Information

  • Date

  • Project Foreman (Prepared By)

  • Personnel

  • Project Name or Location

Emergency Information

  • Location of Primary Assembly Point

  • Location of Severe Weather Shelter

  • Location of Safety Shower/Eye Wash

  • Location of First Aid Kit/Spill Kit

Sequence of Job Steps

  • Step 1: (If applicable) Get Permit Signed/Sign-In/Complete Walk Down

  • Step 2:

  • Step 3:

  • Step 4:

  • Step 5:

  • Step 6: (If Applicable) Clean up/Sign-Out/Close Out Permit/Communicate with Operator

Hazards and Mitigations (Pre-Job/During the Job)

    Direct Hazards of the Job, Actionable Mitigation
  • Hazard

  • Applies to Job Step #

  • Potential Consequence

  • Minor Injury

  • Significant Injury

  • Fatality

  • Equipment

  • Environmental

  • Daily Site Inspection Checklist

PPE Compliance

  • Crew members are meeting the minimum PPE requirements (hard hat, toed boots, ear plugs, H2S/5 gas badge, gloves)

  • All staff is wearing a class II high-visibility vest

  • All staff is wearing safety glasses/goggles

General Safety Checklist

  • (If Applicable) All crew members completed site specifc training

  • Equipment/tools are inspected and in good condition prior to use

  • Crew members are confident/properly trained on the equipment and/or tools used for the job

Excavation Checklist

  • Appropriate drawings have been reviewed and are present onsite for identification of underground installations

  • What is being done to ensure contact with underground installations are avoided?

  • There is an open/active one call ticket

  • Barricades are in place around excavation

  • Is a Confined Space Form Required?

  • Is a Trenching and Excavation Form Required?

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.