Information
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Document No.
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Client / Site Name
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Job #
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Conducted on
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Prepared by
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Location
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Personnel on site
For Work to Be Performed
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Have steps been made to ensure that work will not affect owner and/or owner's activities?
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Any special training required to perform work has already been completed?
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Do you have all of the additional tooling or equipment necessary to do the job safely?
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Are the necessary MSDS forms available?
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Is there sufficient lighting to work?
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Lockout/Tagout is being used when required?
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Is the area barricaded to protect outside personnel?
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Precautions have been made to reduce or eliminate work that may involve any awkward positions, heavy and/or repetitive lifting?
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Have you coordinated our work with other trades onsite?
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Does your crew know the locations of fire extinguishers, phones, and eye wash stations?
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Has all the rigging equipment been inspected?
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All necessary toolbox talks have been reviewed by crew?
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Any special permits have been obtained?
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Has all PPE has been inspected prior to use?
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Equipment is full of fuel, ready to work?
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All equipment is in proper working order with all necessary safety guarding in place?
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All extension cords and corded devices are free from fraying and are in excellent working condition?
Potential Hazards
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Chemical Burn
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Thermal Burn
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Debris In Eye
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Over Exertion
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Elevated Load
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Falls Over 6 Feet
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Overhead Work
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Sprains and Strains
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Dropping Tools
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Lowering Materials
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Hazardous Substances
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Confined Space
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Moving Machinery
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Lead/Asbestos
Hazard Elimination
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Tyvek Suit/Booties
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Inspect Tools
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Inspect Rigging
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Ladders
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Face Shield & Goggles
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PPE
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Housekeeping
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Fire Ext./Watch
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Spill Procedure
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Pipe Hoist
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Chainfall
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Smoke Eater
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Appliance Dolly
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30 Foot Retractable Lanyard
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Fall Harness
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Aerial Lift
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Hearing Protection
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Proper Tools
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Erect Barricades
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GFCI
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Proper Body Position
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Gas Monitor
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Scaffolding
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Welding Screen
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Work Table
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Hard Hat/Glasses
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Arc Flash Suit
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Gloves
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Protective Blankets over Batteries/BUSS
Required Certifications/Certified Employee
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Aerial Lift
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Welding
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Confined Space Entry
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Rough Terrain Forklift
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CPR & First Aid
Required Permits
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Hot Work
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Confined Space
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Mechanical
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Plumbing
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Other?
Sign Off
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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.
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Add signature
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