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Visitor Site Orientation Checklist
HSE 03-04 Orientation and Training
Project Name
Project Number:
Date
*
-
Month
-
Day
Year
Date
Company:
*
Your Name:
*
First Name
Last Name
Part 1: Requirements for Entry
*
Rows
YES
NO
N/A
1. Has a review of the Emergency Response/Project Site Plot Plan been completed?
2. Has the 6 foot fall protection requirement been explained to the visitor?
3. Has the Pre-Job Safety Instruction (PSI) program been explained and reviewed with the 3. visitor?
4. Is the visitor aware that he/she is to be accompanied by the escort identified below at all time?
5. Have site requirements for the use of the following protective equipment been reviewed?
*
Safety Glasses
Gloves
Hearing Protection
Safety Footwear
Dust Mask
Respiratory Equipment
Hard Hats
Face Shields
Mono-Goggles
Fall Protection
Vests
Other
Part 2: Orientation Acknowledgment
This form will be retained on file at the project worksite location
Your Signature:
*
Escort's Name:
*
First Name
Last Name
Escort's Signature:
*
Facilitator's Name: (may be the same as Escort)
*
First Name
Last Name
Facilitator's Signature:
*
Submit
Should be Empty: