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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 Information
Job Name:
Location of Work:
Task Description:
Start Date
MM slash DD slash YYYY
Start Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
End Date
MM slash DD slash YYYY
End Time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
5:00 AM
5:30 AM
6:00 AM
6:30 AM
7:00 AM
7:30 AM
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Division
(Required)
Seattle
Portland
Missoula
Tri Cities
Spokane
Billings
Foreman Name
(Required)
First
Last
Foreman Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Check below to upload paper Pre-Task Plan
I have a paper form.
File
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Max. file size: 100 MB.
Work Task & Environment Evaluation
Is 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 Task
Hazards of the Task
Hazard Control Methods
Personal Protective Equipment
PPE
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
Signatures
By 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.
Crewmember 1 Name:
First
Last
Crewmember 1 Signature
Crewmember 1 - I agree the above name and signature are my own
Yes
Crewmember 2 Name:
First
Last
Crewmember 2 Signature
Crewmember 2 - I agree the above name and signature are my own
Yes
Crewmember 3 Name:
First
Last
Crewmember 3 Signature
Crewmember 3 - I agree the above name and signature are my own
Yes
Crewmember 4 Name:
First
Last
Crewmember 4 Signature
Crewmember 4 - I agree the above name and signature are my own
Yes
Crewmember 5 Name:
First
Last
Crewmember 5 Signature
Crewmember 5 - I agree the above name and signature are my own
Yes
Crewmember 6 Name:
First
Last
Crewmember 6 Signature
Crewmember 6 - I agree the above name and signature are my own
Yes
Crewmember 7 Name:
First
Last
Crewmember 7 Signature
Crewmember 7 - I agree the above name and signature are my own
Yes
Crewmember 8 Name:
First
Last
Crewmember 8 Signature
Crewmember 8 - I agree the above name and signature are my own
Yes
Crewmember 9 Name:
First
Last
Crewmember 9 Signature
Crewmember 9 - I agree the above name and signature are my own
Yes
Crewmember 10 Name:
First
Last
Crewmember 10 Signature
Crewmember 10 - I agree the above name and signature are my own
Yes
Crewmember 11 Name:
First
Last
Crewmember 11 Signature
Crewmember 11 - I agree the above name and signature are my own
Yes
Crewmember 12 Name:
First
Last
Crewmember 12 Signature
Crewmember 12 - I agree the above name and signature are my own
Yes
Crewmember 13 Name:
First
Last
Crewmember 13 Signature
Crewmember 13 - I agree the above name and signature are my own
Yes
Crewmember 14 Name:
First
Last
Crewmember 14 Signature
Crewmember 14 - I agree the above name and signature are my own
Yes
Crewmember 15 Name:
First
Last
Crewmember 15 Signature
Crewmember 15 - I agree the above name and signature are my own
Yes
Pre-Task Plan Revisions
Describe the deviations from the original pre-task plan and detail the revised hazard control methods.
R1
R2
R3
Notes
Additional Email 1
Send a notification to an additional email
Additional Email 2
Send a notification to an additional email
If work conditions change, work
MUST STOP
and the Pre-Task Plan must be revised.
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