Visitor Site Orientation Checklist

Company
Name cannot contain any of the following special characters: * ? / \ : < > " |
Orientation Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Project Name:
Project Number:
Ask your Facilitator
Visitors 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 tim
5. Have site requirements for the use of the following protective equipment been reviewed?

5.

Other
Part 2: Orientation Acknowledgment

This form will be retained on file at the project worksite location
Visitor's Signature
Escort’s Name:
Escort's Signature
Facilitator’s Name:
Facilitator’s Signature:
Should be Empty: