W.A.RASIC CONSTRUCTION

• Description of Work

• Job site number

• Location
  Address

• Superintendent

• Foreman & Crew

• Prepared by

• Conducted on

  Date

1.0 - JSA

• 1.1 - Completed & Signed?

  Yes

  No

  N/A

2.0 - PPE

• 2.1 - Crew wearing required PPE?

  Yes

  No

  N/A

3.0 - Temporary Traffic Control

• 3.1 - Was Traffic Control set up by Rasic employees?

  Yes

  No

  N/A

• 3.2 - If TTC was set up Rasic employees, was it set up in accordance with MUTCD and/or the Watch Manual?

  Yes

  No

  N/A

4.0 - House Keeping

• Does the job site have adequate House Keeping?

  Yes

  No

  N/A

5.0 - Confined Space Entry

• 5.1 - Gas Monitor Calibrated?

  Yes

  No

  N/A

• 5.2 - Log Book completed?

  Yes

  No

  N/A

• 5.3 - Adequate Ventilation?

  Yes

  No

  N/A

• 5.4 - Attendant present?

  Yes

  No

  N/A

• 5.5 - Ladder?

  Yes

  No

  N/A

• 5.6 - Manhole Guard?

  Yes

  No

  N/A

6.0 - Energized Vaults (confined space cont.)

• 6.1 - FR donned?

  Yes

  No

  N/A

• 6.2 - QEW on site?

  Yes

  No

  N/A

• 6.3 - Temperature readings taken?

  Yes

  No

  N/A

7.0 - Excavation, Trenching & Shoring

• 7.1 - Spoilage back 2’?

  Yes

  No

  N/A

• 7.2 - Shoring in trench over 5’?

  Yes

  No

  N/A

• 7.3 - Tabulate Data on site?

  Yes

  No

  N/A

• 7.4 - Shoring per tabulated data?

  Yes

  No

  N/A

• 7.5 - Ladder in trench 4' or deeper?

  Yes

  No

  N/A

• 7.6 - Ladder secured?

  Yes

  No

  N/A

• 7.7 - Gas Monitor in use and calibrated?

  Yes

  No

  N/A

8.0 - Equipment Check List

• 8.1 - Ladders inspected and noted on JSA?

  Yes

  No

  N/A

• 8.2 - Electrical cords inspected and in good condition?

  Yes

  No

  N/A

• 8.3 - Power tools in good repair?

  Yes

  No

  N/A

• 8.4 - Guards on appropriate tools and functional?

  Yes

  No

  N/A

• 8.5 - Air Hoses secured with Whip Checks and/or Pins or Wire?

  Yes

  No

  N/A

• 8.6 - Equipment inspection logs up to date?

  Yes

  No

  N/A

9.0 - Rigging

• 9.1 - Chains/Cable Sling Certified/Tagged?

  Yes

  No

  N/A

• 9.2 - Synthetic slings Certified/Tagged?

  Yes

  No

  N/A

• 9.3 - Move plates with shovel/broom?

  Yes

  No

  N/A

• 9.4 - Using Tag Lines to control lifted loads?

  Yes

  No

  N/A

10.0 - Administrative

• 10.1 - IIPP on site?

  Yes

  No

  N/A

• 10.2 - Required Permitting on Site?

  Yes

  No

  N/A

• 10.3 - Utilities located and secured?

  Yes

  No

  N/A

• 10.4 - Dig Alert ticket up to date?

  Yes

  No

  N/A

• 10.5 - Heat Illness Prevention Plan updated and reviewed?

  Yes

  No

  N/A

11.0 - Miscellaneous

• 11.1 - Wheel chocks used when needed?

  Yes

  No

  N/A

• 11.2 - Additional PPE for specific tasks?

  Yes

  No

  N/A

• 11.3 - Class 3 Vests donned at night?

  Yes

  No

  N/A

• 11.4 - Back up alarms functional?

  Yes

  No

  N/A

• 11.5 - Seat Belts worn by operators when operating?

  Yes

  No

  N/A