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JOBSITE SAFETY WORKSHEET <br />Date /D-ZS-ZZ <br />Locstlon Z7o7./- <br />Lead fx6# <br />I Pre -Job Briefing Time ; eo <br />Description of Work: f�lcct n/v r� �ere;K /.>rC <br />Safety Incidents & Concerns: <br />YES <br />WA <br />Trafnc Control Plan —Attach TCP If modified <br />lv� <br />Confined Spam En tWch Confined Spam Permit <br />✓ <br />Uncontrolled Ene ti Locoxd Taout <br />✓ <br />Boon Truck Used —Attach Lift pkin Mneeded <br />Overhead liflftinlnslgect ripping before as& use <br />✓ <br />Electrical Hazards & Controls <br />❑ Overhead Q Underground Generator ❑ PermanentWinn <br />Hot WoM—Describe <br />Hazardous Materiels Used <br />✓ <br />Fells over feet—COMofled by, <br />V <br />Excavatlon Entry over 3 feet deep <br />Final DepthWidthLength <br />❑ Finn Fom ❑ Sloping ❑ Trench Box ❑ Builda-Box <br />Fired Aid Equipme bTreinin/Fire Extinguisher Must be Current <br />Wlities Located Water blue MlPower red Ly Gas(yellow) Communication (orange) ❑ other <br />Communication with eme a responders grgivided ❑ Radio Dispatch 19�Phone 911 ❑ CiftyPhonesLgii <br />Personal ProtectiveE ui meth h-Vis L9 Heatl es ErHeannit ❑Whole Body ❑other <br />Pre -Job Safety Meeting <br />Name <br />Assignment <br />Name <br />Assignment <br />IAS <br />NCD <br />/A., ri3 v <br />CD <br />Pm <br />C& <br />t <br />UL <br />Revised IWV11 <br />