Information
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Date & Time
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Project Foreman (Prepared By)
- Alan Thell
- Alex Feldhege
- Brian Hendren
- Cameron Sarnstrom
- Cory Schaffer
- Jim Shores
- Joe Warner Jr.
- Phil Currie
- Ron Warner
- Trevor Pugleasa
- Joe Durand Jr.
- Eric Baker
- Matt Baker
- Damian Jensen
- Nick Tappe
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Personnel
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Project Name or Location
Emergency Information
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Location of Primary Assembly Point
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Location of Severe Weather Shelter
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Location of Safety Shower/Eye Wash
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Location of First Aid Kit/Spill Kit
Sequence of Job Steps
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Step 1: (If applicable) Get Permit Signed/Sign-In/Complete Walk Down
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Step 2:
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Step 3:
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Step 4:
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Step 5:
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Step 6: (If Applicable) Clean up/Sign-Out/Close Out Permit/Communicate with Operator
Hazards and Mitigations (Pre-Job/During the Job)
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Direct Hazards of the Job, Actionable Mitigation
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Hazard
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Applies to Job Step #
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Potential Consequence
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Minor Injury
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Significant Injury
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Fatality
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Equipment
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Environmental
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Daily Site Inspection Checklist
PPE Compliance
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Crew members are meeting the minimum PPE requirements (hard hat, toed boots, ear plugs, H2S/5 gas badge, gloves)
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All staff is wearing a class II high-visibility vest
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All staff is wearing safety glasses/goggles
General Safety Checklist
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(If Applicable) All crew members completed site specifc training
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Equipment/tools are inspected and in good condition prior to use
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Crew members are confident/properly trained on the equipment and/or tools used for the job
Excavation Checklist
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Appropriate drawings have been reviewed and are present onsite for identification of underground installations
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What is being done to ensure contact with underground installations are avoided?
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There is an open/active one call ticket
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Barricades are in place around excavation
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Is a Confined Space Form Required?
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Is a Trenching and Excavation Form Required?
