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JOBSITE SAFETY WORKSHEET <br /> Date - 2- ( Location Zt 'rI <br /> Lead S !r-� Pre.lob Briefing Time i2:o 2 � <br /> Descrfption of Work: <br /> ��.� — �✓Z <br /> Safety Incidents & Concerns: <br /> YES !UA <br /> T2ffic Control Plan—Atlzch TCP if modified <br /> Confined 5 ace Ent —Attach Confined S ace Pertnit <br /> Uncontrolied Ener —Attach Lockout Ta out <br /> Boom Truck Used–Atlach Lifl lan if needed <br /> Overhead littin Ins ect ri in before each use <br /> Electrical tiazards&Controls ✓ <br /> Overhead Unde round Generator PertnanentWirin <br /> Hot Work—Describe / <br /> Hazardous Materials Used <br /> Fal�s over 4 feet—Controlled b : <br /> Excavation EntrY over 3 feet deep � <br /> Y <br /> Final Depih3 2 Width Length <br /> ❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build•a•Box <br /> Flrot Aid E ul mantlTrolnin IFiro Extln uish�r Must b�Curnnt <br /> Uti�ities Localed: Water biue Power red Gas ellow Communlcation oran e other <br /> Communication with emer enc res nders rovided Radio Dis atch Phone 911 Ci Phone 9•911 <br /> Personat Protective E ui ment HI h-Vis Head E es Hearin Whole Bod other <br /> Pre-Job Safe Meetin • <br /> Name Assignment Name Assignment <br /> S Ck�(I <br /> SL �� <br /> J � <br /> . <br /> 0 11 � <br /> �� <br /> -���.� TvoYc <br /> ReNsed 12117/11 <br />