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JOBSITE SAFETY WORKSHEET <br />Date -24/- ! <br />Location <br />Lead <br />Description of Work/Safety Comments <br />If all above bold line is N/A, you do not need to complete this form <br />YES <br />N/A <br />Traffic Control Required —Attach TCP if modified <br />Excavation Ent over 3 feet deep <br />Final Depth-3 d Width Length <br />❑ Finn Form ElSloping ❑ Trench Box ❑ Build -a -Box <br />Confined Space Entry —Attach Confined Space Paperwork <br />Uncontrolled Energy —Attach Lockout <br />Iv/ <br />L <br />Hot Work —Describe <br />Overheadpower—Minimum 10' clearance <br />Overhead lifting --Cranes & Rigging Inspected Before Use <br />Falls over 4 feet —Controlled by: <br />Hazardous Materials in Use <br />First Aid Equipment/Training/Fire Extinguisher Must be Current <br />Utilities Located: flovater blue ❑' Power red ❑ Gas(yellow) ❑ Communication (orange) ❑ other <br />CO unication with emergency esponders provided <br />[Radio Dispatch Phone 911 ❑ CityPhone 9 911 <br />Electrical Hazards & Controls GFCI <br />Power Tools <br />Heavy Equipment vehicle number p 6 Y <br />Personal Protective Equipment ❑ Hi h-Vis ❑ Head ❑ Eyes ❑ Hearin ❑ Whole Body ❑ other <br />Pre -Job Safet .Meetin <br />Name <br />Assignment <br />Name <br />Assignment <br />23a',, <br />� <br />Jill <br />l <br />Revised 9/15/09 <br />