PRE-TASK PLAN The supervisor and crew will create this plan establishing safe work practices and common hazard control measures for preventing the occurrence of injuries. Job InformationJob Name: Location of Work: Task Description: Start Date MM slash DD slash YYYY Start Time12:00 AM12:30 AM1:00 AM1:30 AM2:00 AM2:30 AM3:00 AM3:30 AM4:00 AM4:30 AM5:00 AM5:30 AM6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM8:30 PM9:00 PM9:30 PM10:00 PM10:30 PM11:00 PM11:30 PMEnd Date MM slash DD slash YYYY End Time12:00 AM12:30 AM1:00 AM1:30 AM2:00 AM2:30 AM3:00 AM3:30 AM4:00 AM4:30 AM5:00 AM5:30 AM6:00 AM6:30 AM7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM6:30 PM7:00 PM7:30 PM8:00 PM8:30 PM9:00 PM9:30 PM10:00 PM10:30 PM11:00 PM11:30 PMWork Task & Environment EvaluationIs every crew member orientated to the site and familiar with the work environment? Yes No Has the work area been walked by the crew to identify safety and/or impact concerns? Yes No Will the task require special permits or plans? (i.e. confined space entry, hot work, fall protection work plan) Yes No Will the task involve exposure to falls of 4’ or greater? Yes No Will barricading and or signage be required to protect personnel, facilities, or equipment? Yes No Will the task require the use of ladders, MEWPs, scaffolds or work platforms? Yes No Will the task require the LOTO of energized systems? Yes No Will the task involve the use of chemicals? If so, has an SDS been reviewed to proceed with the task? Yes No Will the task involve exposure to high noise levels greater than 85 dBA? Yes No Will the task involve musculoskeletal/ergonomic risk factors? (i.e. repetetive motion, awkward position, joint stress) Yes No Will weather conditions effect the safe completion of the task? Yes No Will the task require additional coordination with other crafts in the work area? Yes No Have all tools & equipment been inspected for safe use prior to starting work tasks? Yes No Has emergency equipment been identified & located? (i.e. fire extinguishers, eyewashes, first aid kit, AED) Yes No What is the evacuation route and designated rally point? Steps of the TaskHazards of the TaskHazard Control MethodsPersonal Protective EquipmentPPE Safety Helmet/Hard Hat Kevlar Sleeves Safety Glasses Respirator Face Shield Full Body Harness Gloves – Cut Level 3 or greater Hearing Protection High Vis Clothing Other (Explain) Other PPE SignaturesBy signing below, I acknowledge that I participated in the creation of this pre-task plan and understand the steps of the task, associated hazards, and hazard control methods.Foreman Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Crewmember Name: Add RemoveUse the + icon next to a crew member name to add additional crew members.Pre-Task Plan RevisionsDescribe the deviations from the original pre-task plan and detail the revised hazard control methods.R1R2R3NotesIf work conditions change, work MUST STOP and the Pre-Task Plan must be revised.