Company
*
Date
*
-
Month
-
Day
Year
Date
Project Number
*
Project Name
Visitor's Name:
*
Part 1: Requirements for Entry
1. Has a review of the Emergency Response/Project Site Plot Plan been completed?
*
Yes
No
N/A
2. Has the 6 foot fall protection requirement been explained to the visitor?
*
Yes
No
N/A
3. Has the Pre-Job Safety Instruction (PSI) program been explained and reviewed with the visitor?
*
Yes
No
N/A
4. Is the visitor aware that he/she is to be accompanied by the escort identified below at all times?
*
Yes
No
N/A
5.
*
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
Visitor Signature
*
STOP: Please hand phone/tablet to a PCL team member to complete below:
Escort's Name
*
Escort's Signature
*
Facilitator's Name
*
Facilitator's Signature
*
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