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CEM-0601 (REV 04/2001)
CONSTRUCTION SAFETY REPORT
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
FIELD OFFICE OR JOB STAMP
TAILGATE SAFETY MEETINGCONTRACT ADMINISTRATIONPROJECT SAFETY REVIEW
PUBLIC SAFETY CT EMPLOYEE SAFETY
5. SIGNATURES OF EMPLOYEES PRESENT (Use attached sheet for additional signatures)
FM 91 1298
ORIGINAL - DISTRICT OFFICE CC - FILE CC - BULLETIN BOARD
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ADA Notice
1. TYPE OF REPORT
NAME TITLE
2. DISCUSSION (List Inspection Findings or Safety Topics Discussed)
NAME TITLE
NAME TITLE
3. ACTIONS TAKEN (List Corrective Actions or Recommendations)
4. SUPERVISOR'S COMMENTS (List comments, instructions, etc.)
SIGNATURE
SIGNATURE
SIGNATURE
SIGNATURE SIGNATURE
SIGNATURE SIGNATURE
SIGNATURE SIGNATURE
DATE
DATE
DATE
SIGNATURE OF 1st LINE SUPERVISOR
SIGNATURE OF 2nd LINE SUPERVISOR
SIGNATURE OF SAFETY OFFICER
DATE
DATE
DATE