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JOBSITE SAFETY WORKSHEET <br />Date <br />• 7_ - <br />Location 193 '1 S $C <br />Lead L 1-1Pre-Job Briefing Time <br />Description of Work: <br />Safety Incidents & Concerns: <br />YES <br />NIA <br />Traffic Control Plan —Attach TCP it modified <br />X <br />Confined Space Ent—Aftach Confined Space Permit <br />Uncontrolled Energy —Attach Lockout Taoout <br />K <br />Boom Truck Used—Affach Lift plan it needed <br />X <br />overhead lifting —inspect rigging before each use <br />X <br />Electrical Hazards & Controls <br />Overhead ❑ Underground Generator Permanent Winn <br />X' <br />Hof Work —Describe <br />X <br />Hazardous Materials Used <br />X <br />Falls over 4 feet —Controlled by: <br />Excavation Entry over 3 feet deep <br />r r <br />Final Depth 6 r, _ Width__ Length t7 <br />❑ Finn Form ❑ Sloping ❑ Trench Box ❑ Build -a -Box <br />First Aid EquipmenLTralnlnq!Fire Extin ulsher Must be Current <br />Utilities Located; or Water (blue) PI Power (red) Gas IYellow) J@ Commurvaiion (araige) other <br />Communication with emergency responders provided Fladio Dispatch g Phone 9l l City Phone 9.911 <br />_� <br />Personal Protective Equipment High -Vs Qr, Head R Eyes IR Hearin Whole Body ❑ other _ <br />Pre -Job Safety Meeting_ <br />Name <br />kssignment <br />Name <br />Assignment <br />- <br />EI•:�k5C.;P., <br />(..--WDT <br />wy-ar-S <br />IEo <br />/faro <br />N6d <br />Eo <br />�rbS <br />UL <br />Revised 12/12/11 <br />