HSE-03-03: Short Duration Worker HSE Orientation Checklist

SHORT DURATION WORKER HSE ORIENTATION CHECKLIST

HSE-03-03
Project # and Name:
Orientation Date:*

MonthDayYear
Date
Name*

First NameLast Name
Company Name:*
If yes, a valid copy of the Working at Heights certificate training must be attached.
PART 1: THE GENERAL HSE ORIENTATION

Have the following been reviewed with the short duration worker? *

Rows	YES	NO	N/A	CL
1. Working safely is a condition of access and of the disciplinary procedures associated with failure to adhere to this or other project site requirements.
2. Legislative jurisdictional HSE requirements.
3. An overview of PCL’s policies, practices and procedures.
4. The Project Site Plot Plan.
5. Regular hours of work, lunch breaks and coffee breaks.
6. The Pre‐Job Safety Instruction (PSI) program and the following steps have been explained and reviewed:

The Pre‐Job Safety Instruction (PSI) program and the following steps have been explained and reviewed:*

Recognizing potential hazardsEliminating potential hazardsControlling potential hazardsMinimizing exposure to potential hazards
7. The proper selection, care and use of the following PPE:*

Hard HatsMono-gogglesFace ShieldsSafety GlassesGlovesHearing ProtectionDust MasksSafety FootwearReflective VestRespiratory EquimentFall ProtectionOther
Have the following site-specific job hazards been reviewed; they are subject, but not limited, to:*

DemolitionWater Service LineGas LinesCongested Work AreasHeavy LiftsRestricted Work AreasPersonal RadiosHarmful GassesOther

If applicable*

Rows	YES	NO	N/A	CL
11. Scaffold requirements.
12. Ladder requirements.
13. Guardrail requirements.
14. Project fall protection plan requirements.
15. Intoxicating beverages and drugs prohibited on the worksite.

Have the following been reviewed with the short duration worker?*

Rows	YES	NO	N/A	CL
17. The emergency response/evacuation procedures.
18. The incident reporting procedures.

PART 3: DESCRIPTION OF WORK
Describe the work you will do:
19. Does your work involve connection or exposure to any building services?

EletricalWaterSpinklerSteamGasCommunnication/ Security/ Controls
Short Duration Worker’s Signature:*
Facilitator's Name:*

First NameLast Name
Short Duration Worker’s Name:*

First NameLast Name
Signature*
NOTE: ALL SHORT DURATION WORKERS MUST SIGN IN AND OUT AT THE PROJECT OFFICE EACH DAY. NON-COMPLIANCE TO THIS SITE REQUIREMENT WILL RESULT IN THE USE OF PCL’S DISCIPLINARY POLICY.
Does your scope of work require you to wear a full body harness in travel restraint/fall arrest?*

YESNO

PART 2: INCIDENT MANAGEMENT
16. Have the following items been reviewed?

Worker’s Right to Refuse WorkWorkplace Violence/Harassment Policies
This form will be retained on file at the project work site location
Should be Empty:

SHORT DURATION WORKER HSE ORIENTATION CHECKLIST