Work Place Exam & Ground Inspection
This form should be completed weekly.
Personnel Details
Please complete all fields thoroughly and accurately. Upon completion of this report, you will receive a copy of your responses via email. Retain this email for your records.
Name
*
Please Select
Ball, Gordon
Isaacs, Joe
Johnson, Matthew
Littrell, Johnny
Priest, Jeff
Ray, Brandon
Sadler, Jonathan
Sartorius, Lee
Teutemacher, Jason
Other
Name
First Name
Last Name
Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Mine/Location
*
Please Select
Argos Cement Plant
Cemex Brooksville Quarry
Cemex Center Hill Quarry
Cemex Inglis Quarry
Cemex St. Catherine Quarry
Central State Aggregates
CYD Jacksonville
CYD Wildwood
Holcim CR Quarry
LaBelle
Lhoist Lowell Mine
Midcoast Aggregates
MM Perry Quarry
MM Soutel
SCI Materials Quarry
Other
Other Location
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Work Place Exam and Ground Inspection
For any items marked "Bad," identify and comment in the provided box following this section.
56.18002 - Work Place Exam
*
Good
Bad
N/A
Roadways, Ramps, Potholes
Electrical
Flammables
House Keeping
Equipment
Water
Power Lines
Loading Site Controls
Noise & Dust Control
Traffic Control/Signals
You indicated "Bad," under "Work Place Exam." Please identify and comment below.
Attach any relevant photos of items marked "Bad" below.
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56.3401 - Ground Inspection
*
Good
Bad
N/A
Water
Cracks
Holes
Unstable Rocks
Soft Ground
Sloped Ground
Highwall Hazards, Fail Protection
Berm Placement, Height
Uneven Ground
You indicated "Bad," under "Work Place Exam." Please identify and comment below.
Attach any relevant photos of items marked "Bad" below.
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Signature
By signing below, I acknowledge the following: I completed this inspection on the date marked in this report. I did not falsify or omit any information relevant to this report. All inspections were physically checked and verified by me before marking each answer.
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