Paving

• 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

• Is the vehicle properly parked/in position?

  Yes

  No

  N/A

• Pedestrian Traffic Areas designated and guarded?

  Yes

  No

  N/A

• Haul Routes and/or Traffic Pattern in place?

  Yes

  No

  N/A

• If necessary, are flaggers/pilot cars in use?

  Yes

  No

  N/A

• Are hazard lights on?

  Yes

  No

  N/A

• 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

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

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

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

• Photos

  Media

• 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

  Select Trevor Duininck Chris Duininck Jason Duininck Judd Duininck Rick Maursetter Jeff Rettig

  • Trevor Duininck
  • Chris Duininck
  • Jason Duininck
  • Judd Duininck
  • Rick Maursetter
  • Jeff Rettig

• Select date

  Date

• Add signature

  Sign

• Supervisor

• Select date

  Date

• Received copy?

• Add signature

  Sign

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