Form – Critical Safety Analysis – M&M Excavating

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What We Do
- Projects Map
Work With Us
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Critical Safety Analysis

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M&M Job Number *

Description of Work *

Are There Utilities? *

Yes
No

Known Utilities *

Gas Main
Gas Service
Gas Distribution
Water Main
Water Service
Storm Sewer
Sanitary Sewer
Sanitary Force
Electric
Telephone
Fiber Optic
Cable

Marked MISS DIG? *

Yes
No

Positive Response *

Yes
No

Weather Forecast

Hazards

Overhead Utilities
Crane or other Lifting Equipment
Bucket Truck
Underground Utilities
Electrical
Excavation
Fire Hazard
Vehicular Traffic or Heavy Equipment
Noise >85 dB
Hand & Power Tools
Hand Hazards
Manual Lifting
Ladders
Scaffolds
Slips, Trips, Falls
Pinch Points
Working w/Chemicals
Asbestos or Lead Paint Potential
Heat Stress Potential
Cold Stress Potential
Environmental
Natural or Site Hazards
Adjacent Work/Processes
Barricades/covers
Overhead Utilities
Other

Additional Hazards *

List additional hazards not listed in the checkboxes above. Please separate each additional hazard with a ",".

How many steps have been taken to mitigate hazards?

Steps taken to mitigate hazards 1

Steps taken to mitigate hazards 2

Steps taken to mitigate hazards 3

Steps taken to mitigate hazards 4

Steps taken to mitigate hazards 5

Steps taken to mitigate hazards 6

Steps taken to mitigate hazards 7

Steps taken to mitigate hazards 8

Steps taken to mitigate hazards 9

Steps taken to mitigate hazards 10

Walk Thru Completed *

Yes
No

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