Pre-Task/Hazard Recognition Plan Project/Equip/Sys Description* Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time : Hours Minutes AM PM AM/PM Name* First Last Email* Phone*Company Building Floor Area Required PermitsPermit # Daily Work Permit Other Required Permits Energized Elec. Work (EEC) How Work (Non-electrical) Building on test/(Smoke & Sprinkler) Special Permit Confined Space Crirtical Lift (Crane) Excavation Task Specific Work Plans Floor/Wall Penetrations Lock Out/Tag Out Procedures Line Breaking Raised Metal Floor Checklist Equipment Demo Workplans Lifting Plan (req'd for >50 pounds Required PPE Hard Hat Safety Glasses Face Shield Goggles Gloves Leather Acid Solvent Kevlar/Cut Resistant Arm Sleeves Foot Protection Boots Steel-Toe Toe Covers Misc. Ear Plugs/Ear Muffs Safety Vest Chemical Resistant Suit/Apron Respirator Energized Elec Work PPE Additional PPE Fall Protection Ladder Inspection Completed Retractable Device Required Inspected Fall Protection Equipment Shock Absorbing Lanyard Required Horizontal Lifeline System Required Anchorage Point Identified Fall Clearance Distance Adequate Fall Rescue/Retrieval Plan Setup HAZARDS - Safe Plan of ActionMaterial Handling Inspected movement path Identified moving equipment Wheels chocked Floor Plating (pinch/black) Hand protection required Awkward size/shape/CG Hand/body positions to avoid injury Laydown area established Spotter Debris Removal Plan Slips, Trips, Falls Inspected for trip/slip hazards Area clean/clear of debris Hazards marked Tools & materials properly stored Electrical/Emergency equipment clear Hand/Cut/Bump Hazards Inspected work area for sharp edges Found sharp edges and protected Inspected walking paths Identified bump hazards and marked Interrupts to Production Area inspected to identify EMO's Protected/Guarded or marked Hand & Power Tools Reviewed safety requirements Inspected condition Guarding OK GFCI in use Identified PPE required Inspected electrical cord Routed cord overhead or taped/barricaded Chemical Hazards Area inspected for potential chemical hazard MSDS Sheet available Identify PPE for highest recognized hazard (see left) Reviewed Decon/Disposal or storage procedures Reviewed contingency plan and equip is on hand Hazardous Energies Lock Out/Tag Out/Verify Confirm that equip is de-energized 1 Lock/1 Key/1 Person Double block & bleed Mech/Elec/Chem/Therm/Stored/Radiation Non-electrical Hot Work Fire Extinguishers Fire Watch Install weld/spark schreens Combustable material removed/protected Adequate ventilation Excavation Reviewed As-Builts/Locates Barricades provided Proper sloping/shoring Access/egress provided Excavation inspected by competent person Hand dig areas are clearly marked (within 3" of utilities) USA Ticket # Scaffolds Competent person inspected daily Condition tags in place Properly secured/wheels locks Toe boards used Footings adequate Vehicular Traffic Traffic Barricades Cones Signs Flagmen Lane Closure Fire Lane is clear Crane or Other Lifting Equipment Lifting/Rigging Equipment Inspected Tag lines in use Areas barricaded Overhead Utility Clearance Verified Signalman assigned Barricades Yellow barricade tape Red barricade tape Rigid barricade required/secured to floor Barricade signage Emergency egress pathways clearly marked Travel paths barricaded/cones to protect foot traffic Environmental Storm water protected Hazardous waste plan Ground protected from metal shavings Dumpster covered Dust controls in place Weather Review Plans for weather incl. heat/wind/moisture Liquids Available Cool Down Periods Sun Screen Heat Stress Symptoms Crew Congestion/Impact to Occupants Inspected areas for potential impact to other crews/customers Coordinated with adjacent work supervisor/customer JOB/TASKMajor Steps of Task:(include Material Handling/Safe Lifting Plans)Tools required to do the job safely:Recognized hazard categories & additional hazards not captured on front pageAdditional safe plans for hazardsEyewash/Shower Location: Fire Extinguisher Location: Phone Location: Team Member Signatures By entering your name in this field you certify that all the information in the above form is, to the best of your knowledge, correct and filled out to completion. You also certify that you were present for the completion of this form.Foreman or Designee Signature* By entering your name in this field you certify your identity and that all the information in the above form is, to the best of your knowledge, correct and filled out to completion.