CSCI Safety Task Assignment

Critical Behavior Observations*

Rows	Yes	No	N/A
1. Maintain 3 Points of Contact
2. Fall Protection (6ft Height/Greater)
3. Aerial Forklift Operation Seatbelt/Harness
4. Blue Stake Marked Prior To Dig Pothole Within 2' Utility
5. Excavations Inspected (Ladders Over 4' Depth Every 25'
6. Proper Access & Egress From Excavations / Shoring Req?
7. Confined Space Tested & Monitored Prior To Entry
8. Operators Completing 360 Prior To Moving Equipment
9. Crane & Rigging Inspected Prior To Operation
10. Operators/Ground Personnel Making Eye Contact
11. Traffic Control Implemented Correctly (Positioning)
12. All Materials In Truck Beds/Trailers Secured
13. Power Tools/Guards & Cords In Good Condition
14. Hardhat, Safety Glasses & High-Vis Shirt/Vest Worn
15. Housekeeping Maintained
16. Equipment Inspected, Fueled, Lubed. Report Damage/Leaks

CBO Notes
Must Explain If You Answered "No" To Any Observation
List Applicable Job Hazard Analysis (JHA/s)
JHA Topic #1*
Please Specify JHA Topic
List "Other" Choice
JHA Topic #2
JHA Topic #3
JHA Topic #4
JHA #1
JHA #2
JHA #3
JHA #4
ExcavatorsRough Terrain CranesBidwell * Work BridgesBackhoeBoom TrucksCompactorsFront-End LoadersBucket TrucksLight PlantsMini ExcavatorPlatform TruckAir CompressorsWater Truck/Water DollyManliftsForkliftDump TruckTruck Mounted AttenuatorOther
What Is The Task?*
(Que Es La Tarea?)
What Materials/Equipment /Tools Are Needed?*
(Que Materiales/Equipo/Y Herramientas Necesito?)
Where Will The Task Take Place?*
(El Lugar De La Tarea?)
What Are The Hazards?*
(Quales Son Los Peligros?)
What Are The Safety Measures You Will Take?*
(Lo Son Las Medidas De Seguridad Que Usted Tomara?)
Name 1*
Signature 1*

Clear
Name 2
Signature 2

Clear
Name 3
Signature 3

Clear
Name 4
Signature 4

Clear
Name 5
Signature 5

Clear
Name 6
Signature 6

Clear
Name 7
Signature 7

Clear
Name 8
Signature 8

Clear
Name 9
Signature 9

Clear
Name 10
Signature 10

Clear
Name 11
Signature 11

Clear
Name 12
Signature 12

Clear
Name 13
Signature 13

Clear
Name 14
Signature 14

Clear
YesNo
YesNo
Notes:
*If Necessary
Supervisor Signature*

Clear
Should be Empty:

CS Safety Task Assignment