AC Visitor Site Orientation Checklist

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.*

Safety GlassesGlovesHearing ProtectionSafety FootwearDust MaskRespiratory EquipmentHard HatsFace ShieldsMono-GogglesFall ProtectionVestsOther
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:

Visitor Site Orientation Checklist