Site Health & Safety Checklist

(post where visible from outside field office)

Project ID:	HWY or Route:	County:
Site Address & Location:
Project Begin Date:	Click here to enter a date.	Project End Date:	Click here to enter a date.
Local Emergency Telephone Numbers:
Ambulance:
Poison Control Center:
Fire Department:
Police Department:
Hazardous Materials Response Unit:
Medical Emergency: (In any medical emergency dial 911)
Hospital:	Phone:
Hospital Address:
Directions to Nearest Hospital:
Severe Weather Emergency:
Shelter Area I:
Shelter Area II:
Notify District Contact
Region Office:	Phone:
Supervisor:	Phone:
Project Manager:	Phone:
Other:	Phone:
Safety Equipment Inventory:
Item	Qty	Location	Inspect. Freq.	Comment
First Aid Kit	1	Office	Weekly
Fire Extinguisher	1	Office	Monthly
Ear Plugs	1 box	Office	Weekly
Safety Glasses	several	Office	Weekly
Safety Vests	several	Office	Weekly
Hard Hats	several	Office	Weekly
Other:
Contractor MSDS Location:

REVIEW IS REQUIRED BY ALL ONSITE PERSONNEL BEFORE BEGINNING WORK
Name:	Initials:	Date:	Click to enter date.
Name:	Initials:	Date:	Click to enter date.
Name:	Initials:	Date:	Click to enter date.
Name:	Initials:	Date:	Click to enter date.
See Attached Map for Shelter Areas and Route to Hospital