MYR Form 40.0003

• Document No.

• Task Description

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Foreman/Supervisor

General Site Info

• Safet Manual on site

  Yes

  No

  N/A

• Emergency Plan in place?

  Yes

  No

  N/A

• Job Briefing/Tailboard Complete?

  Yes

  No

  N/A

• Pre-Job Hazard Analysis Complete?

  Yes

  No

  N/A

P.P.E.

• Hard Hats

  Safe

  At Risk

  N/A

• Proper Foot Wear

  Safe

  At Risk

  N/A

• Fall Protection

  Safe

  At Risk

  N/A

• Eye Protection

  Safe

  At Risk

  N/A

• Safety Vest

  Safe

  At Risk

  N/A

• Long Sleeve Shirts

  Safe

  At Risk

  N/A

• FR Clothing (Proper cal/cm2 FRC for Exposure

  Safe

  At Risk

  N/A

Rubber Goods

• Rubber Gloves / Sleeves

  Safe

  At Risk

  N/A

• Blankets / Line Hose / Cover-up

  Safe

  At Risk

  N/A

• Enter Class and Issue Date

• Rubber Protective Equipment Properly Stored

  Safe

  At Risk

  N/A

• Proper Insulative Cover Applied (Reach plus MAD)

  Safe

  At Risk

  N/A

• Primary and Secondary Points of Contact Covered

  Safe

  At Risk

  N/A

• Enter Class and Issue Date

Hazardous Material

• Storage

  Safe

  At Risk

  N/A

• Labeled Correctly

  Safe

  At Risk

  N/A

• MSDS

  Safe

  At Risk

  N/A

Grounds

• Working Condition

  Safe

  At Risk

  N/A

• Properly Applied

  Safe

  At Risk

  N/A

• Sized Correctly

  Safe

  At Risk

  N/A

• Grounding Plan Completed and Reviewed

  Safe

  At Risk

  N/A

Work Areas

• Traffic Control / Protection

  Safe

  At Risk

  N/A

• Housekeeping Site/Equipment

  Safe

  At Risk

  N/A

FRP Tools (Sticks and Hot Arms)

• In Good Condition

  Safe

  At Risk

  N/A

• Properly Stored

  Safe

  At Risk

  N/A

• Wipe Down Rags Used

  Safe

  At Risk

  N/A

• FRP Inspection Date

Tools

• Safe Working Condition

  Safe

  At Risk

  N/A

• Proper Storage

  Safe

  At Risk

  N/A

Material Handling / Rigging

• Handling in use

  Safe

  At Risk

  N/A

• Correct Rigging Utilized

  Safe

  At Risk

  N/A

Rigging / Stringing Operations

• Written Plan and Checklist onsite?

  Safe

  At Risk

  N/A

• Proper Rigging (Kellum Grips, etc.)

  Safe

  At Risk

  N/A

Ladders / Scaffolds

• In Safe Working Condition

  Safe

  At Risk

  N/A

• Used Properly

  Safe

  At Risk

  N/A

Excavations

• Complete Proper JSSR Form for Excavations

  Safe

  At Risk

  N/A

Misc Electrical

• GFCI's In Use and Working

  Safe

  At Risk

  N/A

Manholes / Vaults

• Confined Space Permit Followed

  Safe

  At Risk

  N/A

Vehicles / Equipment

• Safe Working Condition

  Safe

  At Risk

  N/A

• Grounded / Barricaded

  Safe

  At Risk

  N/A

• Insulated Bucket Test Date

• DOT Inspections Complete

  Safe

  At Risk

  N/A

• Crane Checklist In Use and Qualified Operator

  Safe

  At Risk

  N/A

• Safety Equipment (Flares / Triangles)

  Safe

  At Risk

  N/A

• Wheels Chocked

  Safe

  At Risk

  N/A

• Outrigger Pads In Use on All Surfaces

  Safe

  At Risk

  N/A

• Fire Extinguisher Expiration Date
  
  
  
  

OSP Best Practices (Use JSSR BP)

• Administrative Controls

  Safe

  At Risk

  N/A

• Job Briefings

  Safe

  At Risk

  N/A

• Pre-use Inspection of RPE

  Safe

  At Risk

  N/A

• Qualified Observer

  Safe

  At Risk

  N/A

• Insulate and Isolate

  Safe

  At Risk

  N/A

• Cradle to Cradle

  Safe

  At Risk

  N/A

• Lock to Lock

  Safe

  At Risk

  N/A

• Live Line

  Safe

  At Risk

  N/A

• Fall Arresting Climbing Belt

  Safe

  At Risk

  N/A

• Environmental

  Safe

  At Risk

  N/A

• Bucket Load Capacity