Information

  • Document No.

  • Client / Site Name

  • Job #

  • Conducted on

  • Prepared by

  • Location
  • Personnel on site

For Work to Be Performed

  • Have steps been made to ensure that work will not affect owner and/or owner's activities?

  • Any special training required to perform work has already been completed?

  • Do you have all of the additional tooling or equipment necessary to do the job safely?

  • Are the necessary MSDS forms available?

  • Is there sufficient lighting to work?

  • Lockout/Tagout is being used when required?

  • Is the area barricaded to protect outside personnel?

  • Precautions have been made to reduce or eliminate work that may involve any awkward positions, heavy and/or repetitive lifting?

  • Have you coordinated our work with other trades onsite?

  • Does your crew know the locations of fire extinguishers, phones, and eye wash stations?

  • Has all the rigging equipment been inspected?

  • All necessary toolbox talks have been reviewed by crew?

  • Any special permits have been obtained?

  • Has all PPE has been inspected prior to use?

  • Equipment is full of fuel, ready to work?

  • All equipment is in proper working order with all necessary safety guarding in place?

  • All extension cords and corded devices are free from fraying and are in excellent working condition?

Potential Hazards

  • Chemical Burn

  • Thermal Burn

  • Debris In Eye

  • Over Exertion

  • Elevated Load

  • Falls Over 6 Feet

  • Overhead Work

  • Sprains and Strains

  • Dropping Tools

  • Lowering Materials

  • Hazardous Substances

  • Confined Space

  • Moving Machinery

  • Lead/Asbestos

Hazard Elimination

  • Tyvek Suit/Booties

  • Inspect Tools

  • Inspect Rigging

  • Ladders

  • Face Shield & Goggles

  • PPE

  • Housekeeping

  • Fire Ext./Watch

  • Spill Procedure

  • Pipe Hoist

  • Chainfall

  • Smoke Eater

  • Appliance Dolly

  • 30 Foot Retractable Lanyard

  • Fall Harness

  • Aerial Lift

  • Hearing Protection

  • Proper Tools

  • Erect Barricades

  • GFCI

  • Proper Body Position

  • Gas Monitor

  • Scaffolding

  • Welding Screen

  • Work Table

  • Hard Hat/Glasses

  • Arc Flash Suit

  • Gloves

  • Protective Blankets over Batteries/BUSS

Required Certifications/Certified Employee

  • Aerial Lift

  • Welding

  • Confined Space Entry

  • Rough Terrain Forklift

  • CPR & First Aid

Required Permits

  • Hot Work

  • Confined Space

  • Mechanical

  • Plumbing

  • Other?

Sign Off

  • The tasks have been reviewed in the work area where they will be performed and this plan has been reviewed with the workers on this crew.

  • Add signature

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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.