Pre-Work Assessment Survey

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

• Take a Photo of the Site Sign

  Media

Certifications: (list employee certifications / Tower Rescue, CPR/FA) (list personnel certified)

• If climbing is being conducted are two or more employees on site Tower Rescue Certified?

  Yes

  No

  N/A

• Are two or more employees on site CPR/FA certified?

  Yes

  No

  N/A

• Is employee using hoist qualified/certified?

  Yes

  No

  N/A

• Are employees certified in rigging?

  Yes

  No

  N/A

• Are employees certified in confined space entry?

  Yes

  No

  N/A

Emergency Contacts

• Cell phone coverage?

  Yes

  No

  N/A

• Are 911 systems functional / cell phone?

  Yes

  No

  N/A

• Phone number and address for local Police, Fire and ER

Rescue Procedures (explain rescue procedures under selection)

• Outside Services?

  Yes

  No

  N/A

• Heavy Equipment?

  Yes

  No

  N/A

• Friction Control Device?

  Yes

  No

  N/A

• Internal Crew?

  Yes

  No

  N/A

• Other? (describe)

  Yes

  No

  N/A

Job/Tasks for Scope (describe job tasks under selected category)

• Tower Construction/Survey?

  Yes

  No

  N/A

• Electrical?

  Yes

  No

  N/A

• Civil/Concrete?

  Yes

  No

  N/A

• Drilling?

  Yes

  No

  N/A

• Bridge Construction/Survey?

  Yes

  No

  N/A

• Foundation Construction/Survey?

  Yes

  No

  N/A

• Other? (describe)

  Yes

  No

  N/A

Jobsite Exposures Physical Hazards (select and explain abatement on all that apply)

• Confined Space?

  Yes

  No

  N/A

• Dropped Tools/Equipment?

  Yes

  No

  N/A

• Electrical?

  Yes

  No

  N/A

• Elevation/Site Terrain?

  Yes

  No

  N/A

• Fall from Elevation/Roof Edge?

  Yes

  No

  N/A

• Fire Hazard?

  Yes

  No

  N/A

• Navigable Waters?

  Yes

  No

  N/A

• Heavy Equipment?

  Yes

  No

  N/A

• Overhead Utilities?

  Yes

  No

  N/A

• Slips, Trips, Falls?

  Yes

  No

  N/A

• Underground Utilities?

  Yes

  No

  N/A

• Vehicle Traffic?

  Yes

  No

  N/A

• Other? (describe)

  Yes

  No

  N/A

Jobsite Exposures Health Hazards (select and explain abatement on all that apply)

• Biological Hazards?

  Yes

  No

  N/A

• Chemical Exposures?

  Yes

  No

  N/A

• EME/RFR?

  Yes

  No

  N/A

• Environmental Hazards?

  Yes

  No

  N/A

• HazMat Exposure/Disturbance?

  Yes

  No

  N/A

• Heat Stress/Cold Stress?

  Yes

  No

  N/A

• High Noise (> 85 dBA)?

  Yes

  No

  N/A

• Lifting Hazards?

  Yes

  No

  N/A

• Silica Exposure?

  Yes

  No

  N/A

• Other? (describe)

  Yes

  No

  N/A

Civil Work

• Describe the type and depth of excavation:

• Have private utility locates been completed where required?

  Yes

  No

  N/A

• Have utilities been located where core boring/drilling is required?

  Yes

  No

  N/A

• Public utility locate work order number along with effective and expiration dates:

• Have all owner identified underground obstructions been located & marked?

  Yes

  No

  N/A

• Describe the cave-in control measures to be used if excavation will be greater than 5 feet personnel are entering the trench (sloping, benching, shoring, shield/box, ladder in trench at 4 feet):

• Describe elevation/site terrain/environmental concerns or hazards:

• Describe hazards with site/vehicle access (e.g. boom and cranes/electrical lines) and storage of materials:

• Describe the type of electrical hazards:

Elevated Work

• Type of Elevated Work Location:

• Type of Antenna Boom(s):

• Anchorage Straps Used?

• Controlled Descent Devices?

  Yes

  No

  N/A

• Retractable Lifelines?

  Yes

  No

  N/A

• Rope Grab?

  Yes

  No

  N/A

• Cable Grab?

  Yes

  No

  N/A

• Y-Lanyards?

  Yes

  No

  N/A

• Full Body Harness?

  Yes

  No

  N/A

• Other: (describe)

  Yes

  No

  N/A

• Site Supervisor/Foreman:

  Sign

• Lower Tier Subcontractor Supervisor:

  Sign

• Visitor(s):

  Sign

• Date and Time of Visitor(s):

  Date