Title Page
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Conducted on
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Work Order#
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Job Description
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Location
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Crew
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Crew Foreman
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Personnel
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Truck #'s
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Inspection Type
- Regular
- Outage/Emergency
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Job
- Energized
- De-energized
- Distribution
- Secondary
- Overhead
- Underground
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Equipment
- Service < 26,000
- Bucket
- Digger Derrick
- Pressure Digger
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Tested
- Dielectric
- Structural
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Other Equipment
- Hydro-Vac
- Trencher
- Backhoe
- Wire Trailer
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Other:
PPE
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PPE - A "NO" answer requires a comment.
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Hard Hat(s)
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Eye Protection
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Hearing Protection
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Foot Protection
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Hand Protection
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Rubber Gloves
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Rubber Sleeves
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Fall Protection
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FR Clothing
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Pre-Use Inspection
Job Preperation
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Job Communication
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Job Briefing
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Documented Prior to Work
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Location Reported
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Hotline Tag
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Recloser - Single Operation/Bypass Cutout
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Grounding
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Truck
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Conductor Tested
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Pre-Use Inspection
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Personal Grounds
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Conductor Tested
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Pre-Use Inspection
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Cover Up
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Adequate
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Serviceable
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Pre-Use Inspection
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Traffic Control
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Beacon/Strobe
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Four Way Flashers
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Reflective Vests
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Cones Adequate
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Signs Adequate
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Flagger(s)
Job Preparation Continued
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Poles
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Inspected
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Adjacent Poles
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Adjacent Spans
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Ladders
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Inspected
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Proper Placement
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Secured
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Live Line Tools
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Pre-Use Inspection
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Clean
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Serviceable
Comments
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OTHER CONDITIONS & WORK PRACTICES INVOLVED:
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COMMENTS/CORRECTIVE ACTIONS:
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Foreman/Lineman in Charge:
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Inspected By:
Photos
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