Select date
Job Site Information

Describe Work Being Performed

Type of work being performed

Work is being performed

Grounded Work

Grounds and LO/TO In Place

Isolated Work

Energized Work

Crew Information
Crew Leader
Trucks and Equipment
PPE and Safety Precautions
Job Briefing - Take Photo(s) Please

Hard Hat

Safety Glasses

FR Clothing

Hearing Protection

Rubber Gloves

Rubber Sleeves

Fall Protection

Traffic Vest / Hi-Viz Garment

Traffic Control - Take Photo(s) Please

Personal Protective Ground - Visible From Worksite

Cover Up - Take Photo(s) Please
Equipment and Vehicle Safety

Wheel Chocks

Outrigger Pads

Daily Inspection

Equipment Grounds

Hand-line in Bucket

Overview of Observed Work Practices

What went well:

What went well:

What needs attention:

What needs attention:

Violation(s) of known safety rules:

Violation(s) of known safety rules:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.