Title Page
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Work order # or Job #
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Tech name
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Employee #
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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1. JHA is complete and accurate
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2. Is employee wearing all required PPE?
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3. Is your van clean and organized?
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4. Fire extinguisher in Vehicle?
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5. First Aid/Body fluid kit in vehicle?
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6. Vehicle accident forms?
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7. Is there drinking water available?
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8. Have your ladders been inspected and in good condition?
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Any Safety Violations found?
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Signature for Safety form packet?
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Pictures
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Notes
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Name of technician
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Name of Auditor
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Add media
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Name of Project Manager