Minor Ground Disturbance Checklist Form
Complete this checklist before and during minor ground disturbance work to ensure safety and compliance.
Project or Work Name
*
Location of Work
*
Type of Disturbance
*
Please Select
Hand Digging
Mechanical Excavation
Augering
Hydrovac
Other
Planned Work Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Estimated Depth or Extent of Disturbance
*
Please Select
Less than 0.5 meters
0.5 to 1 meter
1 to 1.5 meters
Greater than 1.5 meters
Utility Locate Verification Completed?
*
Yes, valid and on site
No, locate not completed
Not required for this work
Surface and Ground Conditions
*
Dry
Wet
Frozen
Rocky
Soft/Unstable
Nearby Hazards Identified
*
Overhead Power Lines
Buried Utilities
Traffic or Roadways
Water Bodies
None
Controls and Precautions in Place
*
Barricades/Signage
Spotter Assigned
Personal Protective Equipment
Emergency Procedures Reviewed
Other
Reviewer/Submitter Name
*
First Name
Last Name
Reviewer/Submitter Role or Position
*
Submit Checklist
Should be Empty: