Service Inspection FSG

• Work order #

• Tech name

• Employee #

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Other Personnel

Audit

• JHA is complete and accurate

  Yes

  No

  N/A

• LOTO has been utilized?

  Yes

  No

  N/A

• Means of disconnect available?

  Yes

  No

  N/A

• Is van Clean?

  Yes

  No

  N/A

• Is employee wearing all required PPE?

  Yes

  No

  N/A

• 12 cal suit available?

  Yes

  No

  N/A

• 12 cal suit in good repair?

  Yes

  No

  N/A

• Fire extinguisher in Vehicle?

  Yes

  No

  N/A

• First Aid/Body fluid kit in vehicle?

  Yes

  No

  N/A

• Attach photos of Job

  Media

• Notes:

• Signature of Tech

  Sign

• Other Signature

  Sign

• Inspector signature

  Sign