Title Page

  • Date/Time

  • Inspected By

  • Location
  • System Work Order

  • Clearance Number

  • Hot Line Permit Number

  • Employee In Charge

  • Emergency Caller

  • Crew Members

Observation Summary

  • Notes/Comments



  • Worksite kept neat and orderly?

  • Damaged/Replaced items removed from site?

Pre-Job Briefing

  • Pre-Job Briefing completed/all hazards reviewed?

  • Emergency procedures reviewed?

  • Everyone briefed and knowledgeable of job expectations?

  • Designated observer in place?

  • Switching procedures reviewed and understood?

Personal Protective Equipment (PPE)

  • PPE in good condition?

  • Required PPE in-use?

  • Climbing equipment in good condition?

  • Fall protection worn and in good condition?

  • Tools properly inspected and tested?

  • Proper tools available and used?

  • First Aid kits stocked/available?

  • Fire extinguishers charged/available?

Ergonomics & Working Positions

  • Appropriate body positioning?

  • Lifting techniques exhibited correctly?

  • Physical limitations not exceeded?

  • 3-Points of contact used when accessing equipment?

Energized Work Methods

  • Minimum approach distances observed?

  • Voltage(s) identified and source device set to non-reclose?

  • All difference of potential within work area covered?

  • Designated qualified observer in place?

  • Step/Touch potential hazards addressed?

Work Zone Setup

  • Work zone/traffic control meets KDOT or local guidelines?

  • Locates confirmed?

  • Trenching/Excavation guidelines followed?

  • Public protection/barricades in place?

Vehicle/Equipment Setup & Grounding

  • Vehicles/Equipment chocked/outrigger pads used?

  • Vehicles/Equipment are grounded/barricaded/isolated?

  • Employees clear of equipment when in vicinity of energized lines/equipment?

  • Grounds completely uncoiled and within annual test date?

Lock-Out / Tag-Out

  • Lines and equipment to be worked identified?

  • Visible open point established and tagged?

  • Lines/Equipment tested and grounded?

  • Dispatcher and affected employees notified?


  • Daily pre-trip inspection performed?

  • Wheel chocks and cones used?

  • Lights on for Safety?

  • Tools/Equipment properly secured?

  • Loads are properly secured and identifying markers in place?

Material Handling & Rigging

  • Rigging equipment properly rated and sized for load?

  • Slings/Hoists inspected prior to use?

  • Employees clear of elevated loads?

  • Proper hand signals/communication used?

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.