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� <br />� <br />� <br />JOBSITE SAFETY WORKSHEET <br />Date - z.� � - Location <br />Lead �',� <.— Pre-Job Briefing Time <br />Description of Work: <br />I /�G' �� /J f�''l J'��l '�II:L ! • 11L.., <br />Safety Incidents & Concerns:`' <br />YES N/A <br />Traffic Control Plan—Attach TCP if modified <br />Confined S ace Ent —Attach Confined S ace Permit <br />Uncontrolled Ener —Attach Lockout Ta out <br />Boom Truck Used -Attach Lift lan if needed <br />Overhead liftin —Ins ect ri in before each use <br />Electrical Hazards & Controls / <br />❑ Overhead ❑ Under round ❑ Generator ❑ Permanent Wirin <br />Hot Work—Describe � <br />Hazardous Materials Used <br />Falls over 4 feet—Controlled b: <br />Excavation Entry over 3 feet deep <br />�� � <br />Final Depth �-� � Width Length <br />Finn Form ❑ Sloping ❑ Trench Box ❑ Build-a-Box � <br />, <br />First Aid Equi ment/Trainin /Fire Extin uisher Must be Current <br />Utilities Located: ❑ Water blue ❑ Power red ❑ Gas ellow ❑ Communication oran e ❑ other <br />Communication with emer enc res onders rovided �Radio Dis atc j 'hone 911 ❑ Cit Phone 9-911 <br />Personal Protective E ui ment LTHi h-Vis [�'Head ❑ E es Hearin ❑ Whole Bod ❑ other <br />Pre-Job Safet Meetin <br />Name Assignment Name Assignment <br />� ,'�' G"� -iC�..�'�2r <br />.�� ) dn ) 1 `� � <br />, �.� <br />l `� � .-1. �.l L;�`� r- `7 � ���,- <br />Revised 12/12/11 <br />