Title Page
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Conducted on
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Prepared by
Description of the Job
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Foreman in Charge:
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Today’s Date:
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Jobsite Location:
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Describe Type of Work Being Performed:
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Are the Lines Energized or De-energized:
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Distribution, Secondary, Both:
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Overhead or Underground:
Job Preparation
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Tailgate Conducted & Documented:
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Location Given to Dispatch:
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Energy Source Controls Identified & Set to Non-Reclose:
Personal Protective Equipment
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Hard Hats Worn & in Good Condition:
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Eye Protection ANSI Approved & Worn:
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Proper Hand Protection is Being Used:
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Safety Toe Boots are Being Used:
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Hearing Protection is Available:
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FR Clothing is in Good Condition:
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Rubber Gloves/Sleeves Worn & Inspected Before Use:
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Fall Protection Used & Inspected Before Use:
Grounding
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Truck Grounds are Being Used & in Good Condition:
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Personal Grounds are Being Used & in Good Condition:
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Conductor was Tested Prior to Grounds Being Installed:
Vehicles
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Digger/Bucket Trucks are Properly Set Up:
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Wheel Chocks are Being Used:
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Outrigger Pads are Being Used:
Traffic Control
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Strobe Light are in Working Order & Being Used:
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Traffic Cones are Being Used:
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Roads Signs are Adequate for the Job Being Performed:
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Reflective Vests are Worn:
General Work Practices
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Proper Tools are Being Used to Complete the Task:
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Live-Line Tools Have Been Inspected Prior to Use & Tested Within 1 Year:
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Hand Line are Available & in Good Condition:
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Poles are Tested Prior to Climbing:
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Adequate Cover-Up Materials are Being Used & Properly Covered/Isolated:
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Only Qualified Personnel are Performing Hazardous Work:
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Employees Performing Hot Work are Being Watched by a Designated Observer:
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Clear Communication is Exchanged Among Crew Members:
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Employees can Explain Direction of Feed & Closest Protection Device:
Auditor Verification Signatures
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Safe Jobsite:
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Safe Work Procedures Followed:
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Include Photos if Applicable:
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Signature:
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Signature:
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Signature: