• Review #

  • Conducted on:

  • Reporting Office:

  • Personnel:

  • Job Task:

  • Project / Vision Proposal #

  • Job Location:
  • Reviewing Person:


  • Daily Job Site Safety Briefing has been has been filled out, discussed and reviewed with all field personnel. Form is readily accessible.

  • Closest medical facility is identified, including distance to.

  • A minimum of one employee is 1st Aid and CPR trained/certified.

  • General-Additional Comments:

PPE - Personal Protective Equipment -

  • Hard hats

  • Safety glasses

  • Correct foot wear

  • Hand protection

  • List glove type in use (i.e. leather; nitrile; kevlar; other):

  • Safety vests

  • Insulated measuring stick

  • Inspection date is current on stick, it is clean, no visible damage and operating properly

  • Sufficient drinking fluids are available (personal water jug)

  • Other PPE:

  • PPE-Additional Comments:

Job Site Safety Practices

  • Visually inspects pole and work area from a safe distance to identify any hazards prior to approaching.

  • Eliminates hazards or uses safe work practices to minimize hazards. <br>

  • Identifies & positions themselves to avoid pinch points (oncoming traffic, guardrails, etc.) while working

  • Follows established safe work practices when walking along roads with no sidewalks.

  • Follows the established safe work practices when measuring mid-spans where vehicular traffic is possible.

  • Follows the established safe work practices when extending & retracting the insulated measuring stick.

  • Communicates with co-worker throughout the job task.

  • Properly identifies themselves and act in a professional manner when interacting with the public, customers and the client.

  • Job Site Safety Practices-Additional Comments:

Vehicle Compliance / Safety

  • Vehicle parked correctly (pull in - pull out, back in - pull out, pull in - back out, etc.).

  • Spotter used when backing the vehicle.

  • Safety cones and 360 walk a round preformed correctly.

  • Beacon is mounted on top vehicle and operating correctly.

  • Vehicle registration and insurance certificate current.

  • Safety Equipment: fire extinguisher; first aid kit; vehicle safety tool, etc.

  • Equipment and other valuables are stored out of sight when vehicle is unoccupied.

  • Vehicle Compliance / Safety-Additional Comments:

  • Signatures
  • Reviewer's Signature

  • Employee 1 Signature

  • Employee 2 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.