Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Person in charge
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Add location
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Select date
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Gopher state one call ticket number?
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What are you doing for an energy source control?
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What are the job steps ?
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Hazards (Examples slips trips falls, Overhead objects, traffic, steep ditch, trenching, energized, de-energized
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Job Duties/Work Procedures (who is doing what)
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What PPE are you using on this Job? 1. Hard Hat 2. Leather Gloves 3. Rubber Gloves 4. Road signs and cones 5. shoring or shelving 6. Chainsaw chaps 7. Safety Glasses 8. Rubber hoses, Rubber Blankets, Rubber sleeves and Rubber Gloves 9. If there is any other pieces of equipment please list below.
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Any other details about this job? OCR number, hold tag number, special hazards,
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Draw out of job if needed.
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Picture of Hazard
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Crew Signatures
