SIGN IN LOG

TYPE OF MEETING (Sign everyone in first then choose the meeting type)

Was this a Monthly Sub Safety Committee Meeting?

Topic

Topic of discussion.

Topic leader

Name of leader

Was this a Weekly/Toolbox Safety Meeting?

Topic

Topic of discussion.

Topic leader

Name of leader

Was this a Weekly Sub Safety Committee Terminal Walk?

Please have each member or team(s) complete at least one MBJ3 Bi-Weekly Jobsite Inspection form.

Was this a Accident/Incident Review?

What type of accident or incident?

Date and time of accident/incident

Name and ROCIP badge number of the affected employee

Affected employee Job title (position)

Worker status

What is the temporary agency name?

Explain why your answer was N/A.

Highest level of treatment received.

Company name for affected worker

Specific location of accident/incident, for example: Column line 70A-C, Entry vestibule E17, etc.).

Describe the injury or illness, parts of body affected, and object/substance that directly injured or made affected employee ill.

Were there any witnesses?

Witness #1's Name

Was a statement taken?

Witness #1's Name

Was a statement taken?

Witness #2's Name

Was a statement taken?

Witness #1's Name

Was a statement taken?

Witness #2's Name

Was a statement taken?

Witness #3's Name

Was a statement taken?

What directly happened to cause the Accident/incident? Choose all that apply.

Was a person excessively fatigued, impaired, upset, bored, distracted or overwhelmed?

Human Engineering

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Should the person have had and used a written procedure but did not?

Human Engineering

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

Procedures

Not Used / Not Followed

No Procedure

Procedure not available or inconvenient for use

Procedure difficult to use

Procedure used not required but should be

Wrong

Typo

Sequence wrong

Facts Wrong

Situation not covered

Wrong revision used

Second checker needed

Followed Incorrectly

Format confusing

> 1 step / action

Excess references

Multi unit references

Limits need improvement

Details need improvement

Data / computations wrong or incorrect

Graphics need improvement

No checkoff

Checkoff misused

Misused second check

Ambiguous instructions

Equipment Identification needs improvement

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Was a mistake made while using a procedure?

Not Used / Not Followed

No Procedure

Procedure not available or inconvenient for use

Procedure difficult to use

Procedure used not required but should be

Wrong

Typo

Sequence wrong

Facts Wrong

Situation not covered

Wrong revision used

Second checker needed

Followed Incorrectly

Format confusing

> 1 step / action

Excess references

Multi unit references

Limits need improvement

Details need improvement

Data / computations wrong or incorrect

Graphics need improvement

No checkoff

Checkoff misused

Misused second check

Ambiguous instructions

Equipment Identification needs improvement

Were alarms or displays to recognize or to respond to a condition unavailable or misunderstood?

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

Were displays, alarms, controls, tools, or equipment identified or operating improperly?

Training

No Training

Task not analyzed

Decided not to train

No learning objective

Missed required training

Understanding Needs Improvement

Learning objective needs improvement

Lesson plan needs improvement

Instruction needs improvement

Practice / repetition needs improvement

Testing needs improvement

Continuing training needs improvement

Procedures

Not Used / Not Followed

No Procedure

Procedure not available or inconvenient for use

Procedure difficult to use

Procedure used not required but should be

Wrong

Typo

Sequence wrong

Facts Wrong

Situation not covered

Wrong revision used

Second checker needed

Followed Incorrectly

Format confusing

> 1 step / action

Excess references

Multi unit references

Limits need improvement

Details need improvement

Data / computations wrong or incorrect

Graphics need improvement

No checkoff

Checkoff misused

Misused second check

Ambiguous instructions

Equipment Identification needs improvement

Human Engineering

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

Did the person need more skill/knowledge to perform the job or to respond to conditions or to understand system responses?

Training

No Training

Task not analyzed

Decided not to train

No learning objective

Missed required training

Understanding Needs Improvement

Learning objective needs improvement

Lesson plan needs improvement

Instruction needs improvement

Practice / repetition needs improvement

Testing needs improvement

Continuing training needs improvement

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Was the work performed in an adverse environment? (such as hot, humid, dark, cramped, or hazardous)

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

Did work involve repetitive motion, uncomfortable positions, vibrations, or heavy lifting?

Training

No Training

Task not analyzed

Decided not to train

No learning objective

Missed required training

Understanding Needs Improvement

Learning objective needs improvement

Lesson plan needs improvement

Instruction needs improvement

Practice / repetition needs improvement

Testing needs improvement

Continuing training needs improvement

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Human Engineering

Human - Machine Interface

Labels Need Improvement

Arrangement/Placement

Displays Need Improvement

Controls Need Improvement

Monitoring Alertness Need Improvement

Plant / Unit Differences

Excessive Lifting

Tools / Instruments Need Improvement

Work Environment

Housekeeping Needs Improvement

Hot / Cold

Wet / Slick

Lights Need Improvement

Noisy

Obstruction

Cramped Quarters

Equipment Guard Needs Improvement

High Radiation / Contamination

Rough Terrain

Complex System

Knowledge based decision required

Monitoring too many items

Non-Fault Tolerant System

Errors not detectable

Errors not recoverable

This must be a team performance issue. Questions moving forward will be directed at team performance.

