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JOBSITE SAFETY WORKSHEET <br /> Location 1 1 �e� <br /> Date - -�� Pre�lob Briefing Time / • <br /> Lead ��Y <br /> Description of Work/Safety Comments <br /> ��� � �"'F� YES NIA <br /> If all above bold line is NIA,you da not need to complete this form <br /> Treffic Control Re uired—Attach TCP if modified <br /> Excavation Entry ove�3 feet deep Length <br /> Final Depth -3�— �dth_�_ ✓ <br /> ❑ Finn Form ❑ Sloping ❑ <br /> Trench Box ❑ Build-a-Box <br /> ✓ <br /> Confined S ace Ent —Attach Confined S ace Pa ervvork � <br /> Uncontrolled Ener —Attach Lockout J <br /> Hot V�'ork—Describe � <br /> Overhead ower—Minimum 10'dearance / <br /> !1 <br /> Overh=ad Iiftin —�ranes&Ri ain Ins ected Before Use � <br /> Falls over 4 feet—Controlled by: <br /> Hazardous Materials in Use <br /> First Aid E ui menUTreinin IFire Extin uisher Must be Current <br /> Utilities Located: ❑ Water blue �J Power red � Gas ello�v <br /> ❑ Communiration 'oranoe ❑ other <br /> Communication wiih emergency responders provided �i�Y phone 9-911 <br /> �f2adio Dis atch [�'hone 971 ❑ <br /> Electricai Hazards&Controls GFCI <br /> Power Toois <br /> Hea E ui ment vehicle nuR / <br /> -7' �/� �� o o� <br /> Personal Protective E ui mer h-Vs l� Head � es � Hearina ❑Whole Bod ❑ other <br /> Pre-Job Safe Meetin <br /> Name Assignment <br /> Name Assignment <br /> I�t,��-- T t/ <br /> C- '� <br /> ! , <br /> Y� ,6 �. ��' i� 3 <br /> �� �"mY� <br /> � Revised 9/75f09 <br />