Contractor Name and Logo
- Job location
- Date and start time
- Work order or job number
- Person in charge
- Owner's representative on site
- Weather and site conditions
Today's Work Plan
- Tasks for today, in order
- Hold points and who releases each one
- Locate ticket status, utility crossings and pothole status
- PPE required today per the employer's safety program, including high-visibility apparel where the MUTCD work-zone rules require it and hard hats where the employer's program or OSHA requires them, checked for everyone
Site Hazards and Controls
- Hazards found on this site today and the control for each
Aerial Hazards to Discuss
Lines from AE-04 hazards
- Electrical Contact
- Falls from Poles and Lifts
- Struck by Vehicles
- Lift Tip-Over
- Pole Failure
- Lightning and High Wind
Directional Bore Hazards to Discuss
Lines from UG-05 hazards
- Electrical Strike
- Gas Line Strike
- Pit Cave-In
- Inadvertent Fluid Returns (Frac-Outs)
- Work Zone Traffic
Splicing Hazards to Discuss
Lines from SPL-02 hazards
- Glass Fiber Shards in Eyes and Skin
- Invisible Laser Light from Live Fibers
- Hazardous Atmosphere in Manholes and Vaults
- Engine Exhaust (Carbon Monoxide) Drawn into Manholes
- Splicer Arc and Heat-Shrink Oven Igniting Gas
- Energized Power Cables and Splices in Joint-Use Manholes
- Flammable Gel Cleaner and Alcohol
- Falls and Electrical Contact at Aerial Closures
Roles and Assignments
- Person in charge
- Competent person
- Traffic control
- Spotter or attendant
- Trained rescuers
- First aid and CPR trained
Emergency Contacts
- Emergency services
- Nearest hospital or urgent care, and the route there
- Supervisor
- Owner's emergency contact
- Power and gas utility emergency lines
- One-call center, for damage reports
Emergency and Rescue Plan
- Rescue method and equipment for today's work: pole-top, bucket or confined-space retrieval
- Response to electrical contact, a gas release or an injury, per the employer's emergency plan
- Where the crew gathers and who calls emergency services
Stop-Work Triggers
- Conditions that stop work today
- Who restarts the work after a stop
Aerial Records to Keep
Lines from AE-04 Records to Keep
- Signed tailboard or job briefing sheet with the emergency plan, the rescue plan and the names of trained rescuers.
- Daily lift inspection record.
- Traffic control layout used and any permit conditions.
- Poles rejected at inspection, reported to the owner.
- Any incident, near miss or stop-work event, reported per the employer's program.
Directional Bore Records to Keep
Lines from UG-05 Records to Keep
- Bore plan and profile, with crossing clearances noted.
- Locator calibration record.
- Strike system test.
- Tailboard sign-in sheet.
- Traffic control setup photos.
Splicing Records to Keep
Lines from SPL-02 Records to Keep
- Tailboard sign-in sheet with the hazards discussed.
- Pre-entry atmospheric readings (oxygen, flammable, toxic) and times, plus continuous-monitoring readings or alarms, per the employer's program.
- Gas monitor calibration or bump-test record.
- Any injury, near miss or exposure report.
| Printed Name | Company or Crew | Role | Signature |
|---|---|---|---|
Sign-Off
Person in Charge
- Name
- Signature
- Date