Did verbal communications or shift change play a role in this problem?

No communication or not timely

Communication System needs improvement

Late communication

Turnover needs improvement

No standard turnover process

Turnover process not used

Turnover process needs improvement

Misunderstood verbal communications

Standard terminology not used

Standard terminology needs improvement

Repeat back not used

Long message

Noisy environment

Did failure to agree about the who/what/when/where of performing the job play a role in this operation?

Communications

No communication or not timely

Communication System needs improvement

Late communication

Turnover needs improvement

No standard turnover process

Turnover process not used

Turnover process needs improvement

Misunderstood verbal communications

Standard terminology not used

Standard terminology needs improvement

Repeat back not used

Long message

Noisy environment

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Training

No Training

Task not analyzed

Decided not to train

No learning objective

Missed required training

Understanding Needs Improvement

Learning objective needs improvement

Lesson plan needs improvement

Instruction needs improvement

Practice / repetition needs improvement

Testing needs improvement

Continuing training needs improvement

Was communication needed across organizational boundaries?

No communication or not timely

Communication System needs improvement

Late communication

Turnover needs improvement

No standard turnover process

Turnover process not used

Turnover process needs improvement

Misunderstood verbal communications

Standard terminology not used

Standard terminology needs improvement

Repeat back not used

Long message

Noisy environment

This must be a management system issue. Questions moving forward will be directed at this system.

Was a task performed in a hurry or a shortcut used?

Management System

Standards, Policies, or Administrative Controls (SPAC) need improvement

No SPAC

Not strict enough

Confusing or incomplete

Technical error

Drawing / print needs improvement

Standards, Policies, or Administrative Controls (SPAC) not used.

Communication of SPAC needs improvement

Recently changed

Enforcement needs improvement

No way to implement

Accountability needs improvement

Oversight / Employee Relations

Infrequent audits & evaluations

Audits & evaluations lack depth

Audits & evaluations not independent

Employee communications need improvement

Employee feedback needs improvement

Corrective Action

Corrective action needs improvement

Corrective action not yet implemented

Trending needs improvement

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Had management been warned of this problem or had it happened before?

Standards, Policies, or Administrative Controls (SPAC) need improvement

No SPAC

Not strict enough

Confusing or incomplete

Technical error

Drawing / print needs improvement

Standards, Policies, or Administrative Controls (SPAC) not used.

Communication of SPAC needs improvement

Recently changed

Enforcement needs improvement

No way to implement

Accountability needs improvement

Oversight / Employee Relations

Infrequent audits & evaluations

Audits & evaluations lack depth

Audits & evaluations not independent

Employee communications need improvement

Employee feedback needs improvement

Corrective Action

Corrective action needs improvement

Corrective action not yet implemented

Trending needs improvement

Were policies, administrative controls, or procedures not used, missing, or in need of improvement?

Management System

Standards, Policies, or Administrative Controls (SPAC) need improvement

No SPAC

Not strict enough

Confusing or incomplete

Technical error

Drawing / print needs improvement

Standards, Policies, or Administrative Controls (SPAC) not used.

Communication of SPAC needs improvement

Recently changed

Enforcement needs improvement

No way to implement

Accountability needs improvement

Oversight / Employee Relations

Infrequent audits & evaluations

Audits & evaluations lack depth

Audits & evaluations not independent

Employee communications need improvement

Employee feedback needs improvement

Corrective Action

Corrective action needs improvement

Corrective action not yet implemented

Trending needs improvement

Work Direction

Preparation

No preparation

Work Package / Permit Needs improvement

JHA Briefing Needs Improvement

Walk-thru Needs Improvement

Scheduling Needs Improvement

Lock / Out Tag Out Needs Improvement

Fall Protection Needs Improvement

Selection of Worker

Not Qualified

Fatigued

Upset

Substance Abuse

Team Selection Needs Improvement

Supervision During Work

No Supervision

Crew Teamwork Needs Improvement

Procedures

Not Used / Not Followed

No Procedure

Procedure not available or inconvenient for use

Procedure difficult to use

Procedure used not required but should be

Wrong

Typo

Sequence wrong

Facts Wrong

Situation not covered

Wrong revision used

Second checker needed

Followed Incorrectly

Format confusing

> 1 step / action

Excess references

Multi unit references

Limits need improvement

Details need improvement

Data / computations wrong or incorrect

Graphics need improvement

No checkoff

Checkoff misused

Misused second check

Ambiguous instructions

Equipment Identification needs improvement

Should an independent quality control check caught the problem.

