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Critical Safety Analysis

Date *

M&M Job Number *

Jobsite Information

Description of Work *

Upload Video of Jobsite

Drag & Drop Files, Choose Files to Upload

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

Potential Hazards

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 ",".

Steps to Mitigate Hazards

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

Competent Persons

Name 1 *

First

Last

Name 2

First

Last

Name 3

First

Last

I Attended this Critical Safety Analysis

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First

Last

Name 35

First

Last

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Secured Jobsite Checklist

Date and time completed *

Date

Time

Jobsite *

Person completing walk-thru *

First

Last

Are all construction entrances properly barricaded? *

Yes
No
N/A

Upload picture of construction entrances *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are all cones, barrels and signage properly placed and visible? *

Yes
No
N/A

Upload picture of placed or lack of placed cones, barrels and signage *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are all signs and barricades secured from falling into traffic? *

Yes
No
N/A

Upload picture of secured of non-secured signs and barricades *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are excavations properly fenced, barricaded off/bermed, secured so fencing will not fall? *

Yes
No
N/A

Upload picture of secured/non-secured excavation *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are excavation properly sloped? *

Yes
No
N/A

Are materials and equipment put in is designated area and minimum of 30ft from open traffic lanes? *

Yes
No
N/A

Upload picture of equipment *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Is all trash picked up? *

Yes
No
N/A

Is equipment and trucks properly secured with windows closed? *

Yes
No
N/A

Upload picture of equipment and trucks *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are trailers locked? *

Yes
No
N/A

Are all driveways and open streets passable? *

Yes
No
N/A

Upload picture of driveways and open streets *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Are signs not in use laid down properly? *

Yes
No
N/A

Are equipment tracks clean? *

Yes
No
N/A

Are all fuel cans locked up in the cage? *

Yes
No

Are sub-contractors adhering to our safety protocols? *

Yes
No
N/A

Are all M&M employees off the jobsite? *

Yes
No

Are all weather sensitive tools/equipment put in a dry enclosed area? *

Yes
No

Were there any corrections? *

Yes
No

Description of what was corrected *

Pictures of what was corrected *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Notes

Good Catch/Near Miss

Name *

First

Last

You may enter ANONYMOUS here if you prefer to submit this form anonymously.

M&M Job # or Job Name *

You may enter the city if you don't know or prefer to keep it anonymous.

I'm submitting a... *

Good Catch
Near Miss
Other

Other *

When did the event occur? *

Describe the Good Catch or Near Miss *

What was learned or changed due to the Good Catch or Near Miss? *

What’s your ‘&’?

Tell us *

Show us

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Upload your pictures or videos

Choose a category *

Job Site Moments
Outdoor Adventures
Family & Traditions
Hobbies & Skills

Your name *

First

Last

Email *

Phone

I give consent *

I give M&M permission to use the photos and videos I upload for their media, such as ads, social media, and their website.

SAFETY MEETING

Date and Time *

Date

Time

Job Number *

Supervisor/Meeting leader *

First

Last

Do all employees have the proper PPE for the day? *

Yes
No

Points Discussed *

Comments/Questions

M&M is an equal opportunity employer ----- Report all Injuries ------ Report all equipment issues or needed repairs

I Confirm That I Attended This Safety Meeting An I Understand The Content, As Well As Have All Required PPE.

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I confirm that everyone signed into the safety meeting.

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M&M EXCAVATING

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Safety & Quality

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Family & Community