Title Page
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Site conducted
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Conducted on
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Utility Region
- ACE
- BGE
- DELMARVA
- PECO
- PEPCO
- Crown Castle
- Blair Park
- Storm Restoration
- Service Work
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Work Order Number
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Location
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Prepared by
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General Foreman
- Bob Krieger
- Craig Brown
- Scott Poe
- Joe Murphy
- Jimmie Moore
- Jake Hutslar
- Jeremy Houdeshell
- Will Nix
- Ryan Edwards
- Robbie Pardee
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Supervisor/Foreman
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Supervisor/Foreman Signature
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Job Description
JSA Forms
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JSA Forms
Event Free Performance Tools
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Are All Applicable Event Free Performance Tools Documented on the Job Briefing Form?
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Are All Applicable Event Free Performance Tools Being Utilized by the Crew?
Wire Pull Checklist
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Crew has completed the wire pull checklist for the wire pull they are conducting?
Green Cone
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Green Cone
Traffic Control
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Traffic Control Used?
Work Zone
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Work Zone Established?
Electrical Hazards
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All Electrical Hazards Identified and Mitigated?
Other Hazards
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Hazards Identified and Mitigated?
PPE
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All PPE Being Used?
Fall Protection & Securement
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Fall Protection & Securement Used?
Proper Cover
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Proper Cover Used?
Proper Grounds
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Grounds Installed?
Housekeeping
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Housekeeping Compliant?
Material Storage
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Material Storage Secured, Organized, and Cleanly?
Hand Tools
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Proper Hand Tools Being Used and Utilized Appropriately?
Ladders
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Proper Ladders Being Used and Utilized Appropriately?
Confined Space
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Confined Space Work Being Conducted and All Procedures Being Followed?
Excavation Safety
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Excavations Being Performed and All Procedures Being Followed?
Wheel Chocks
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Wheel Chocks Out on All Parked Vehicles?
Outrigger Pads
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Outrigger Pads Out When Outriggers in Use?
Line of Fire From Above Zone
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Line of Fire From Above Zone Established While Working Aloft?
Rigging Methods
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Correct Rigging Methods Utilized?
Handlines
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Proper Handlines are Readily Available With Workers Aloft and Being Used When Necessary?
Fire Extinguishers
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Fire Extinguishers are on site, labeled, stored appropriately, inspected, and are in good working order?
First Aid Kits
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First Aid Kits are on site, labeled, stored appropriately, inspected, and stocked?
AED
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AED is on site, labeled, stored appropriately, inspected, and in good working order?
Additional Comments
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Additional Comments
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Pictures
