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JO�SSITE SAFETY WORKSHEET <br /> Date -��/-� �- Location <br /> Lead U S6l � <br /> Description of Work/Satety Comments <br /> h S/` �/ ✓! �c � � Ser�; e.e_ <br /> II all above bo�d line is N/A,you do not need fo complete ihis form <br /> YES N/A <br /> Trat(ic Conlrol Re uired—Attach TCP i!modified <br /> 6xcavation Entry over 3(eet deep / <br /> final Depth3 6 I� Widih Length ✓ <br /> � Finn Form ❑ Sloping O Trench Box ❑ Build-a-Box <br /> v <br /> Confined S ace Ent —Attach Con(ined S ace Pa erwork � <br /> Uncontrolled Ener —Attach Lockout <br /> Hol Work—Describe <br /> Overhead ower—Minimum 70'clearance <br /> Overhead liftin �ranes&Ri in Ins ected Belore Use <br /> Fails over 4 feet—Controlled by: <br /> Hazardous Materials in Use <br /> Firsl Aid E ui menUTrainin /F'xe Ex1in uisher Must be Current � <br /> Ulilities located: aler blue �' Power red ❑ Gas eilow ❑ Communicalion oran e ❑ o«�e� <br /> CortNtiunication with emergenc esponders provided <br /> ��Radio Dis alch Phone 911 ❑ Cil Phone 9-911 <br /> Electrical Hazard58 Conlrols GfCI <br /> Power Tools <br /> Heav E ui menl vehicle number � � Y <br /> Personal Proteciive E ui ment � Hi h-Vis ❑ Head ❑ 6 es ❑ Hearin ❑Whole Bod ❑other <br /> Pre-Job Safet Meetin <br /> Name Assignmenl Name Assignment <br /> y� , �o� t� � a �'l <br /> 'j, -�O!/ <br /> ��� � -�U�`f� <br /> Revised 9�15�09 <br />