IS ISOLATION REQUIRED?YesNo
OCCUPATION:OPERATORMECHANIC
Pre-Trip Inspection:
SAFEAT RISKN/A
Speeding:
Weather/Road Conditions:
Backing:
Seat Belt/Emergency Brake:
Head Protection:
Eye/Face Protection:
Hearing Protection:
Back:
Hand/Arms:
Foot Protection:
Knees:
Respiratory Protection:
Line of Fire:
Eyes on Task:
Mind on Task:
Balance/Traction/Grip Human Performance Tool Use:
Safe Selection:
Safe Condition:
Safe Use:
Communication: Customer/Contractor/Other:
Pre-Job Briefing:
Capacities/Ratings:
Securing Loads:
Work Lighting:
Energy Control/Tagout:
Crew Communication:
Following Established Work Method/Procedure:
Minimum Approach Distance:
Confined Space/Manhole Entry:
Excavation:
Guarding/Barricades:
Electrical Switching:
Walking/Working Surfaces:
Weather Conditions:
Housekeeping/First Aid Kit/Fire Extinguisher:
Dogs/Poisonous Plants/Insects:
Lifting/Bending/Twisting:
Reaching/Pulling/Lifting:
Repetitive Motion/Static Position:
Stretching:
*I verify that all information above is accurate to my knowledge, and that all observation, coaching, and feedback will be done in a confidential and non-threatening way.
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