NEP Crew Visit Form

• Site

  Select

• Conducted on

  Date

• Prepared by

  Select Mike Jeffries Justin Roberts Joe Lemen Josh Hirner MDC Personnel

  • Mike Jeffries
  • Justin Roberts
  • Joe Lemen
  • Josh Hirner
  • MDC Personnel
• Location
  Address

• Crew Personnel

  Select A.J. Holtschlag Cole Pennewell Corey Schmohe Cyle Jones Dalton Rockhold Damon Scott Drew Moyer James Porter Jamie Taylor Jeremy Hudson Jerry Daniels Jesse Snow Jimmy Powell Joe Lemen Joel Hill Josh Chinn Josh Hirner Justin Roberts Kevin Scholl Logan Cumby Luke Frericks Matt Simmons Mike Jeffries Phil Scifres Richard Epperson Rick Steidinger Steve Gottman Steve Smith Tanner Elam Tim Goehl Tom Pearn

  • A.J. Holtschlag
  • Cole Pennewell
  • Corey Schmohe
  • Cyle Jones
  • Dalton Rockhold
  • Damon Scott
  • Drew Moyer
  • James Porter
  • Jamie Taylor
  • Jeremy Hudson
  • Jerry Daniels
  • Jesse Snow
  • Jimmy Powell
  • Joe Lemen
  • Joel Hill
  • Josh Chinn
  • Josh Hirner
  • Justin Roberts
  • Kevin Scholl
  • Logan Cumby
  • Luke Frericks
  • Matt Simmons
  • Mike Jeffries
  • Phil Scifres
  • Richard Epperson
  • Rick Steidinger
  • Steve Gottman
  • Steve Smith
  • Tanner Elam
  • Tim Goehl
  • Tom Pearn

• Job Briefing Completed?

  Yes

  No

  N/A

• Was it Thorough?

  Yes

  No

  N/A

• Did everyone sign it?

  Yes

  No

  N/A

PPE

• Hard hats

  Yes

  No

  N/A

• Safety Glasses

  Yes

  No

  N/A

• Harness?

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Proper Clothing

  Yes

  No

  N/A

• Work Gloves

  Yes

  No

  N/A

• Additional PPE

Grounding?

• Truck Grounds

  Yes

  No

  N/A

• Personal Protective Grounds

  Yes

  No

  N/A

Hot Line Work

• Rubber gloves

  Yes

  No

  N/A

• Sleeves

  Yes

  No

  N/A

• Adequate Cover UP

  Yes

  No

  N/A

• One Shot

  Yes

  No

  N/A

Traffic Control

• Cones utilized

  Yes

  No

  N/A

• Proper Signage

  Yes

  No

  N/A

• Flagger

  Yes

  No

  N/A

• Safety Vests?

  Yes

  No

  N/A

• Strobe lights Utilized

  Yes

  No

  N/A

Underground

• Excavation on site?

  Yes

  No

  N/A

• Was an entry/exit ladder used, if they were digging more than 4‘ of depth?

  Yes

  No

  N/A

Vehicles

• Wheel chocks

  Yes

  No

  N/A

• Vehicles on site.

• Bins are clean and orderly?

  Yes

  No

  N/A