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Date Project — Select project —PHL 105 Area / Location of Work Foreman — Select foreman —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Work Description

Labor

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Notes

Date Project — Select project —PHL 105 Foreman — Select foreman —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)... Weather — Select — Clear / Sunny Partly Cloudy Overcast Rain Snow High Wind Extreme Heat Cold Temperature (°F)

Work Performed Today Equipment on Site Materials Delivered Visitors / Inspections Delays or Issues

Labor

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Additional Notes

Date Project — Select project —PHL 105 Received By — Select —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Supplier / Vendor Purchase Order / Ticket # Material Description Condition of Material Condition Notes

Date of Purchase Project — Select project —PHL 105 Purchased By — Select —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)... Reason for Purchase

Receipt Photo (optional) 📷Take or Choose Photo ✕ Remove Photo

Date of Incident Time of Incident Project — Select project —PHL 105 Foreman on Site — Select foreman —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Injured Employee — Select employee —Daniel Burgos AlevanteJames ForsythAngel GonzalezRaul Sampedro IbarraNilson LemusOscar Sampedro MejiaArmando MunozAndres Leonardo Paguay LemaJon TaniAlfredo Villanueva AlburquequeRigoberto ZunigaOther (type name)... Type of Injury — Select type — Cut / Laceration Burn Strain / Sprain Eye Injury Fall Struck By Object Crush / Pinch Inhalation Other Body Part Affected Description of Incident Medical Treatment Required Witnesses Corrective Actions Taken Reported By — Select —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Date Project — Select project —PHL 105 Reported By — Select —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Violation Type — Select type — PPE Not Worn Fall Protection Housekeeping Electrical Hazard Fire Hazard Unsafe Work Practice Equipment Misuse Lockout/Tagout Violation Other Employee(s) Involved Description of Violation Corrective Action Taken Severity

Date Project — Select project —PHL 105 Reported By — Select —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Equipment Issue Type — Select issue — Won't Start / Breakdown Physical Damage Needs Inspection Missing / Not on Site Safety Issue Needs Fuel / Fluids Other Description of Issue Status Notes

Week of Project — Select project —PHL 105 Conducted By — Select foreman —Rigo ZunigaJon TaniPeter TaniAngel GonzalezRaul IbarraOther (type name)...

Safety Topic — Select topic — Housekeeping & Fall PreventionCrane & Rigging Safety Personal Protective Equipment (PPE)Welding Safety & Fire Prevention Electrical SafetyHand & Power Tool Safety Ladder SafetyLockout/Tagout (LOTO) Hazard Communication & SDSHeat Illness Prevention Cut & Laceration PreventionEye & Face Protection Struck-By HazardsConfined Space Awareness Forklift & Material Handling SafetySlips, Trips & Falls Scaffold SafetyErgonomics & Lifting Safety Fire Extinguisher UseEmergency Action Plan Custom Topic Talking Points

Attendance

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Additional Notes