Visu-Sewer

• Conducted on

  Date
• Location
  Address

• Prepared by

• Supervisor

• Crew Leader

• Crew Members

• Job Number

Site and Traffic Control

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

First Aid Kits

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Fire Protection/Extinguishers

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Ladders/Stairs/Walking Surfaces

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Equipment Maintenance

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Housekeeping/Health/Hygiene

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Spill Kits

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Electrical and Power Tools

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Hazcom / Right-to-Know

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Fall Protection

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Confined Space Procedure

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Daily Huddle

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Hard Hat

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Reflective Clothing

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Safety Boots

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Safety Glasses

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

LOTO

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Excavations

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Night Work

• Hazard 1

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

General Safety

• Hazard 1

  Safe

  At Risk

  N/A

• Hazard 2

  Safe

  At Risk

  N/A
Additional Hazards

• Hazard Identified

  Safe

  At Risk

  N/A

Inspection Results

• Calculate Overall Score (Make any needed adjustments based on Additional Hazards or Blatant Violations). Blatant Violations Result in a 0.6 Multiplier.

• Did the site pass inspection?

  Yes

  No

  N/A

• Foreman Signature

  Sign

Individual Crew Member Performance

• Crew Member Name

• Truck Number

• Hard Hat

  0

  1

  2

  3

• Reflective Clothing

  0

  1

  2

  3

• Safety Shoes

  0

  1

  2

  3

• Truck Score

  0

  1

  2

  3

Individual Crew Member Performance

• Crew Member Name

• Truck Number

• Hard Hat

  0

  1

  2

  3

• Reflective Clothing

  0

  1

  2

  3

• Safety Shoes

  0

  1

  2

  3

• Truck Score

  0

  1

  2

  3

Individual Crew Member Performance

• Crew Member Name

• Truck Number

• Hard Hat

  0

  1

  2

  3

• Reflective Clothing

  0

  1

  2

  3

• Safety Shoes

  0

  1

  2

  3

• Truck Score

  0

  1

  2

  3

Individual Crew Member Performance

• Crew Member Name

• Truck Number

• Hard Hat

  0

  1

  2

  3

• Reflective Clothing

  0

  1

  2

  3

• Safety Shoes

  0

  1

  2

  3

• Truck Score

  0

  1

  2

  3

Individual Crew Member Performance

• Crew Member Name

• Truck Number

• Hard Hat

  0

  1

  2

  3

• Reflective Clothing

  0

  1

  2

  3

• Safety Shoes

  0

  1

  2

  3

• Truck Score

  0

  1

  2

  3