Title Page

  • Site conducted

  • Conducted on

  • Location
  • Lead Lineman

  • Foreman

  • Is there a work order number?

  • Work order number:

  • Task Code

  • Voltage Present:

  • Within minimum approach of energized conductor?

  • Sub?

  • OCR/Fuse pole number

  • One Shot/Tag

  • Inform Dispatch

  • Ground Trucks

  • Proper PPE

  • Visual Open?

  • Test For Voltage?

  • Grounded?

  • Tagged?

OSHA Requirements

JOB BRIEFING

  • Discussed hazards with the job?

  • Discussed work procedures involved?

  • Discussed PPE?

  • In sub station?

  • Clothing HC required

  • Discussed energy source controls?

  • Were all questions answered?

Additional Risk/Mitigating Factors

  • Additional Risk

  • Mitigating Factors

Signatures

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add 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.