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, JOBSITE SAFETY WORKSHEET <br /> • Route to Safety within 4 days <br /> Date - �-� Loca�tion ��� f%/1a %� 2 <br /> Name f� L'/� ✓ __ Job# 'z !J� 0 1� "7 <br /> Start T'ime •� d lJ �ry� _ End Time / � O'(7 ,��ij <br /> , <br /> Doscription of Work 1�5 ��L L �� � S�� ✓ /c� <br /> iII all abova bold line is NIA,you do nol�ieed to�:omplele lhis lorm YES N/A <br /> Traffic Conirol Required—Atta;h TCP il modified __ <br /> E�cavalion[Nry over 3 feet daup , , ❑ Notify Dispatch <br /> IJ i <br /> Final Dopth '( � � Width_ � Lenglh � � <br /> ❑ Shoring ❑ Sloping ❑ Trench Boz <br /> Confintsd Space[nlry—Altach Confinod Space Paperwork �] Notiry Dispatch <br /> Unconlrolled[ner —Allach Lockoul Form <br /> Utilities Located/10-foot minimum overfiead clearance from ovorhead power <br /> Cranes 3 Ri in —Ins ecled 6etore Usa <br /> Falls over 4 feot are conlrolled <br /> CommunicaUon wilh emorgen responders provided <br /> Radia Di alcF� Phone 911 ❑ City Phona 9-911 <br /> First Aid E ui ment/Tratnt ra Eictin ulshar Musl be Current <br /> List Eleclrical Hazards 8 Controls GfCI • � <br /> List Hazardous Malcrials in Use ✓v � <br /> List Power Tools <br /> Lisl Hea E ui menl vehicle number � � 4�� � <br /> I_isl Personal Pmteclive Equipment �igh-�s [�.Hard Hal �ctearing Proledion <br /> � <br /> Chain Saw Cha s [ e/Face Re irator <br /> Personnel On-Site <br /> Name Assignmenl Name Assignment <br /> � . l�r/� �P l,t/5 T <br /> � c� lo U/ST <br /> G . .� �C S LB O <br /> � R ` - C� <br /> Revised d1/06 (�l�� <br /> 'I <br />