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0 JOBSITE SAFETY WORKSHEET <br /> Date'' I Location 6,1-kU <br /> Lead J Pre-Job Briefing Time 8;OO <br /> Description of Work: P-\11cg (AN' ,PLA( f,J2 <br /> Safety Incidents & Concerns: <br /> YES N/A <br /> Traffic Control Plan—Attach TCP if modified • <br /> Confined Space Entry—Attach Confined Space Permit / <br /> Uncontrolled Energy—Attach Lockout Tagout 1 <br /> BoomTruck <br /> uck Used—Attach <br /> Attach Lift plan if needed / <br /> Overhead lifting—Inspect rigging before each use ✓/ <br /> El trical Hazards&Controls 1 <br /> Overhead 0 Underground ❑ Generator ❑ Permanent Wiring <br /> Hot Work—Describe I <br /> Hazardous Materials Used <br /> Falls over 4 feet—Controlled by: v <br /> Excavation Entry over 3 feet deep <br /> Final Depth Width Length <br /> El Finn Form 0 Sloping ❑ Trench Box ❑ Build-a-Box <br /> First Aid Equipment/Training/Fire Extinguisher Must be Current <br /> Utilities Located: Water(blue) d Power(red) ❑ as (yellow) El Com unication (orange) 0 other <br /> Communication with emergency onders provided l adio Dispat h Phone 911 ❑ CityPhone 9-911 <br /> Personal Protective Equipment resHigh-Vis Head Eyes �] Hearing ❑Whole Body [other riv„-, MAcii...., <br /> Pre-Job Safety Meeting <br /> Name Assignment Name Assignment <br /> Rottowpi <br /> 21,Y 1k!s <br /> Revised 12/12/11 <br />