SAFETY TASK ASSIGNMENT Lock, Tag, Try † † Does the ladder(s) have a current

Excavation † † inspection? † Yes † No

The STA should be completed daily for each task. Signs/Barricades † †
Post this STA in a conspicuous location Confined Space † † APPLICABLE PERMITS:
throughout the length of the task. Each crew Crane Lift † † 7. Is a fire watch or vessel attendant required?
member involved with the task should sign this Line Break/Hot Tapping † † † Yes † No
STA. At the end of the task, give this STA to the Scaffolds † † Name: ______________________________
Project/Site Management. If deviation from Other (specify) † †
known safe work practice/ procedure occurs, EMERGENCY EQUIPMENT:
work must be stopped. EMPLOYEE CERTIFICATIONS 8. Identify below the location of the nearest
REQUIRED: safety shower and alarm box. ___________
Supervisor: ______________Date: ______ Yes No ___________________________________
Location of Task: _____________________ Crane Operator † † Alarm Box # ____________
___________________________________ Forklift Operator † †
_______________________________________ Mobile Equipment Operator † †
HOUSEKEEPING:
_______________________________ Powder-Actuated Tool User † †
9. Are trash receptacles available in the work
Task Description: ____________________ Competent Person (lead, asbestos,
area?
___________________________________ excavations, confined space,
Location: ___________________________
___________________________________ hazardous material, scaffolds) † †
Does task require special training? Other (specify) † †
FALL PROTECTION:
† Yes † No 10. Have areas been identified as requiring fall
If yes, what type? GENERAL INFORMATION:
protection systems and have they been
_______________________________________ 1. Should Safety/Representative be involved in the
installed? (i.e., static lines, barricades,
_______________________________ planning of this task? † Yes † No
hole covers, etc.) † Yes † No
2. What are the hazards associated with the Explain: __________________________
PERSONAL PROTECTIVE task? ______________________________ __________________________________
EQUIPMENT REQURIED: ___________________________________
FIRE PROTECTION:
Yes No Type Have they been explained to the 11. Are flammable/combustible materials
Fall Protection † † ___________ employees? † Yes † No stored, separated, inspected and secured
Eye/Face † † ___________ per procedure? † Yes † No
Respirator † † ___________ 3. What weather conditions could affect the
Foot † † ___________ safety performance of this task?
___________________________________ ASSIGNED EMPLOYEES:
Hand † † ___________ Name Badge #
Hearing † † ___________ _______________________ _______
Coveralls † † ___________ TOOLS & EQUIPMENT:
_______________________ _______
4. User inspection is required of all tools, _______________________ _______
PPE Examples: Monogoggles, face shield, acid ladders, electrical cords, rigging and safety
______________________ _______
hood, sandblasting hood, welding (goggles, equipment. Has this been completed?
_______________________ _______
shield, sleeves), ear protection, gloves (leather, † Yes † No _______________________ _______
chemical resistant, gauntlets), shin/foot _______________________ _______
MATERIAL STORAGE: _______________________ _______
protection, boots (rubber/hip), rain suit, life vest,
5. Has a material storage area been identified MY SAFETY PRINCIPLES
safety harness, fall protection equipment, and approved? † Yes † No
breathing air assembly.
SCAFFOLDS/LADDERS: • Plan Every Job
PROCEDURES/PERMITS REQUIRED:
6. Inspect all scaffolds/ladders before use.
Yes No Has the the scaffold tag(s) been signed? • Anticipate Unexpected Events
Hot Work † † † Yes † No
• Use The Right Tool For The Job Yes _____ No _____
________________________________________
• Use Procedures As Tools ________________________________

• Isolate The Equipment 2. Was the accident/incident reported to the safety

department? Yes _____ No _____

SAFETY
• Identify The Hazards 3. What problems were encountered with today’s
work assignment?
• Minimize The Hazards _______________________________________

TASK
_______________________________
• Protect The Person
4. What can be done tomorrow to improve
• Assess People’s Abilities performance?

• Audit These Principles

_______________________________________
_______________________________

5. Miscellaneous concerns:
ASSIGNMENT
________________________________________
________________________________

6. Reviewed by:
Supervisor:
General Foreman:

ASSIGNED EMPLOYEES:
NAME BADGE #
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
______________________ _____________
TURN FORM IN TO PROJECT/SITE ______________________ _____________
MANAGEMENT AT END OF SHIFT OR WHEN ______________________ _____________
TASK IS COMPLETED.

POST SAFETY TASK REVIEW:

SUPERVISOR: _________________________
UNITED
DATE: ________________________________ JUBAIL
1. Was anyone injured or did an unplanned incident
occur today? If yes, explain.