Clear and Grub Safety Inspection
Site
Date/Time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
24-Hour Time Minutes
Safety Inspector
First Name
Last Name
Foreman/Lead
First Name
Last Name
Machine #1 Operator
First Name
Last Name
Machine #1
Machine #2 Operator
First Name
Last Name
Machine #2
Machine #3 Operator
First Name
Last Name
Machine #3
Job Safety Briefing performed for the crew?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Job Hazard Analysis performed?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Does the JHA Process Form match the work?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Is the JHA Form complete and with hazards and mitigation?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Limits of working area clearly marked?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Underground utilities marked?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Overhead lines marked?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Equipment Operator of machine #1 has competency (contractor documentation)?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Equipment Operator of machine #2 has competency (contractor documentation)?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Daily equipment inspection for machine #1 completed?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Daily equipment inspection for machine #2 completed?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Spotter used when close to boundary or sensitive areas?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Equipment Operator has insect repellent?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Slings and chains inspected?
*
Acceptable
Marginal
Unacceptable
N/A
N/O
Submit
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