LJ TRAFFIC CONTROL

• date

  Date

• client name

• Contractor Foreman

• work order number

Flaggers on site

• Name

Work zone

• Address of work area

• What is the speed limit

• How many lanes

• What type of zone are you setting up

  Urban low

  Urban high

  Rural

• what spacing is used

• take photos of signs

  Media

• What kind of taper will you be using

  Merging

  Shifting

  One lane flagger

  Shoulder

• do you have at least 6 cones with a proper taper

  Yes

  No

• take a picture of your taper

  Media

• describe the work zone

• take photos of entire work zone

  Media

• Are your wearing your proper ppe

  Select Yes No

  • Yes
  • No

• Hard hat

  Yes

  No

• Class 2 or 3 reflective vest

  Yes

  No

• Safety glasses

  Yes

  No

• Steel toe shoes/boots

  Yes

  No

• Air horn

  Yes

  No

• Whistle

  Yes

  No

• Gloves

  Yes

  No

• Walkie talkie

  Yes

  No

• Hard hat halo

  Yes

  No

  N/A

• Night wand

  Yes

  No

  N/A

Safety

• Do you have a charged fire extinguisher

  Yes

  No

• Is your first aid kit easily accessible

  Yes

  No

• Did you pre stretch

  Yes

  No

• What warning device will you have on you

• Who do you contact (on site) if emergency happens

• What is the nearest hospital

• Hospital address

• Hospital phone number

• Weather

• Road conditions

• Do you have plenty of water

  Yes

  No

• Do you have snacks

  Yes

  No

• Do you have sun screen

  Yes

  No

• Do you have bug spray

  Yes

  No
Potential harzards

• Name 3 potential hazards and what we can do to prevent this

Truck

• Do you have all requirements to perform all zones

  Yes

  No

• Stands

  Yes

  No

• Signs

  Yes

  No

• Paddles with proper specifications

  Yes

  No

• Do you have a black binder

  Yes

  No

• What is your truck number

• Did you complete a truck check today

  Yes

  No

• Vehicles free of clutter? <br>

  Yes

  No

• is the bed of the truck free of garbage

  Yes

  No

arrow-board

• Is arrow-board used

  Yes

  No

• Arrow-board number

• Are tires in good condition

  Yes

  No

• Are safety chains operating properly

  Yes

  No

• All bulbs woork

  Yes

  No

• Is the crank cable working properly

  Yes

  No

• Are both taillights working properly

  Yes

  No

• Are both brake lights working properly

  Yes

  No

• Are you flagging

  Yes

  No

• are you certified

  Yes

  No

• is it visible

  Yes

  No

  N/A

• is it up to date

  Yes

  No

• flagger is first on site and last to leave

  Yes

  No

• flagger properly cleans up work zone

  Yes

  No

• does flagger maintain 360 view while setting up the zone

  Yes

  No

  N/A

• does flagger have warning device at all times

  Yes

  No

  N/A

• is flagger wearing proper ppe

  Yes

  No

  N/A

• did flagger plan emergency exit in case of emergency

  Yes

  No

  N/A

• is the flagger at least 40 ft from the taper

  Yes

  No

  N/A

• can the flagger view the entire zone and not turn back to oncoming traffic

  Yes

  No

  N/A

• can both flaggers communicate properly by walkie and have back up

  Yes

  No

  N/A

• flagger does not place paddle inside cones for any reason

  Yes

  No

  N/A

• flagger is not sitting in truck, leaning on truck or sitting on tailgate

  Yes

  No

  N/A

• flagger is not on phone for any reason (calls, texting, games etc)

  Yes

  No

  N/A
signature

• Crew member

  Sign

supervisor (when applicable)

• Supervisor

  Sign