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JOBSITE SAFETY WORKSHEET <br /> Date �p _ — �� Location 4tiN0 R:.l �� <br /> Lead f\� -s- Pre-Job Briefing Time S.i5�I M <br /> Description of Work/Safety Comments <br /> r��,)- +o /v4�,}¢r awr�zr ���. <br /> If all above bold ifne is NIA,you do not need to complete this fortn YES N/A <br /> Traffic Control Re uired—Attach TCP if modified " � <br /> Excavalion Entr�r over 3 feet deep � � <br /> Final Deplh 3 � Width 3 Length y <br /> ❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build-a•Box <br /> Confined S ace Ent —Atlach Confined S ace Pa envork � <br /> Unconlrolled Ener —Attach Lockait <br /> Hol Work—Describe <br /> Overhead ower—Minimum 10'clearance <br /> Overhead liftin —Cranes 8 Ri in Ins ecled Before Use <br /> Falls over ti feet—Conlrolled by: <br /> Hazardous Materials in Use �� <br /> First Aid E ui mentlTreinin IF(re Ext(n uisher Must be Current <br /> Utilities Located: � Water blue ❑ Power red ❑ Gas ellow ❑ Ccmmunication oran e ❑ other <br /> Communication with emergen�responders provided <br /> [�- Radio Dis alch l5 Phone 911 ❑ Cit Phone 9-911 <br /> Eleclncal Hazards 8 Controls GFCI � <br /> PowerTcols Qs �t �T S1�✓ <br /> Hea E ui ment vehiclenumber ���'`�� ����"�3 <br /> Personal Prolective E ui ment �-Hi h-Vis .�Head Id� es earin ❑Whole Bod ❑ other <br /> Pre-Job Safe Meetin <br /> Name Assignment Name Assignment <br /> H,,;6� wT ,�„ �,�„�II v� <br /> s►�;�h w�r <br /> ytil�vz�-�n raEo <br /> �'c t-��,r-�5 V�. <br /> Revised 9115/09 <br />