  • Road signs are adequate for the job being performed:

  • Reflective vests are worn:

  • A flagger is being used to control traffic:


  • Proper tools are being used to complete the task:

  • Tools have been inspected and are in good condition:

  • Live-line tools have been inspected prior to use and tested within 1 year:

  • Hand lines are available and in good condition:

  • Ladders have been inspected and are in good condition:

  • Means of ingress/egress present in excavations >4 feet:

  • Excavations >5 feet have been shored/stepped back by a competent excavation safety trained employee:

  • Poles are tested prior to climbing:

  • Adequate cover-up material is being used, properly covered/isolated:

  • Only qualified personnel are performing hazardous work:

  • Employees performing hot work are being watched by a designated observer:

  • Guards are in place on tools and equipment that need them:

  • Clear communication is exchanged among crew members:

  • Employees can explain direction of feed and closest protection device:


  • Safe jobsite:

  • Safe work procedures followed:

  • Comments: ("NO" items require an explanation)

  • Include photo's, if applicable:

  • Signature:

  • Signature:

  • 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.