Title Page

  • Conducted on

  • Prepared by

  • Site Supervisor

  • Location
  • Job description

  • Emergency Contact Phone Number

Site Briefing

Work Procedures

  • Brief description of work procedures for job

  • Will work be performed energized

  • Have protective grounds been installed?

  • Will work be performed as "hot"?

Hazards

  • Energized equipment

  • Terrain (slips, trips & falls)

  • Traffic

  • Working at heights

  • Equipment on site (excavator, backhoe, etc.)

  • Noise (chainsaw, chipper, etc.)

  • Environmental Hazards

  • Underground Utilities

  • Have underground utilities been located?

  • Other:

  • Other:

Energy Source Controls

  • Hot Line Tag Required

  • Circuit

  • Has Peak Shaving Plant been taken out of service?

Special Precautions

  • Identify any special precautions that are out of the normal work activities.

PPE

  • Hard Hat

  • Safety Glasses

  • Rubber Gloves

  • Glove Class

  • Rubber Sleeves

  • FR/AR Uniform

  • Hearing Protection

  • Fall Protection

  • High Visibility Clothing

  • Other:

Personnel Onsite

  • Name:

  • Name:

  • Name:

  • Name:

  • Name:

  • Name:

  • Name:

  • Name:

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.