SAMPLE SITE SPECIFIC SAFETY PLAN

SITE:DATE:TIME:

LOCATION: ______

DESCRIPTION: ______

______

WEATHER CONDITIONS: ANTICIPATED HIGH ______LOW ______REL HUMIDITY ______

CLOUD COVER ______% WET BULB TEMPERATURE INDEX ______

THREE DAY FORECAST: ______

______

CONTROL ZONE LOCATIONS: HOT ______

WARM ______

MATERIAL HAZARDS

MATERIAL / C.A.S. / ROUTES / EL / IDLH / SIGNS/SYMPTOMS

PERSONAL PROTECTIVE EQUIPMENT

FUNCTION / RESPIRATORY / DERMAL / ACCESSORIES
ENTRY
DECONTAMINATION
MONITORING
DRUM OPENING

MEDICAL TREATMENT

TREATMENT FOR FIRST AID INJURIES: ______

______

TREATMENT FOR TRAUMATIC INJURIES: ______

______

TREATMENT FOR CHEMICAL INJURIES: ______

______

TOXICOLOGIST: ______( ) ______- ______

MEDICAL MONITORING TO BE PERFORMED ON-SITE: PULSE RATE CORE TEMP RESP RATE

BLOOD PRESSURE BODY WEIGHT HEAT STRESS MONITORING OTHER ______

MONITORING PLAN

TYPE / FREQUENCY / ACTION LEVEL / ACTION

SITE MANAGEMENT & COMMUNICATIONS

SUPERVISOR

COMMUNICATIONS:

Communications with personnel in the isolation area will be carried out by radios operating on a frequency of ______also known as channel ______.

Communications on-site will be carried out by radios operating on a frequency of ______which is also known as channel ______.

Communications with off-site personnel and agencies will be handled by the following process:

______

______

EMERGENCY COMMUNICATIONS:

Fire Response: ______Emergency Medical Service: ______

Haz-Mat Response: ______Law Enforcement: ______

Emergency Management: ______Environmental Regulation: ______

METHOD OF PERSONAL ACCOUNTABILITY: ______

______

DECONTAMINATION PLAN

Decontamination of operating personnel shall be carried out utilizing the following steps and procedures:

1) ______2) ______3) ______4) ______5) ______

6) ______7) ______8) ______9) ______10)______

The solution to be used during the scrub wash portion of decontamination will be: ______

No equipment will be removed from the isolation area without being properly decontaminated. The procedures for use on equipment shall be: ______

______

______

Remarks concerning decontamination: ______

EMERGENCY PROCEDURES

All employees will monitor conditions in their work areas for unsafe conditions or practices. If such a condition is observed, the employee is authorized to take whatever actions he/she may safely due to terminate the unsafe condition or act. The employee shall immediately notify the Site Safety Officer of the condition and any actions taken to correct.

Fires, injuries, un-wanted chemical reactions and un-safe conditions shall be immediately reported to the Site Safety Officer and/or the Emergency Evacuation Alarm shall be sounded. The evacuation alarm is recognized as repeating short air horn blasts and hand held whistles. Immediately upon hearing the evacuation signal all employees shall:

PERSONNEL IN ISOLATION AREAS: Report immediately to the decontamination area and begin the decontamination process.

PERSONNEL OPERATING IN DECONTAMINATION: Immediately prepare to receive persons from the isolation area. Perform decontamination procedures in accordance with the emergency decontamination plan.

SITE SAFETY OFFICER: Investigate the Emergency from a safe distance and report findings to the Site Supervisor. Order an all clear when appropriate based upon findings.

SECURITY OFFICERS: Report to access control points and provide for accountability using standard operating procedures.

STAFF OFFICERS and SITE SUPERVISOR: Report to the command post.

During a site emergency, radio silence will be utilized to allow for the orderly transfer of emergency information. Do not use your radio unless you have emergency radio traffic or you are called upon by the Safety Officer or the Site Supervisor.

Any injuries in the isolation area shall constitute a On-Site Emergency and will require activation of the emergency signal. Injuries in the support area will be investigated and, if the safety of isolation area personnel is compromised the emergency evacuation signal shall be ordered.

ABANDON SITE SIREN: The abandon Site Siren will be activated only upon the order of the Safety Officer or Supervisor. When ordered, emergency decontamination shall be performed and all employees on site will exit the site to the nearest site control gate. Security will provide for accountability in accordance with standard operating procedures. Local emergency Management Officials shall be notified immediately of any order to abandon the site.

ENTRY TRACKING

Entry # 1Time Start: ______Time End: ______Members: ______

Entry # 2Time Start: ______Time End: ______Members: ______

Entry # 3Time Start: ______Time End: ______Members: ______

Entry # 4Time Start: ______Time End: ______Members: ______

Entry # 5Time Start: ______Time End: ______Members: ______