Information
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Document No.
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Conducted on
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Foreman
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Personnel
- Nate
- Steve
- Tom
- Justin
- Josh
- Bill
- Braden
- Shane
- Randy W
- Dave
- Pat
- Chad
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Are Outside Crews Going to Be Working On the Jobsite?
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Which Outside Crews?
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Work Order
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Rescue 911 Address
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Weather
- Sunny
- Raining
- Windy
- Overcast
- Snowy
- Cold
- Night
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Will Wind Speed Cause Additional Hazards?
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Plan in Place to Address Wind Hazards?
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Additional Information?
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Type of Work to Be Done?
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Trimming In Energized Zone?
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Able to Maintain Clearance from Energized Lines?
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Coordinate With Operations to De-energize Line Section
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Is Chipping Required?
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Is Chipper Access Clear?
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Is Chipping Required?
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Is Chipper Access Clear?
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Tree Condition?
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Unsafe to Climb, Make Alternate Plan
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Climbing Plan in Place?
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Climbing Equipment to Be Used?
- Saddle, Buckstrap, Secondary Fall Protection
- Descender
- Carabiners
- Climbing Pulleys
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Climbing Plan in Place to Address Leaning Concern?
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Climbing Equipment to Be Used?
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Climbing Plan in Place to Address Tree Condition Concerns?
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Climbing Equipment to Be Used
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Is Clean Up Required?
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Does Ticket Show Consumer Will Clean UP?
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Is Rigging Required For the Work to Be Done?
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Type of Rigging to Be Done?
- Rope Blocks
- Digger Truck
- Rope Hoist
- Other
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PPE To Be Used
- Steel Toe Boots, FR Clothing, Hard Hat, Safety Glasses
- Hearing Protection
- Face Shield
- Chaps
- Road Way Vest
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Is work to be done on/near a roadway?
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Road Type?
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INDOT Notified
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Traffic Control Plan in Place?
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Is Flagging Required?
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Why Not?
- 15 minutes or less
- 10 feet from the fog line
- No traffic on roadway
- Other
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Flaggers Means of Communication?
- Hand Signals
- 2-Way- Radios
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Traffic Control Devices to Be Used?
- Utility Work Ahead Signs
- One Lane Road Signs
- Flagger Ahead Signs
- Stop/Slow Paddles
- Cones
- Block Vehicle
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Traffic Control Devices to Be Used?
- Utility Work Ahead Signs
- Cones
- Other
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Additional Hazards or Concerns Related to the Job Site, or Work to Be Done?
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Enter Additional Information
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Add media
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Signing
Person
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Initials Here
