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Record of Safety Meeting / Tailgate
Please input all fields marked with *
Name:
Phone:
LSD / NTS:
Job Description:
Safety Meeting Discussion:
(topics should include job scope, hazards, controls & everyone's roles & responsibilities)
Emergency Response Plan:
(Muster area(s), medical providers, emergency procedures & contact numbers, etc.)
LEVEL OF RISK
High
Medium
Low
JSA Reference No.:
Hazard Assessment:
(select all that apply)
Communications
Multiple Crews
Emergency Response
Working Alone
Hazardous Atmosphere
Fire/Explosion
Slips & Trips
Pinch Points
Overhead Work
Fall Potential/Heights
Falling Objects
Respiratory
Electrical Exposure
Chemical Exposure
Noise Exposure
Temperature Extremes
Ventilation
Lifting/Handling
Visibility/Lighting
Rigging
Moving Parts
Mobile Equipment
Repetitious Work
Water
Ground Disturbance
Confined Spaces
Hot Work
Pressure
Underground
Surface Conditions
Other (explain)
Procedure No.
Task / Job
Hazard / What Can Go Wrong?
Control Measures / Prevention
Safety Meeting Checklist:
Yes
No
is everyone on location fit for duty?
Yes
No
is everyone on location properly trained / qualified to do their job?
Yes
No
Do all contractors have a Field Permit in place?
Yes
No
Has the job scope and procedures
Yes
No
Has the hazards specific to the job been identified?
Yes
No
Has the required hazard controls been implemented and confirmed?
Yes
No
Explain any NO responses:
Safety Meeting Signoff:
Name (Print):
Signature
Clear Signature
Name (Print):
Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
Clear Signature
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