Visitor Site Orientation Checklist

Part 1: Requirements for Entry*

Rows	YES	NO	N/A
1. Has a review of the Emergency Response/Project Site Plot Plan been completed?
2. Has the 6 foot fall protection requirement been explained to the visitor?
3. Has the Pre-Job Safety Instruction (PSI) program been explained and reviewed with the 3. visitor?
4. Is the visitor aware that he/she is to be accompanied by the escort identified below at all tim
5. Have site requirements for the use of the following protective equipment been reviewed?

Safety GlassesGlovesHearing ProtectionSafety FootwearDust MaskRespiratory EquipmentHard HatsFace ShieldsMono-GogglesFall ProtectionVestsOther
Part 2: Orientation Acknowledgment

This form will be retained on file at the project worksite location
Visitor's Signature*

Clear
Escort’s Name:*
Escort's Signature*

Clear
Facilitator’s Name:*
Facilitator’s Signature:*

Clear
Should be Empty: