Master Template

• Supervisor

• Foreman

• Date

  Date

• Job No.

• Location
  Address

• Prepared by

Daily Safety & Pre-Task Planning

• Are Daily Safety & Pre-Task Planning forms being completed?

  Yes

  No

• Is the work being done matching the form?

  Yes

  No

  N/A

• Why is not being completed?

• Daily huddle completed?

  Yes

  No

  N/A

• Employee Comments

Comments

• Name

• Comments

Emergency Plan

• Do employees know of the emergency plan?

  Yes

  No

  N/A

• 911 Confirmation

• Clinic/Hospital Location

New Employees

• Jobsite Orientation

• Integration

• New Employee Concerns

Concerns

• Name

• Concern

New Employee

• Have you completed job site orientation?

  Yes

  No

  N/A

• Are you being welcomed in/how are you fitting in?

• Do you have any concerns?

New Employee

• Have you completed job site orientation?

  Yes

  No

  N/A

• Are you being welcomed in/how are you fitting in?

• Do you have any concerns?

New Employee

• Have you completed job site orientation?

  Yes

  No

  N/A

• Are you being welcomed in/how are you fitting in?

• Do you have any concerns?

TPR (Open Ended Questions)

• Issues and Concerns?

Comment

• Describe

Machinery

• Lubricated?

• Clean?

• Seat belt?

• Safety equipment?

• Any issues with One Call or Operator Care?

  Yes

  No

  N/A

• Explain

Overhead

• Power Lines

  Yes

  No

  N/A

• How far away (in ft.)?

• Phone Lines?

  Yes

  No

  N/A

Underground

• Power Lines

  Yes

  No

  N/A

• How far away (in ft.)?

• Phone Lines?

  Yes

  No

  N/A

• Fiber-optics?

  Yes

  No

  N/A

• Gas lines?

  Yes

  No

  N/A

• Water Lines?

  Yes

  No

  N/A

• Sewer Lines?

  Yes

  No

  N/A

• Designated employee parking?

  Yes

  No

  N/A

• Picture

  Media

• Suggestions for parking spots

• Picture

  Media

• Pedestrian Traffic Areas designated and guarded?

  Yes

  No

  N/A

• Picture

  Media

• Haul Routes and/or Traffic Pattern in place?

  Yes

  No

  N/A

• Work zone signing/traffic control manual in place?

  Yes

  No

  N/A

• Type of Soil Present

  A

  B

  C

  Mix

Which types? (check all that apply)

• A

• B

• C

• Is the trench safe?

  Yes

  No

  N/A

• Picture

  Media

• Ladders within 25ft of employees?

  Yes

  No

  N/A

• Are employees aware of the rescue plan?

  Yes

  No

  N/A

• Chains and Slings

Equipment

• What is the condition of the chains/slings?

  Satisfactory

  Unsatisfactory

  Need Repair

• Photos

  Media

• Have the chains/slings been inspected and certified within the last year?

  Yes

  No

  N/A

• Date of last inspection

  Date

Employees

• Are employees operating within the danger zone/swing zone of equipment?

  Yes

  No

  N/A

• Are employees aware of danger zone/swing zone?

  Yes

  No

  N/A

Crane

• Is there a Certified Crane Operator (CCO)?

  Yes

  No

  N/A

• Load chart and lift chart located in the crane?

  Yes

  No

  N/A

• Condition of the crane?

  Satisfactory

  Unsatisfactory

  Need Repair

• Are employees working underneath crane loads?

  Yes

  No

  N/A

• Picture

  Media

Pile Driver

• Is the driver/hammer in good condition?

  Yes

  No

  N/A

• Are the manufacturing plates attached and inspected?

  Yes

  No

  N/A

• Date of Last Inspection

  Date

Tool

Tool

• Name of Tool

• Proper Guarding on Tool?

  Yes

  No

  N/A

• Exterior Damage?

  Yes

  No

  N/A

• Describe

• Picture

  Media

• Are cord(s) cut, frayed, damaged?

  Yes

  No

  N/A

• Describe

• Picture

  Media

PPE

• Proper PPE worn? (select all that apply)

  Select Respirator Safety Glasses Face Shield Gloves Chaps Hearing Protection Safety toed shoes

  • Respirator
  • Safety Glasses
  • Face Shield
  • Gloves
  • Chaps
  • Hearing Protection
  • Safety toed shoes

Lifts (Scissors, Aerial, Boom)

Lift

• Lift #

• Daily inspection complete?

