Southland Industries

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SERVICE PRE-TASK PLANNING WORKSHEET

Please input all fields marked with *

Supplemental Safety Topic:

Project: *

Foreman: *

Cell: *

Specific Location: *

Date: *

JHA:

Division : *

Foreman Email:

WALK WORK AREA: Do not begin work before all hazards are mitigated

MATERIAL HANDLING Yes No

Trade / Crew Size

Sheet Metal:

Plumbers:

Fitters:

Controls:

Service:

Description of Work:

ELECTRIC POWER TOOLS Yes No

PERSONAL FALL ARREST Yes No

Inspection Performed

Approved anchorage points identified

Correct Equipment Available

Fall distance calculation performed

Trained in Equipment Use

Explain Below

BARRICADES Yes No

Control zones must be established if hazards exist to other trade workers or the public.

WORK AT HEIGHT Yes No

Ladder Scissor Boom

Are documented training records available for each model of equipment

Yes No

SCAFFOLDS Yes No

Inspection performed by onsite safety or other designated competent person

Capacities Known

CRANE WORK Yes No

Approved crane pick plan

Barricade erected to include entire travel path of load

Traffic control

All employees within the fly zone must have documented training in rigging and signaling

LO/TO Yes No

Are documented training records available

Yes No

HOTWORK Yes No

Permit Required

Yes

N/A

Follow instructions on permit and all policies and procedures.

CONFINED SPACES Yes No

Are documented training records available

Yes No

Permit Completed(Required)

Multi gas detector(Required)

Permit must be returned to safety dept. upon completion of work

PPE Yes No

Standard PPE includes hard hat, safety glasses, gloves, safety toe boots

Standard PPE

Yes

Special

Please List

SEQUENTIAL TASK PLANNING

Sequence of Basic Jobs Step

Hazards Involved

Methods to Eliminate/Control Hazards

Additional Comments:

Crew Members Name:

Mon

Tue

Wed

Thu

Fri

Sat

Sun

"I acknowledge that I will will comply with the safety procedures outlined above and understand that failure to do so could result in injury and is grounds for disciplinary action. I further acknowledge that I reported to work Fit For Duty today and that I am leaving work injury free. If I was involved in an incident, I will report it to my Foreman immediately."

1. First Name *

Last Name *

Date Of Birth *

Signature

Clear Signature

Foreman Signature: *

Clear Signature

Safety Signature: *

Clear Signature

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SERVICE PRE-TASK PLANNING WORKSHEET

SEQUENTIAL TASK PLANNING

SEQUENTIAL TASK PLANNING

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