TCM Corp.

PRE-TASK PLANNING WORKSHEET

Please input all fields marked with *

Project: *

Foreman: *

Cell: *

Specific Location: *

Date: *

JHA:

Division : *

Trade / Crew Size

Sheet Metal:

Plumbers:

Fitters:

Controls:

Service:

Description of Work:

WALK WORK AREA Do not start work before all hazards are mitigated

Open Holes Mitigation

Leading Edge Mitigation

Slip/Trip Hazards Mitigation

Congested with other trades If yes, coordinate with other trades

Will weather conditions affect the safe completion of this work?

Yes No

If yes, what is being done to minimize or mitigate safety concerns?

Nearest Evacuation route:

Nearest Fire Extinguisher:

MATERIAL HANDLING Yes No

Inspection performed and documented

Yes No

Forklift *

Chain Fall

Other

Equipment Capacities

Pallet Jack

Come a Long

Other

Load Weights Known

Duct Jack

Electric Hoist

Other

Spotter

* Documented model specific training required for forklift operation

Check with Safety dept. if training is required.

Foreman or supervisor notified of any failed items noted during inspection:

Yes No

Manual material handling of spiral duct or sharp edged materials requires the use of cut resistant sleeves and gloves.

ELECTRIC POWER TOOLS Yes No

Inspection Performed:

Yes No

GFCI Available

Yes No

Portal Band Saw
Reciprocating Saw(Saw All)
Grinder
Jig Saw
Circular Saw
Other

All work is to be secured before cutting or grinding. Exceptions to this rule may be granted by safety department on a case by case basis.

Remove damaged extension cords from service.Do not attempt to repair.

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

Additional Comments:

PRE-TASK PLANNING

Sequence of Basic Jobs Step

Hazards Involved

Methods to Eliminate/Control Hazards

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."

Foreman Signature: *

Clear signature

Safety Signature: *

Clear signature