Step 1 of 5

Primary Information

Date:

Location:

District:

Task:

Task Leader:

CSJ / Project ID:

Supervisor:

Supervisor Phone:

Safety Officer:

Safety Officer Phone:

Nearest Hospital:

Crew Members / Visitors - print name and initial below

Step 2 0f 5

Potential Hazards & Mitigation

Potential Hazard	Mitigation Steps
Exposure to traffic (3rd party vehicles, construction zones & vehicles, noise)	Work Zone Plan (TCP) – see page 2
Survey operations (location of setup or control points, limits & hazards of survey area)
Contact with overhead or underground utilities
Uneven, unstable or slippery walking surfaces
Environmental hazards (sun, ticks, poison ivy, snakes, etc.)
Weather hazards (heat, cold, rain, wind, visibility, ice, etc.)
Tall grass & hidden hazards
Hand tools (cutting, striking, digging)