Work Order/Pre-Job HA

• Customer

• Work Order #

• Prepared by

• LSD

• Date

  Date

• Unit Make

• Unit Model

• Unit Serial #

• Unit Hours

Scope of Work

• Job Scope

• Description of Work

• Regular Hours

• OT Hours

• KMs Driven

• Technician

• Signature

  Sign

• Client Signature

  Sign

Potential Hazards

• Chemicals (dust, gases, vapors)

  Yes

  No

  N/A

• Driving

  Yes

  No

  N/A

• Electricity

  Yes

  No

  N/A

• Energized equipment

  Yes

  No

  N/A

• Confined spaces

  Yes

  No

  N/A

• Excavations/trenches

  Yes

  No

  N/A

• Underground hazards

  Yes

  No

  N/A

• Gases/vapors/fumes

  Yes

  No

  N/A

• Heat (fire/burning)

  Yes

  No

  N/A

• Heat or cold stress

  Yes

  No

  N/A

• Lack of radio communication

  Yes

  No

  N/A

• Lifting heavy loads

  Yes

  No

  N/A

• Moving machinery/Heavy Equipment

  Yes

  No

  N/A

• New worker

  Yes

  No

  N/A

• Noise

  Yes

  No

  N/A

• Overhead power lines

  Yes

  No

  N/A

• Rotating equipment

  Yes

  No

  N/A

• Sharp objects

  Yes

  No

  N/A

• Slippery conditions

  Yes

  No

  N/A

• pinch points

  Yes

  No

  N/A

• Static electricity

  Yes

  No

  N/A

• Steep slopes/uneven surfaces

  Yes

  No

  N/A

• Traffic

  Yes

  No

  N/A

• Vibration

  Yes

  No

  N/A

• Water

  Yes

  No

  N/A

• Weather

  Yes

  No

  N/A

• Welding/cutting

  Yes

  No

  N/A

• Wildlife

  Yes

  No

  N/A

• Working alone

  Yes

  No

  N/A

• Do you have a call system in place, per Powershift Working Alone Policy?

  Yes

  No

• Working at heights

  Yes

  No

  N/A

• Housekeeping

  Yes

  No

  N/A

• H2S

  Yes

  No

  N/A

• O2 Deficiency

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Hazard Controls

• Additional lighting (e.g. Flashlight/trouble light)

  Yes

  No

  N/A

• Additional training

  Yes

  No

  N/A

• Barricades

  Yes

  No

  N/A

• Communication device

  Yes

  No

  N/A

• Confined space entry procedures

  Yes

  No

  N/A

• Check in/out procedures

  Yes

  No

  N/A

• Coveralls

  Yes

  No

  N/A

• Emergency or rescue procedure

  Yes

  No

  N/A

• CSA eye protection

  Yes

  No

  N/A

• Fall arrest/travel restraint system

  Yes

  No

  N/A

• Fall protection

  Yes

  No

  N/A

• Fire extinguisher/fire blanket

  Yes

  No

  N/A

• First aid kit

  Yes

  No

  N/A

• Gas monitors

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Was your gas monitor bump tested?

  Yes

  No

• When?

  Date

• CSA hard hat/helmet

  Yes

  No

  N/A

• CSA hearing protection

  Yes

  No

  N/A

• Hot work permit

  Yes

  No

  N/A

• JLG/Genie lifting device

  Yes

  No

  N/A

• Ladders for safe access and egress

  Yes

  No

  N/A

• Lockout tag procedure

  Yes

  No

  N/A

• Do you have your own lock?

  Yes

  No

• Machine guarding

  Yes

  No

  N/A

• Mechanical ventilation

  Yes

  No

  N/A

• Other personal protection equipment

  Yes

  No

  N/A

• Overhead clearance established

  Yes

  No

  N/A

• Pedestrian barricades

  Yes

  No

  N/A

• Personal floatations device

  Yes

  No

  N/A

• CSA protective footwear

  Yes

  No

  N/A

• Safe work procedure

  Yes

  No

  N/A

• Scaffolds (inspected and tagged)

  Yes

  No

  N/A

• Shovel/bucket

  Yes

  No

  N/A

• Signs

  Yes

  No

  N/A

• Spotter

  Yes

  No

  N/A

• Water

  Yes

  No

  N/A

• Welding shield

  Yes

  No

  N/A

• Other

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Inspection by:

  Sign

• Other employee/subcontractors:

  Select Yes No

  • Yes
  • No