Title Page

  • Scope of Work

  • Conducted on

  • Conducted by

  • Supervisor

  • Location
  • Competent Person

  • Weather

  • Trades On-site

1.0 Workplace

  • 1.1-Code 753 (Mark Outs)

  • 1.2-Inspector

  • 1.3-Competent Person

2.0 Administrative

  • 2.1-Documentation of Job Briefing

  • 2.2-HASP on-site & current

  • 2.3-Air monitor in use, calibrated, & current

  • 2.4-Current permits posted & visible

  • 2.5-Complete Job Package on-site

  • 2.6-First Aid Kit/Blood Bourne Pathogen Kit on-site & current

  • 2.7-Spill Kit on-site

  • 2.8-Fire extinguisher visible, current, & immediately available

  • 2.9-Current RWLB matrix posted

3.0 Work Area Protection

  • 3.1-Flagger present

  • 3.2-Barricades/Cones/Stanchions complete & in compliance

  • 3.3-MUTCD signs in use where required

  • 3.4-Arrow board operating & in use when applicable

  • 3.5-Pedestrians provided with a safe & clear path of travel

  • 3.6-Plates Pinned, ramped, flush, skid resistant, & in complete compliance

  • 3.7-Slings & chains in good condition

  • 3.8-Rubber Electrical Gloves (KV) dated with expiration date

  • 3.9-Proper PPE in use when required

  • 3.10-Vehicle's engine turned off (Idling regulations)

  • 3.11-Wheels chocked when truck on standby (driver not in cab)

  • 3.12-All tools in good condition

  • 3.13-Adequate set-up

  • 3.14-Housekeeping in place on-site & in trucks to prevent slips, trips, and falls

4.0 Excavation

  • 4.1-Spoils & equipment 2' away from excavation

  • 4.2-Gas monitoring where required

  • 4.3-Ladders used at 4' depth or greater and extending 3' above landing

  • 4.4-Ladders in place every 25' of lateral travel

  • 4.5-Shoring/sheeting at 4'6" or greater or when required

  • 4.6-Daily excavation inspection conducted

  • Notes/Other:

Sign off

  • On-site Representative

  • Auditor's signature

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