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Pre-Work Assessment Survey

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Take a Photo of the Site Sign
Certifications: (list employee certifications / Tower Rescue, CPR/FA) (list personnel certified)
If climbing is being conducted are two or more employees on site Tower Rescue Certified?
Are two or more employees on site CPR/FA certified?
Is employee using hoist qualified/certified?
Are employees certified in rigging?
Are employees certified in confined space entry?
Emergency Contacts
Cell phone coverage?
Are 911 systems functional / cell phone?
Phone number and address for local Police, Fire and ER
Rescue Procedures (explain rescue procedures under selection)
Outside Services?
Heavy Equipment?
Friction Control Device?
Internal Crew?
Other? (describe)
Job/Tasks for Scope (describe job tasks under selected category)
Tower Construction/Survey?
Bridge Construction/Survey?
Foundation Construction/Survey?
Other? (describe)
Jobsite Exposures Physical Hazards (select and explain abatement on all that apply)
Confined Space?
Dropped Tools/Equipment?
Elevation/Site Terrain?
Fall from Elevation/Roof Edge?
Fire Hazard?
Navigable Waters?
Heavy Equipment?
Overhead Utilities?
Slips, Trips, Falls?
Underground Utilities?
Vehicle Traffic?
Other? (describe)
Jobsite Exposures Health Hazards (select and explain abatement on all that apply)
Biological Hazards?
Chemical Exposures?
Environmental Hazards?
HazMat Exposure/Disturbance?
Heat Stress/Cold Stress?
High Noise (> 85 dBA)?
Lifting Hazards?
Silica Exposure?
Other? (describe)
Civil Work
Describe the type and depth of excavation:
Have private utility locates been completed where required?
Have utilities been located where core boring/drilling is required?
Public utility locate work order number along with effective and expiration dates:
Have all owner identified underground obstructions been located & marked?
Describe the cave-in control measures to be used if excavation will be greater than 5 feet personnel are entering the trench (sloping, benching, shoring, shield/box, ladder in trench at 4 feet):
Describe elevation/site terrain/environmental concerns or hazards:
Describe hazards with site/vehicle access (e.g. boom and cranes/electrical lines) and storage of materials:
Describe the type of electrical hazards:
Elevated Work
Type of Elevated Work Location:
Type of Antenna Boom(s):
Anchorage Straps Used?
Controlled Descent Devices?
Retractable Lifelines?
Rope Grab?
Cable Grab?
Full Body Harness?
Other: (describe)
Site Supervisor/Foreman:
Lower Tier Subcontractor Supervisor:
Date and Time of Visitor(s):
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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