Title Page
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Job name
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Location
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Date
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Prepared by
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Team members
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Description of work - Provide a brief description of the overall job task being completed today.
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Step 1 - List the first step of the job
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Step 2
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Step 3
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Step 4
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Step 5
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Step 6
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Step 7
Pre-task plan
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Hand and Power Tools - Will hand and power tools be used?
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List tools being used
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Have tools been inspected to ensure safe and appropriate tools for the job?
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Are electrical cords safely insulated and grounded?
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Are punches and chisels free of mushrooming or cracks
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Are power tools in good working order and have cords with ground prong and no frayed insulation?
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Flying Debris or Silica Dust - Will the work involve flying debris or silica dust?
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Choose appropriate safety glasses, goggles or faceshield.
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For silica dust, list control measures that will be used to include water, dust extraction etc.
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Manual Material Handling - Will material or equipment be lifted?
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Over 100 lbs? - Use lifting equipment.
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From 50-100 lbs? - Use team lift.
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Under 50 lbs? - Use better posture including: Position elbows closer, Flex knees, Align spine, Build a bridge and Use same side hand and foot.
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Will ladders be used?
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Is there an alternative to ladders that can be used such as scissor or boom lift or scaffolding?
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What alternative device will you be using?
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Is this the appropriate ladder for the job? (non-metal for electrical, rated for the load, a-frame verses extension, proper height)
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Has the ladder been inspected for cracks, cleanliness of rungs, labels present, material is sturdy, feet in good working condition?
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Is the area for ladder use level and clean of debris?
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Is the ladder the proper height for the job?
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Will hazardous chemicals be used?
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List chemicals
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Have Safety Data Sheets been obtained and reviewed?
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What PPE is required for these chemicals?
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Heavy Equipment - Will heavy equipment be used?
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Work at Heights - Will work be done over 6 feet from the ground or lower surface?
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List which form of fall protection will be used below:
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Fall arrest or fall restraint system (Anchorage, Body Harness, Compatible lanyard)
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Warning lines 15 feet from edge of roof on low slope roof with safety officer present.
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Handrail installed or standard barrier guardrail.
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Net system
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Describe fall prevention plan.
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Hazardous Energy - Will work be done on or around energized electrical devices or other forms of hazardous energy?
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Are electrical cords free of nicks, cuts, missing ground pins and electrical tape repairs?
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All damaged cords or wiring must be replaced or repaired by a certified electrician.
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Are GFCI outlets available?
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Will work be done on energized equipment?
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Describe lockout tagout procedures.
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Are other forms of hazardous energy present? (hydraulic, pneumatic, steam, gravity, kinetic etc.)
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Describe lockout plan.
