Information

  • Company Name:

  • Utility Name

  • Auditor(s) name:

  • Date/Time:

DESCRIPTION OF THE JOB

  • Jobsite location:

  • Name of foreman in charge:

  • Describe type of work being performed:

  • Are lines energized or de-energized:

  • Secondary or Distribution (or both):

  • Overhead or Underground:

JOB PREPARATION

  • Was tailgate/job briefing conducted and documented:

  • All applicable hazards identified

  • Pre-trip inspection was performed on CMV(s):

  • Pre-flight of aerial unit was performed:

  • Energy source controls (Energy Control/LOTO) have been identified:

  • DVIR Filled out correctly

WORK ZONE EVALUATION

  • Hard hat(s) properly worn and in good condition:

  • Eye protection in ANSI approved and 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 worn and inspected prior to use:

  • Rubber sleeves worn and inspected prior to use:

  • Fall protection used where appropriate and all components inspected prior to use:

  • Hand line available and in good condition

  • Proper cover-up on work as well as second points of contact

  • Designated observer as required on HOT WORK

  • Clear 3-way communication among crew members

TRAFFIC CONTROL

  • Beacon/strobe lights are in working order and being used:

  • Traffic cones are used and properly placed:

  • Road signs are adequate for the job being performed:

  • Reflective vests are worn:

  • A flagger is being used to control traffic:

GROUNDING

  • Digger/Bucket Truck grounds are being used and in good condition:

  • Personal grounds are being used and in good condition:

  • Conductor was tested prior to grounds being installed:

  • Crew members can explain proper grounding techniques:

  • Grounds are properly stored:

VEHICLES

  • Digger/bucket trucks are properly set up:

  • Wheel chocks are being used:

  • All material on the vehicle is properly stowed:

  • Outrigger pads are being used:

  • Fire extinguishers are properly charged and stored and inspected

  • First-aid kit is stocked and location is properly marked:

  • AED is available and location is properly marked:

GENERAL WORK PRACTICES

  • Proper tools are being used to complete the task:

  • Tools have been inspected and are in good condition:

  • Live-line tools have been inspected prior to use and tested within 2 years:

  • Ladders have been inspected and are in good condition:

  • Means of ingress/egress present in excavations >4 feet:

  • Excavations >5 feet have been shored/stepped back by a competent excavation safety trained employee:

  • Poles are tested prior to climbing:

  • Only qualified personnel are performing hazardous work:

  • Guards are in place on tools and equipment that need them:

AUDITOR VERIFICATION SIGNATURE(S)

  • Safe jobsite:

  • Safe work procedures followed:

  • Comments: ("NO" items require an explanation)

  • 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.