Contractor

Date & Time

Job (name/#)

Superintendent

Superintendent’s Phone #

Specific Task

Consider These Items:

Check If Required

1. Have you walked the job? All hazards identified?

yes/no

 LOTO procedures

 Fall Protection/PFAS

2. Obvious hazards noted: open trenches, overhead obstructions, live electrical lines, public exposure, etc.?

yes/no

 Permit Required Confined Space

 Respiratory Protection (particulate, air purifying, supplied air - specify)

3. Has work been discussed and coordinated with all crafts? When?

yes/no

 Air Monitoring, Ventilation (ACH)

 Hearing Protection

yes/no

 MSDS

 Traffic Control

5. All competent persons identified? List each.

yes/no

 Hardhat, Safety Glasses, Other (list)

 Barricades/Signage

6. Emergency procedures needed?

yes/no

 Lifts: Telescopic, Articulated, Scissor

 Cranes or Equipment Lifts

7. Any work at height or below ground?

yes/no

 Scaffolding

 Critical Lifts

yes/no

 Trenching & Excavation

 Fire extinguisher and/or Fire Watch

yes/no

 Other (specify)

 Other (specify)

yes/no

Comments:

Task Plan

List Steps & Hazards

Action to Control

1.

2.

3.

4.

5.

6.