Pre Excavation - Modify

• Location

• Conducted on

  Date

• Prepared by

• Document No.

Introduction

• Project / Site Name

• Excavation Scope and volume

• Has the Competent Person had training in excavation and trench safety?

  Yes

  No

  N/A

• Name of Competent Person

Soil Analysis

• Is soil analysis and classification required prior to excavation?

  Yes

  No

  N/A

• Has the Competent Person had training in, are knowledgable about soil analysis

  Yes

  No

  N/A

• Soil analysis method used

  Visual

  Manual

  Chemical

• Soil classification

• Select soil characteristics (select all that apply)

  Select Cemented Layered Fissured Cohesive Plastic Granular Dry Moist Saturated Submerged

  • Cemented
  • Layered
  • Fissured
  • Cohesive
  • Plastic
  • Granular
  • Dry
  • Moist
  • Saturated
  • Submerged

• Are any soil contaminants present?

  Yes

  No

  N/A

• Detail soil contaminants and quantity

General

• Has a Risk Assessment been completed by a Competent Person?

  Yes

  No

  N/A

• When are excavations, adjacent areas, and protective systems inspected by a competent person?

  Select Daily prior to start of work As needed throughout the shift After every rainstorm or other occurrence that could increase the hazard

  • Daily prior to start of work
  • As needed throughout the shift
  • After every rainstorm or other occurrence that could increase the hazard

• Underground utilities located, marked and noted, with operator and relevant personnel informed?

  Yes

  No

  N/A

• Is Traffic Control in place where required?

  Yes

  No

  N/A

• Are hard hats and all other appropriate PPE worn by all employees?

  Yes

  No

  N/A

• Are all employees protected from loose rock or soil that could pose a hazard by falling or rolling into the excavation?

  Yes

  No

  N/A

• Are barriers provided at all remotely located excavations, wells, pits, shafts, etc.?

  Yes

  No

  N/A

• Are walkways and bridges over excavations equipped with standard guard rails and toe-boards?

  Yes

  No

  N/A

Protective and Support Systems

• Type of protective system being used?

  Select Shoring Hydraulic Shoring Shielding Soldier Sets Battering / Sloping Benching

  • Shoring
  • Hydraulic Shoring
  • Shielding
  • Soldier Sets
  • Battering / Sloping
  • Benching

• Protective system appropriate for soil type, trench size and expected loads?

  Yes

  No

  N/A

• Have materials and equipment used for protective / support systems been inspected by the Competent Person and found to be in good condition?

  Yes

  No

  N/A

Access & Egress

• Are there safe means of egress regularly spaced across space of excavation?

  Yes

  No

  N/A

• Walkways, bridges, ladders and ramps are in safe, secure positions?

  Yes

  No

  N/A

• Are all personnel reasonably able to use access and egress?

  Yes

  No

  N/A

• Are all personnel familiar with emergency, rescue and evacuation procedures?

  Yes

  No

  N/A

Sign Off

• Name & Signature of Competent Person

  Sign

• Name & Signature of Site Foreman / Supervisor

  Sign