Ground Disturbance Safety Checklist Form
Use this form to verify site details, work activity, utility checks, hazards, controls, and readiness before ground disturbance work begins.
Site and Work Identification
Job/Project Name
*
Work Location / Site Area
*
Checklist Completion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Completed By (Name and Title)
*
Ground Disturbance Activity Details
Type of Ground Disturbance Activity
*
Excavation
Trenching
Boring
Digging
Grading
Drilling
Utility Repair
Other
Planned Depth or Extent of Disturbance
*
Expected Start Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Safety Verification Checklist
Pre-work safety verification
*
Utility locates/marking completed
Permit or authorization obtained
Underground utilities identified
Overhead utilities identified
Exclusion zone or barricades in place
PPE available and required
Soil or ground conditions assessed
Emergency plan reviewed
Communication method reviewed
Hazards or special precautions identified
Hazards or special precautions identified
Checklist status
*
Ready to proceed
Proceed with controls
Stop work until issues are resolved
Submit Ground Disturbance Safety Checklist
Should be Empty: