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JOBSITE SAFETY WORKSHEET <br /> Date 3�2 -!2 Location 1 < k � <br /> Lead � � Pre-Job Briefing Time � : �3 .; <br /> Description of Work/Safety Comments <br /> c ,�r�' ` �st <br /> If aIl above bold line is NIA,you do not need to completa this form YES N/A <br /> Traffic Control Re uired—Attach TCP if modified <br /> Eucavation Entry ove��3 feet deep <br /> Final Deplh 3 � �did�h Lenglh / <br /> ❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build-a-Box ✓ <br /> Confined S ace Ent —Attach Confined S ace Pa envork <br /> Uncontrolled Ener —Attach Lockout <br /> Hot Work—Describe <br /> Overhead ower—Minimum 10'clearance <br /> Overhead liftinq—Cranes&Ri qin ins ected Before Use <br /> Falls over 4 feel—Controlled by: <br /> Hazardous Materials in Use <br /> First Aid E ui mentlTreinin IFire Extin uisher Must 6e Current <br /> Utilities Located: ❑ Waler bluel ❑ PoWer red ❑ Gas ellow ❑ Communication oran el ❑ other <br /> C�munication with emergen�esponders provided <br /> Radio Dis atch Phone 911 ❑ Cit Phone 9-911 <br /> Electrical Hazards&Controls GFCI) <br /> Power Tools <br /> L <br /> Hea E ui ment vehicle number) c� <br /> � � U <br /> Personal Protective E ui ment Hi h-Vis L�Head ❑ F es ❑ Hearina ❑Whole Bod ❑other <br /> Pre-Job Safe Meetin <br /> Name Assignment N^me Assignment <br /> S 1- s�z��� <br /> � � ,b 70c�`/ <br /> J ,S <br /> Revised 9115/09 <br />