Hazard Checklist

• Welding or Burning
• Underground Utilities
• Overhead Danger
• Motorized Lifts
• Activity requires input from Safety Coordinator and Insurance Carrier
• Noise Exposure
• Construction Barriers / Public Protection
• Chemical Exposure
• Cranes
• Excavations
• Electrical
• Demolition
• Lockout/Tagout
• Scaffolds
• Ladders
• Other
• Other Details:

Personal Protective Equipment (PPE) Checklist

Eye

• Safety Glasses
• Full Face Shield
• Welder's Shield

Ear

• Ear Plugs
• Ear Muffs

Hand

• Work Gloves
• Chemical Resistant
• Water Resistant

Feet

• Work Boots
• Rubber Boots
• Metatarsal Guards

Head

• Hardhats

Respiratory

• Dust Mask
• Air purifying or Atmosphere Supplying Respirator (requires user training and Fit Test)

Fall Protection

• Full body harness with shock absorbing lanyard

Fire Extinguisher

• Type A
• Type B
• Type C

Other

• Other
• Other Details:

General Items

• Contract & Insurance Fully Executed:
  Yes No
• SAR approved (if applicable):
  Yes No
• Review Subcontract and Detailed Scope of Work:
  Yes No
• Review Contract Drawings and Specifications:
  Yes No
• Establish Project Coordination Meetings Schedule:
  Yes No
• Review Subcontractor Installation Schedule:
  Yes No
• Review Mobilization / Laydown / Logistics / Special Deliveries / Off Hours Work:
  Yes No
• Permits required:
  Yes No
• Comments:

Safety Plan Items

• VRH Safety Orientation Training:
  Yes No
• Jobsite Security/Escorts/Badging (SWAC Cards):
  Yes No
• Review Site Specific Safety Plan (SSSP):
  Yes No
• Review MSDS Sheets:
  Yes No
• Review Hazard Assessments Required (Attached):
  Yes No




• These are the Hazard Assessments associated with this Pre-Mobilization Agenda. You may add or remove as desired.



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• Comments:

Quality Control Plan Items

• Review of Approved Shop Drawings & Submittals:
  Yes No
• Review required Controlled Inspections:
  Yes No
• Review Subcontractor proposed on-site personnel qualifications:
  Yes No
• Review Manufacturer Installation Instructions:
  Yes No
• Review Approved Mock-ups (if applicable):
  Yes No
• Establish timing for First Work approval Phase Inspection:
  Yes No
• Confirmed required preliminary work for this trade is complete:
  Yes No
• Comments:

Property Damage

• Property Damage
• Name of Property Owner:
• Phone Number:
• Property Type:
• Address:
• City, State, Zip:
• Description of Property Damage:

Bodily Injury

• Bodily Injury
• Name of Person Injured:
• DOB:
• Social Security No.:
• Cell Phone Number:
• Work Phone Number:
• Employer:
• Describe in detail what the injured party was doing at time of alleged incident:
• What were the injuries sustained by the worker? Be specific in describing the body part affected and the type of injury (i.e., laceration, bruise, burn, strain, etc.):
• Was the Port Authority Police called?
  Yes No
• If "Yes", please provide additional details (i.e., Badge #, Office Name, Precinct, Municipality, etc.):
• Was an ambulance called?
  Yes No
• Did the employee go for medical attention other than by ambulance?
  Yes No
• Was First Aid given to the Employee?
  Yes No
• Was the Employee sent home?
  Yes No
• Did the Employee return to work?
  Yes No

Witnesses

• List the name of workers and their employers name including cell phone:
• Notes:

Root Cause Analysis

• Investigative Team:
• Timeline Leading Up To Event. Please list the date(s) and times leading up to the incident:
• Identification of Root Cause:
• Corrective Action:

• VRH Punchlist #:
• Owner Reference #:
• Title:
• Room/Location
• Description:
• Schedule Impact: Please Select Yes No TBD
• Scope Status: Please Select In Scope Out of Scope TBD
• Drawing/Reference#:
• Complete By Date:
• Completed Date: