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• <br /> JOBSITE SAFETY WORKSHEET <br /> • <br /> Date - a5-/ Location. 69 j - eAt <br /> Lead 10 Pre-Job Briefing Time �J► <br /> Description of Work:U <br /> l + /n ,,,,^^ ( <br /> 5q,cc'`JG.--'E t o m -cep v 3 A-, VU5-ere1,eo <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 Tagoutkttittic <br /> k Used—Attach Lift plan if needed V <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 <br /> Final Depth $ f Width �✓�� Length 2 a � J/ <br /> ❑r Finn Form ❑ Sloping X Trench Box ❑ Build-a-Box <br /> First Aid Equipment/Training/Fire Extinguisher Must be Current <br /> Utilities Located: 'Water(blue) /Er Power(red) Gas(yellow), ❑ Communication(orange) ❑ other <br /> Communication with emergency responders provided Radio Dispatch hone 911 0 City Phone 9-911 <br /> Personal Protective Equipment High-Vis jiff Head (Eyes ,i,.1 Hearing ❑Whole Body ❑other <br /> Pre-Job Safety Meeting <br /> Name Assignment Name Assignment <br /> • S <br /> [-r. <br /> \)ck\Aex PL— <br /> Revised 12/12/11 <br />