Title Page
-
Date and Time:
-
Division:
-
Project:
-
Project #:
-
Plan Reviewer:
-
Pre-job Checklist
-
1. PPE
-
2. Signs/Cones Placed
-
3. Wheels Chocked
-
4. Stretch/Warm Up
-
5. Print/Job Review
-
6. Property Damage Noted
-
7. Customer Contacted
-
8. Pre-Task Card Review
-
Task:
-
Recognized Hazards (Check all that apply):
-
Chemicals
-
Material Handling
-
Pedestrian/Vehicle Traffic
-
Company Vehicle Placement
-
Job Access
-
Underground Utilities
-
Fire/Explosion
-
Sprinkler Systems
-
Propane Tanks
-
Machine Guarding
-
Heavy Equipment
-
Energized Electric
-
Struck By's
-
Slip/Trip/Fall Hazard
-
Pinch Points/Caught Betweens
-
Excessive Noise
-
Eye Injury
-
Other:
-
Hazard Protection (Check all that apply):
-
Hearing Protection
-
High Voltage Electric Protection
-
Barrier Protection Erected
-
Propane/Gas Tanks Isolated
-
Material Safety Data Sheet
-
Equipment Inspection
-
Tool Inspection
-
Flagger/Traffic Control
-
Other:
-
1. Discuss yesterday's incidents?
-
Yes
-
No
-
N/A
-
2. Site Safety Orientation Complete?
-
Yes
-
No
-
3. Task Scope Understood?
-
Yes
-
No
-
Post-Job Checklist
-
1. All Excavations Secured
-
2. Customer Equipment Secured
-
3. Signs/Cones Removed
-
4. Truck/Trailer/Equipment Secured
-
5. On-Site Equipment Secured
-
Crew covered in this plan:
-
Weather:
-
Temperature:
-
Other Comments:
-
Covered Crew Signature
-
Covered Crew Signature
-
Covered Crew Signature
-
Covered Crew Signature
-
Covered Crew Signature
-
Covered Crew Signature