  Yes

  No

  N/A

• Used correctly?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media

• Describe

Ladder

Lift

• Daily inspection complete?

  Yes

  No

  N/A

• Used correctly?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media

• Describe

• Tied off?

  Yes

  No

  N/A

• Temporary or Permanent?

  Temporary

  Permanent

Guardrail

Guardrail
• Location
  Address

• Damage?

  Yes

  No

  N/A

• Photo

  Media

• Top rail, mid rail, and toe kick?

  Yes

  No

  Other

• Top

• Mid

• Toeboard

Body Harness and Lanyards

Harness

• Serial #

• Daily inspection?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media
Lanyard

• Serial #

• Daily inspection?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media
Harness

• Daily inspection?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media
Harness

• Daily inspection?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media
Lift

• Lift #

• Daily inspection complete?

  Yes

  No

  N/A

• Used correctly?

  Yes

  No

  N/A

• Damage?

  Yes

  No

  N/A

• Photo

  Media

• Describe

Are employees wearing....?

• Safety Vests?

  Yes

  No

  N/A

• Are the vests in good condition (clean, reflective material visible, etc.)?

  Yes

  No

  N/A

• Safety glasses?

  Yes

  No

  N/A

• If grinding/cutting, are face shields also being worn?

  Yes

  No

  N/A

• Hearing protection (if required)?

  Yes

  No

  N/A

• Hard hats?

  Yes

  No

  N/A

• Are hard hats free from nicks, gouges, and is suspension inside hard hat adjusted properly?

  Yes

  No

  N/A

• Sun protection? (sunscreen, UV protective clothing)?

  Yes

  No

  N/A

• Seat belts on equipment being worn?

  Yes

  No

  N/A

• Fall protection (if required)?

  Yes

  No

  N/A

Chain Saw Safety (if applicable)

• Chaps being worn and fitted properly?

  Yes

  No

  N/A

• Hard hat?

  Yes

  No

  N/A

• Face shield and safety glasses being worn?

  Yes

  No

  N/A

• Hearing protection?

  Yes

  No

  N/A

• Gloves being worn?

  Yes

  No

  N/A

• Erosion control measures in place?

  Yes

  No

  N/A

• Following SWPPP?

  Yes

  No

  N/A

• Do employees have cell phones on their person?

  Yes

  No

  N/A

• Are cell phones being used during work hours?

  Yes

  No

  N/A

• Date of Last Job Site Inspection

  Date

• Name of Supervisor

• Executive Safety Committee Member

  Trevor Duininck

  Chris Duininck

  Judd Duininck

  Rick Maursetter

  Jeff Rettig

• Select date

  Date

• Add signature

  Sign

• Supervisor

• Select date

  Date

• Received copy?

• Add signature

  Sign

• Lock-out/tag-out procedures in place?

  Yes

  No

  N/A

• Add media

  Media

Wiring, Hoses, Jacks, Vessels

Problems

• Describe any problems, if applicable

• Photos, if applicable

  Media

Extinguishers

Extinguisher

• Serial #

• Date of last inspection

  Date

• Are extinguishers clearly marked?

  Yes

  No

  N/A

• Are extinguishers free from material in front and around of them?

  Yes

  No

  N/A

• Do employees know how to use extinguishers? (P.A.S.S. method)

  Yes

  No

  N/A

Gas cylinders

• Are cylinders stored properly?

  Yes

  No

  N/A

• Photo

  Media

Sprinklers

Are these guarded?

• Pulleys?

  Yes

  No

  N/A

• Belt heads?

  Yes

  No

  N/A

• Tail shafts?

  Yes

  No

  N/A

• Chains?

  Yes

  No

  N/A

• Sprockets?

  Yes

  No

  N/A

• Falling rock areas?

  Yes

  No

  N/A

• Danger signs present?

  Yes

  No

  N/A

• Nip points?

  Yes

  No

  N/A

• Crush points?

  Yes

  No

  N/A

• Permit to enter confined space?

  Yes

  No

  N/A

• Entrance/Exit clearly marked?

  Yes

  No

  N/A

• Spotter present?

  Yes

  No

  N/A

4 Gas Meter

• 4 gas meter sample taken before entering confined space?

  Yes

  No

  N/A

• Meter "bump" tested?

  Yes

  No

  N/A

• Employee equipped with 4 gas meter?

  Yes

  No

  N/A

Rescue Plan

• Rescue equipment within proximity of entrance/exit?

  Yes

  No

  N/A

• Do employees know rescue plan?

  Yes

  No

  N/A