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JOBSITE SAFETY WORKSHEET <br />Route to Safety within 4 days <br />Date — �- <br />Name <br />. . Ir . - - - <br />Location t7l <br />Job # 7 <br />Start Time <br />End Time 0 0 � <br />Description of Work Pe <br />If all above bold line is NIA, you do not need to complete this form <br />YES <br />N/A <br />Traffic Control Required —Attach TCP if modified <br />Excavation Entry over 3 feet deep , , ❑ Notify Dispatch <br />ly Q <br />Final Depth "C Width Length D <br />❑ Shoring ❑ Sloping ❑ Trench Box <br />Confined Space Entry —Attach Confined Space Paperwork ❑ Notify Dispatch <br />Uncontrolled Energy -Attach Lockout Form <br />Utilities Located / 10-foot minimum overhead clearance from overhead power <br />Cranes & Rigging —Inspected Before Use <br />Falls over 4 feet are controlled <br />Communication with emergen responders provided <br />❑ Radio Di atch Phone 911 ❑ Ci Phone 9-911 <br />First Aid Equipment/Traini /Fire Extinguisher Must be Current <br />List Electrical Hazards & Controls GFCi / v <br />List Hazardous Materials in Use A <br />List Power Tools <br />c, <br />Lis( Heavy Equipment vehicle number �a..J' l�A100 <br />List Personal Protective Equipment i h-Vis and Hat ,Jeanng Protection <br />❑ Chain Saw Chas E e/Face ❑ Respirator ❑ <br />Personnel On -Site <br />Name <br />Assignment <br />Name <br />Assignment <br />�to <br />7- <br />c � 6 <br />W!U `T <br />R <br />r <br />Revised 6/1/06 <br />