Title Page
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Name:
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Date:
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Site Foreman Name:
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Contact Number:
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Company:
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Nearest Hospital:
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Location:
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Start Time:
Description of Work
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Road Conditions:
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Road:
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Specify:
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Site Distance:
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Specify:
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Weather:
- Snow
- Fog
- Rain
- COld
- Hot
- Windy
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TCP/LCT Scope Of Work
- Single Lane Alternating
- Slowing Traffic
- Lane Closure/Merge
- Cross Over
- Pedestrian Watch
- Shoulder Work
- Turn Lane Closed
- Road Closed
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Scope of work notes // Contractor Tool Box Notes
Risk Assessment
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Visibility
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Line of Sight
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Slips and Trips
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Falls/Open Hole
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Weather
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Dust
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Fumes
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Excessive Noise
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Blind Spots
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Overhead lines
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Working Alone
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Mobile Equipment
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Traffic volume
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Lighting Conditions
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Underground Utilities
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Fatigue
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Other
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TOTAL ASSESSMENT:
TCP/'s & LCT's Present
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Name and Signature:
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SN#:
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Name and Signature
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SN#:
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Name and Signature
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SN#:
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Name and Signature
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SN#:
Traffic Plan Quick Check
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Is the escape route identified?
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Have TCP's and LCT's Been Orientated?
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Does the speed need to be reduced?
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New TCP's/LCT's (Two years or less)
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I hereby acknowledge this hazard assessment is mandatory as per company policy and Worksafe BC and all information on this form is accurate to the best of my knowledge.
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Name and Signature:
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M.O.T. Figure #
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Speed Limit:
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Actual Speed:
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Lead TCP/LCT:
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Do you have an escape route?
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First Aid Attendant:
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Nearest First Aid Kit:
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Add drawing
