North Houston Pole Line

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Project #:

  Yes

  No

  N/A

• Location:

  Yes

  No

  N/A

• Vehicle/Equipment #:

  Yes

  No

  N/A

• Date:

  Yes

  No

  N/A

Vehicle

• Drivers Log (if required)

  Yes

  No

  N/A

• D.V.I.R. Log

  Yes

  No

  N/A

• Windshield

  Yes

  No

  N/A

• Horn

  Yes

  No

  N/A

• Tires

  Yes

  No

  N/A

• Mirrors

  Yes

  No

  N/A

• Seat Belts OK & Worn

  Yes

  No

  N/A

• Parking Brake

  Yes

  No

  N/A

• Lights

  Yes

  No

  N/A

• Body Components

  Yes

  No

  N/A

• Seat Belts Worn

  Yes

  No

  N/A

Excavation, Trenching, Shoring

• Competent Person Trench Inspection

  Yes

  No

  N/A

• Trenches > 4' Shored or Benched

  Yes

  No

  N/A

• Means of Access and Egress

  Yes

  No

  N/A

• Spoil Piles Back 3'

  Yes

  No

  N/A

• Underground Facilities Marked

  Yes

  No

  N/A

• CGI On-site

  Yes

  No

  N/A

• Locate Request Copies On Jobsite

  Yes

  No

  N/A

Tools/Equipment

• Safety Guards In Place

  Yes

  No

  N/A

• Operators Trained

  Yes

  No

  N/A

• Seat Belts Used While Operating Equipment

  Yes

  No

  N/A

• Safety Cans Used For Gasoline

  Yes

  No

  N/A

• Fire Extinguishers Available, Inspected, Tagged, and Employees Trained To Use

  Yes

  No

  N/A

Emergency Equipment

• Certified First Aid/CPR Person

  Yes

  No

  N/A

• AED Inspection

  Yes

  No

  N/A

General

• Personal Protective Equipment

  Yes

  No

  N/A

• Job Briefing Completed

  Yes

  No

  N/A

• Competent Person At Site

  Yes

  No

  N/A

• Traffic Control/Signs

  Yes

  No

  N/A

• First Aid Kits Stocked

  Yes

  No

  N/A

• Housekeeping

  Yes

  No

  N/A

Remarks:

• Foreman

  Yes

  No

  N/A

• Add signature

  Sign

• Auditor

  Yes

  No

  N/A

• Add signature

  Sign