TRENCH INSPECTION AND ENTRY AUTHORIZATION FORM

TRENCH INSPECTION AND ENTRY AUTHORIZATION FORM
All unsafe conditions must be corrected prior to trench entry. If any hazardous conditions are observed, the trench must be immediately evacuated and no one allowed to re-enter until corrective action has been taken
LOCATION
Date

MonthDayYear
Date
TIME OF INSPECTIONS

Hour Minutes

AM/PM Option
WEATHER CONDITIONS
APPROXIMATE TEMPERATURE
CREW LEADER
SUPERVISOR
PROTECTION METHODS

(Walls MUST be vertical - NO voids)
SHORING
DIMENSION DEPTH IN FEET
TOP WIDTH x LENGTH (IN FEET)
BOTTOM WIDTH x LENGTH (IN FEET)
SOIL TYPE

Solid rock (most stable)Average soilFill materialLoose sand
SOIL TESTED:

YesNo
SHORING

TimberPneumaticHydraulicScrew JacksTrench Shield
UNEVEN, IRREGULAR WALLS

Sloping: q 1:1 (45°) q 1 1/2 (34°)
TRENCH BOX

Yes
ENVIRONMENTAL CONDITIONS
Gas detector used?

YesNo
Confined space permit issued?

YesNo

HAZARDOUS CONDITIONS

	Yes	No
Saturated soil/standing or seeping water
Cracked or fissured wall(s)
Bulging walls
Floor heaving
Frozen soil
Super-imposed loads
Vibration
Depth greater than 10'

PLACEMENT OF SPOILS & EQUIPMENT

	Yes	No
Spoils at least 2 feet away from edge of trench
Equipment at least 2 feet from edge
Backhoe at end of trench
Compressor, etc. at remote location

LADDER LOCATION

	Yes	No
Located in protected area
Within 25 feet of safe travel
Secured
Extends 36 inches above the landing
Leads to safe landing

Other

	Yes	No
Shoring equipment and materials inspected prior to use?
Is trench SAFE to enter?

PROTECTION METHODS