PROJECT: Name or # / Start Date
Building:
Floor: / End Date
Crew Size:

Environmental Health & Safety

Pre-Task Plan Check List

Crew Foreman Review______

Elect. Sup. (if applicable)______PSU EHS Review______

Ask the following during evaluation of your work and check “Yes” or “No” as it applies to the task:

Have you personallywalked your work area? / Yes/No / Does this task require disassembly of systems or equipment? / Yes/No
Are enough personnel assigned to this task to complete it safely? / Yes/No / Does this work require flushing or discharging of fluids? / Yes/No
Will weather conditions affect the safe completion of your task? / Yes/No / Have all portable electric equipment and tools been inspected prior to use? / Yes/No
Does this task require special training? / Yes/No / Should EHS department be involved in planning? / Yes/No
Dust/fume/odor/exhaust control devices in place and operating? / Yes/No / Has the work been coordinated with other work
in the area? / Yes/No
Does this task require any permits / procedures? / Yes/No / Are you familiar with the evacuation routes? / Yes/No
Asbestos, lead or other hazardous material concerns? MSDS/SDS reviewed? / Yes/No / Have you identified all emergency equipment? / Yes/No
Will your work impact existing buildings/occupants? / Yes/No / Are you working around live systems or equipment? / Yes/No
Have employees been trained in the proper usage of required PPE? / Yes/No / Are shop drawings and as-builts on hand? / Yes/No
Have necessary containments been established? / Yes/No / Have all Utility outages been pre-scheduled? / Yes/No
Should PSU CPSO be notified? / Yes/No / Have ALL the air intakes been identified? / Yes/No

Check if any of the following apply to the task being planned here (attach additional information needed):

___LOTO (Lockout/tagout)* / ___Eye/Face PPE / ___Respirator/Dust Mask*
___Barricades/Control Zones/Signage / ___Hand/Arm PPE / ___Emergency Spill Kits/Response Tools
___Haz.Com. (MSDS/SDS) * / ___Full Body PPE / ___Task Lighting Equipment
___Energized Electrical Hot Work * / ___Hearing PPE / ___Scaffolds
___Non-Electrical Hot Work * / ___Fall Protection PPE / ___Flush/Discharge
___Dust or Silica Dust Control / ___Confined Space Entry * / ___Ergo (Repetitive Motion/Vibration/Impact)

Print Crew Member’s Names/ Signatures required

* Unless a Contractor has provided their own program, PLEASE reference the appropriate PSU Program and follow that program accordingly.

Revised: 6/5/2015 (Rev 3)

Task to be accomplished:
Author/Planner: / Housekeeping plan: (daily cleanup required)
Date plan prepared:
SEQUENCE OF CONSTRUCTION ACTIVITIES / HAZARD ANALYSIS
(Hazards Involved) / METHOD/S TO ELIMINATE/
CONTROL HAZARDS

Emergency: 911 & CPSO 725-4404 Location of nearest: Shower/Eyewash: ______Fire Extinguisher: ______

Non-Emergency:EHS @ 503-725-3438If conditions change, the work must STOP and the Pre Task Plan must be updated

Revised: 1/29/2014 (Rev 2)