KGP CO JHA Aerial Construction Form

• Date & Time

  Date
• Location of work being preformed?
  Address

• Closest Medical Facility?

  Vaughan Medical Facility

• Area of work?

  Select FDH-184 FDH-197 FDH-196

  • FDH-184
  • FDH-197
  • FDH-196

• Who is performing inspection?

  Select Sal Sveistys Jesse Butterfield

  • Sal Sveistys
  • Jesse Butterfield

• Crew lead on site?

  Select Sal Sveistys

  • Sal Sveistys

• Crew members on site?

  Sal Sveistys

  Jesse Butterfield

  Richard Kline

  Rico Johnson

• Did you preform daily safety briefing?

  Yes

  No

  N/A

• Is equipment functioning properly?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Types of work being preformed?

  Select Aerial Construction Underground Fiber Pulling Installation of Anchors

  • Aerial Construction
  • Underground Fiber Pulling
  • Installation of Anchors

• Are signs and logos in place?

  Yes

  No

  N/A

• What hazards are associated with your daily task?

  Select Electrical Hazard Fire Hazards Fall Hazards Overhead Environmental UndergroundUtilities.

  • Electrical Hazard
  • Fire Hazards
  • Fall Hazards
  • Overhead
  • Environmental
  • UndergroundUtilities.

• What precautions are being taken to prevent injuries or damages?

  Select Fire extinguisher Cones Traffic Control Lanyard in Bucket Proper Climbing Gear (If needed) High Viz Insulated Gloves (If needed) Located utilities

  • Fire extinguisher
  • Cones
  • Traffic Control
  • Lanyard in Bucket
  • Proper Climbing Gear (If needed)
  • High Viz
  • Insulated Gloves (If needed)
  • Located utilities

• Are the members of your crew certified flaggers?

  Select Yes No N/A

  • Yes
  • No
  • N/A

Emergency Services

• Local Police

  334-874-2137

• Fire Department

  334-874-2150

• Local Hospital

  334-418-4100

• Yes

  No

  N/A