• Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Dayshift or Nightshift?

  • Has a proper face Preparation been completed?

  • Has line been shot? What are the offsets?

  • Has Grade been shot? What are the offsets?

  • Has Grade line been painted on the wall?

  • What is the distance of the front plug to the face?

  • Dimensions of Excavation:

  • Is the ventilation in good shape and 50' from the face?

  • Are Atomizers set up for use?

  • Supporting Media


  • Is the ground support installed as per print and to company standards?

  • Is screen/shotcrete installed as per company standards? (ie. 5' from floor, overlap etc...)

  • Is there overbreak due to poor ground conditions?

  • Description of conditions:

  • Supporting Media:

  • Does the driller have a working methane tester?


  • Workplace: (Road conditions, Housekeeping, ventilation, standing water)

  • Notes:

  • Ventilation: (Required CFM's, Actual CFM's, Installation, Quality, Distance from face)

  • Notes:

  • Ground Support: (Bolted to compliance, quality, screen tight to wall/back, correct overlap, within 5' of floor)

  • Notes:

  • Housekeeping: (neat, organized, clean)

  • Notes:

  • Services: (Air, Water, Quality, to standard, leaking)

  • Notes:

  • Supporting Media:

  • Signature:

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