No Inspection

Inspection not required

No hold point

Hold point not performed

QC Needs Improvement

Inspection instructions need improvement

Inspection techniques need improvement

Foreign material exclusion during work needs improvement

If you haven't figured it out by now then the work was just an idiot, LOL!!!!

Describe the corrective action taken

Include all pictures

Explain the special case

Include all pictures

Explain in detail what property was damaged

Rate potential severity for injury based on the sequence of events for this incident.
Add pictures that show location and near miss event.

Rate potential severity for injury based on the sequence of events for this incident.

A citation must be given for this infraction.

Name(s), ROCIP badge number(s) and explanation of citation(s) of all those receiving a citation.

Explain the near miss in detail.

Describe corrective or additional corrective action taken

Was this another type of meeting?

Describe the type and content of the meeting.

SIGN IN SHEET

Use this for Weekly/Toolbox Safety Meetings only!

Name of Weekly/toolbox Meeting Attendee
Take picture of ROCIP Badge.
Add signature

Use this for all meetings involving the Safety Committee members only!

Attendee
Name of Attendee

Cell Phone: 903-220-2176, Email:salome@lantekavc.com

Salome Macias

Cell Phone: 214-577-0053, Email:francisco@hpenvirovision.com

Francisco Rangel

Cell Phone: 469-500-0817, Email: plara@osburncontractors.com

Paul Pina

Cell Phone: Email- Adonis_amaya1995@icloud.com

Jose Amaya
Trey Foster

Cell Phone: 214-790-3233: Email- tbohannon@dynamicsystemsusa.com

Tim Bohannon

Cell Phone: 214-425-8999: Email- daniel.james@thestcgroup.com

Daniel James

Cell Phone-214-918-6612: Email- Daniel@hpenvirovision.com.com

Daniel Flores

Cell Phone-972-800-0428: Email- oumana@sw-construction.com

Oscar Umana

Cell Phone-940-232-0740: Email- Darrell.bird@northstarfire.com

Darrel Bird

Cell Phone-214-907-0966: Email- jerry.newby@denalics.com

Jerry Newby

Cell Phone-469-865-4983: Email- richard.frame@siemens.com

Rick Frame

Cell Phone-817-948-6661: Email- msample@dynamicsystemsusa.com.com

Michael Sample

Cell Phone-214-418-8537: Email- rjones@elogicinc.net

Robert Jones

Cell Phone-817-201-6788: Email- rarredondo@manhattanconstruction.com

Robert Arredondo

Cell Phone-214-243-0026: Email- George@gentzlerelectric.com

George Guzman

Cell Phone-214-490-5544: Email- jarred@gentzlerelectric.com.com

Jarrad Quilty

Cell Phone-214-677-6326: Email- bpowers@manhattanconstruction.com

Bryce Powers

Cell Phone-254-577-9434: Email- chris.robertson@mcdean.com

Chris Robertson

Cell Phone-214-766-3475: Email- cindy.brummett@denalics.com

Cindy Brummett

Cell Phone-214-325-4402: Email- cmagers@manhattanconstruction.com

Cleve Magers

Cell Phone-214-869-7546: Email- franciscozepeda@marekbros.com

Francisco Zepeda

Cell Phone-469-803-6765: Email- jcornelius@manhattanconstruction.com

John Cornelius

Cell Phone-817-550-7270: Email- jlopez@manhattanconstruction.com

Juan Lopez

Cell Phone-214-799-9880: Email- Julie@skyebuild.com

Julie Watson

Cell Phone-214-529-2671: Email- mgates@sw-construction.com

Matt Gates

Cell Phone-325-201-8516: Email- aosmoot64@gmail.com

Odean Smoot

Cell Phone-972-595-4455: Email- rescovedo@walkertx.com

Richard Escovedo

Cell Phone-817-223-1105: Email- zheadden@burlesonelectric.net.com

Zac Headden

Cell Phone-469-408-0755: Email- rwright@VESDFW.com

Robert Wright

Cell Phone-214-808-0787: Email- amendoza@phillipsmay.com

Alex Mendoza

Cell Phone-214-717-1298: Email- yjimenez@carrcopainting.com

Yuritzi Jimenez

Cell Phone-972-802-0500: Email- jbisballe@natlfire.com

Jeff Bisballe

Cell Phone-972-439-4910: Email- sal@rndicompanies.com

Sal Inzillo
Add signature
Company Name

Company Name

Cell phone / ROCIP Badge #

Email address / Other information

Use this as the sign-in for all other meetings!
Add signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.