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, <br /> 4ETT JOBSITE SAFETY WORKSHEET <br /> Date ii V(Zo Location 6M0. etavoR,E <br /> Lead 10 Pre-Job Briefing Time 1;00 . <br /> Description of Work: <br /> Safety Incidents & Concerns: <br /> YE N/A <br /> Traffic Control Plan—Attach TCP if modified <br /> Confined Space Entry—Attach Confined Space Permit <br /> Uncontrolled Energy—Attach Lockout Tagout v <br /> Boom Truck Used—Attach Lift plan if needed 1 <br /> Overhead lifting—Inspect rigging before each use <br /> EI ctrical Hazards&Controls I <br /> Overhead 0 Underground ❑ Generator 0 Permanent Wiring <br /> Hot Work—Describe / <br /> JiHazardous Materials Used <br /> Falls over 4 feet—Controlled by: <br /> Excavation Entry over 3 feet deep <br /> Final Depth Width Length <br /> 0 Finn Form ❑ Sloping ❑ Trench Box 0 Build-a-Box <br /> First Aid Equ'pment/Training/Fire Extinguisher Must be Current <br /> Utilities Located: ] Water(blue) Power(red) ❑ Gas(yellow) ❑ Co munication (orange) 0 other <br /> Communication with emergency ponders provide u Radio Dispatch Phone 911 0 City Phone 9-911 <br /> Personal Protective Equipment re High-Vis [.Head Eyes dHearing 0 Whole Body ❑other <br /> Pre-Job Safety Meeting <br /> Name Assignment Name Assignment <br /> I iNKI, SLivrtC.' W4SC <br /> (fil isit`� <br /> v_tiol (At, <br /> Revised 12/12/11 <br />