Visitor Site Orientation Checklist
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Company
*
Orientation Date:
*
/
Day
/
Month
Year
Date
Project Name:
*
Please Select
Yard Facilities
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 visitor?
4. Is the visitor aware that he/she is to be accompanied by the escort identified below at all times?
5. Have site requirements for the use of the following protective equipment been reviewed?
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
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:
*
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