Information
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Document No.
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Project Name
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Work Location
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Task Performed
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Client / Site Name
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Project Number
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Conducted on
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Prepared by
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Emergency Planning
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Location (Closest Physical Street Address)
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First Aid/CRP Persons Onsite
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Personnel
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For Emergencies Dial 911/For Non‐Emergencies Dial WorkCare (888) 449‐7787
Personal Protective Equipment
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Eye/Face Protection
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Type of Eye/Face Protection
- Safety Glasses
- Goggles
- Face Shield
- Welding Hood
- Other
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Other?
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Foot Protection
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Type of Foot Protection
- Safety Toe
- EH Rated
- Rubber Boots
- Other
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Other?
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Hand Protection
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Type of Hand Protection
- Leather
- Cut Resistant
- Chemical
- Other
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Other?
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Head Protection
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Type of Head Protection
- Hardhat
- EH Rated Hardhat
- Other
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Other?
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Fall Protection
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Type of fall protection
- Personal Fall Arrest
- Guardrails
- Lifeline
- Other
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Other?
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Hearing Protection
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Type of Hearing Protection
- Ear Plugs
- Canal Caps
- Ear Muffs
- Other
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Other?
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Protective Clothing
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Type of Protective Clothing
- Tyvek
- FR Rated
- Heat Resistant
- Cold Resistant
- Other
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Other?
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Respiratory Protection
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Type of Respiratory Protection
- Filter Facepiece
- Half Mask
- Full Facepiece
- HEPA
- SCBA
- Other
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Other?
Procedures/Programs
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Check which TRC Compliance Programs apply to the work being performed.
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Fall Protection Program
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LOTO/Energy Control Program
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Trenching/Excavation Program
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Confined Space Program
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Scaffold/Aerial Lift Program
Training
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Check applicable TRC training programs required for the task being performed.
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Fall Protection
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Aerial Lift
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Scaffold
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Confined Space
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Trench/Excavation
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OSHA 10 Construction
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OSHA 30 Construction
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HAZWOPER
G.E.M.S.
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Gravity
- Falling from a height
- Falling objects
- Falling structures
- Climbing obstructions
- Aerial device operation
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Electrical
- Electrical contact
- Back-feed
- Flash potential
- Overhead Lines
- Underground lines
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Mechanical
- Equipment failure
- Equipment under tension
- Loaded springs
- Moving parts
- Cranes/Rigging
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Kinetic
- Traffic
- Driving conditions
- Moving/Shifting loads
- Rotating machinery
- Vehicle stability
- Heavy equipment operation
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Other/Environmental
- Asbestos/Lead
- Animals/Insects
- Confined space
- Excavations
- Heat/Cold
- Pressurized fluids/gases
Task Safety Analysis
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List all hazards associated with this task.
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Barriers to eliminate/control above hazards?
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
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Signature of crew members present
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Add signature
Post Task Analysis
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Did any injuries or incidents occur today? If yes,<br>explain.
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Explain injury or incident.
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Was the injury or incident reported the safety<br>department?
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What problems did you have with today’s work assignment?
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What can we do tomorrow to improve performance?
