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JOBSITE SAFETY WORKSHEET <br /> Ev <br /> Date — Location t <br /> Lead WeAvCA Pre-Job Briefing Time C� <br /> Description of Work: <br /> Safety Incidents & Concerns: <br /> YES N/A <br /> Traffic Control Plan—Attach TCP if modified <br /> Confined Space Entry—Attach Confined Space Permit <br /> Uncontrolled Energy—Attach Lockout Tagout <br /> Boom Truck Used—Attach Lift plan if needed <br /> Overhead lifting—Inspect rigging before each use <br /> Electrical Hazards&Controls <br /> ❑ Overhead ❑ Underground ❑ Generator ❑ Permanent Wiring <br /> Hot Work—Describe <br /> Hazardous Materials Used <br /> Falls over 4 feet—Controlled by: <br /> Excavation Entry over 3 feet deep r leS J <br /> Final Depth � Width L Length / ell �J <br /> �• <br /> ❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build-a-Box <br /> First Aid Equipment/Training/Fire Extinguisher Must be Current <br /> Utilities Located: ❑ Water(blue) Power(red) as (yellow) ommunication (orange) ❑ other <br /> Communication with emergency responders provided ❑ Radio Dispatch one 911 <br /> ❑ Cit Phone 9-911 <br /> Personal Protective Equipment iah-Vis MHead esarin ole BodyEl other <br /> Pre-Job Safety Meeting <br /> Name Assignment Name Assignment <br /> a <br /> r e, k v <br /> Revised 12/12/11 <br />