Title Page

  • Conducted on

  • Prepared by

Description of the Job

  • Foreman in Charge:

  • Today’s Date:

  • Jobsite Location:

  • Describe Type of Work Being Performed:

  • Are the Lines Energized or De-energized:

  • Distribution, Secondary, Both:

  • Overhead or Underground:

Job Preparation

  • Tailgate Conducted & Documented:

  • Location Given to Dispatch:

  • Energy Source Controls Identified & Set to Non-Reclose:

Personal Protective Equipment

  • Hard Hats Worn & in Good Condition:

  • Eye Protection ANSI Approved & Worn:

  • Proper Hand Protection is Being Used:

  • Safety Toe Boots are Being Used:

  • Hearing Protection is Available:

  • FR Clothing is in Good Condition:

  • Rubber Gloves/Sleeves Worn & Inspected Before Use:

  • Fall Protection Used & Inspected Before Use:

Grounding

  • Truck Grounds are Being Used & in Good Condition:

  • Personal Grounds are Being Used & in Good Condition:

  • Conductor was Tested Prior to Grounds Being Installed:

Vehicles

  • Digger/Bucket Trucks are Properly Set Up:

  • Wheel Chocks are Being Used:

  • Outrigger Pads are Being Used:

Traffic Control

  • Strobe Light are in Working Order & Being Used:

  • Traffic Cones are Being Used:

  • Roads Signs are Adequate for the Job Being Performed:

  • Reflective Vests are Worn:

General Work Practices

  • Proper Tools are Being Used to Complete the Task:

  • Live-Line Tools Have Been Inspected Prior to Use & Tested Within 1 Year:

  • Hand Line are Available & in Good Condition:

  • Poles are Tested Prior to Climbing:

  • Adequate Cover-Up Materials are Being Used & Properly Covered/Isolated:

  • Only Qualified Personnel are Performing Hazardous Work:

  • Employees Performing Hot Work are Being Watched by a Designated Observer:

  • Clear Communication is Exchanged Among Crew Members:

  • Employees can Explain Direction of Feed & Closest Protection Device:

Auditor Verification Signatures

  • Safe Jobsite:

  • Safe Work Procedures Followed:

  • Include Photos if Applicable:

  • Signature:

  • Signature:

  • Signature:

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.