Title Page

  • Conducted on

  • Weather Conditions

  • Division

  • Show Up Location

  • Customer

  • Work Type

  • Work Order Number

  • Job Location
  • Prepared by

  • Preparer Employee Number

  • Superintendent

  • General Foreman

  • Supervisor/Foreman

  • Job Description

Job Briefing Form

  • Job Briefing Form

  • Are All Applicable Event Free Performance Tools Documented on the Job Briefing Form?

Rules & Procedures

  • Are All Applicable Event Free Performance Tools Being Utilized by the Crew?

  • Energy Source Hazards Identified with Energy Wheel.

  • 360° Walkaround

  • Wheel Chocks

  • Outrigger Pads

  • Situational Awareness / Eyes on Path

  • Signaling & Spotter

  • Hazard Communication

  • Proper Hydration & Fatigue Management

Work Area Protection

  • Green Cone

  • Traffic Control

  • Work Zone

  • Line of Fire From Above Zone

PPE

  • Head Protection

  • Eye Protection

  • Hand Protection

  • Foot Protection

  • Rubber Gloves & Sleeves

  • Dielectric Footwear

  • Fall Protection

  • Hearing Protection

  • Chainsaw Chaps

  • Respiratory Protection

Rubber & Hard Cover

  • Rubber Cover Inspected and in Good Condition?

  • Hard Cover Inspected and in Good Condition?

  • Proper Cover Installed?

Grounding & Bonding Systems

  • Grounds Inspected and in Good Condition?

  • Line / Equipment Tested Properly and Confirmed De-energized?

  • Primary Grounds Installed as Required? (Specify EPZ, Running etc, LOF))

Tooling & Equipment

  • Tool Condition

  • Tool Use

  • Equipment Condition

  • Equipment Use

  • Insulated Tools

  • Voltage Testers

Ergonomics

  • Three Points of Contact

  • Lifting

  • Work Positioning

Housekeeping

  • Clutter

  • Garbage

  • Tripping Hazards

  • Spills / Leaks

Emergency Response Material

  • Fire Extinguishers

  • First Aid Kits

  • AED

  • Burn Kit

  • Eyewash Stations

Excavation Safety

  • One Call / Dig Ticket

  • Prudent Digging Methods

  • Spoil Retention

  • Excavation Securement

  • Emergency Rescue

Other Hazards

  • Other Hazards Identified and Mitigated?

Additional Comments

  • Additional Comments

  • Pictures

Audit Closeout

  • Audit Closure

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.