WORKPLACE SAFETY PLAN

Includes: First Aid Assessment; Emergency Response Information;

Hazard Assessment; Safety Meeting; Site Log

Date:
Job / Project Name and Number:
Work Site Location (include directions):
Latitude: / Longitude:
UTM Coordinates: / E / N / Z
Prime Contractor:
Subcontractor:
FIRST AID ASSESSMENT
Job Functions, Work Processes, and Tools:
Types of Injuries that Can Potentially Occur (list):
Overall Work Site Hazard Rating: L M H / Total Workers per Shift:
Surface Travel Time to Hospital:20 minutes or less Greater than 20 minutes
Barriers to First Aid:
Route to Medical Facility:
Designated First Aid Attendant:
Location of ETV:
Sample table below is High Hazard Rating and Greater than 20 Minutes Surface Travel Time to Nearest Hospital:
Number of Workers per shift / Supplies, Equipment & Facility / Level of First Aid Certificate
for Attendant /

Transportation

1 / Personal First Aid Kit
2-5 / Level 1 First Aid Kit / OFA Level 1
6-10 / Level 1 First Aid Kit
ETV equipment / OFA Level 1 with Transportation Endorsement / ETV
11-30 / Level 3 First Aid Kit
 Dressing Station
ETV equipment / OFA Level 3 / ETV

For complete OFA requirements, visit WorkSafeBC’s webpage:www2.worksafebc.com/publications/OHSRegulation/Part3.asp#SectionNumber:3.14

JOB SITE / EMERGENCY CONTACT INFORMATION

Company Office:
Project Manager: / Work: / Home: / Cell:
Site Supervisor: / Work: / Home: / Cell:
Land Ambulance: / Air Ambulance: / RCMP:
WorkSafeBC: / Wildfire: /
Avalanche Incident:
PEP: / Helicopter: / Fire Department:
On-site Mobile Radio Frequencies:
Name of Road: / Frequency:
Name of Road: / Frequency:
Name of Road: / Frequency:
Name of Road: / Frequency:
Name of Road: / Frequency:
Name of Road: / Frequency:
Other Information:

PRE WORK HAZARD ASSESSMENT

Overhead Hazards (trees, snags, power lines)
Yes No / Road Hazards
Yes No
Steep Slopes
Yes No / Heavy Slash, Blowdown, Other Obstacles
 Yes No
Dangerous Terrain (gullies, ridges, cliffs)
Yes No / Energy Hazards (mines, pipelines, electrical)
Yes No
Unstable Surfaces (wet, soft, slippery)
Yes No / Weather Conditions
Yes No
Riparian Areas
Yes No / Dangerous Wildlife (bears, cougars, wasps)
Yes No
Item # /
Hazard Description and Controls
/ Hazard Class
(L, M, H) / Location of Hazard
Hazard Assessment Conducted by: / Signature:

Ensure that Hazard Corrective Action Order is completed if hazards are identified!

PRE WORK SAFETY MEETING
Pre Work Hazard Assessment Report and Corrective Action Orders reviewed: Yes  No
Emergency response plan reviewed and available: Yes  No
First aid personnel and location of first aid equipment supplies reviewed: Yes  No
Personal protective equipment requirements reviewed: Yes  No
Safe Job Procedures and Safe Work Practices reviewed: Yes  No
Contract specifications and Environmental Instructions reviewed: Yes  No
Personnel’s well-being check-in procedures tested and reviewed: Yes  No
Hazards defined and reviewed: Yes  No
Designated safe work area defined and reviewed: Yes No
Discussion:

Personnel Attending Meeting:

Name and Job Function: / Signature:
Supervisor / Facilitator: / Signature:
SITE LOG
(To be completed by on-site Supervisors)
Identify new hazards and changes to the overall plan, e.g.:
  • New hazards not identified in pre-work
  • First aid coverage/ETV/fire equipment modifications
  • ERP changes
  • Man check changes
  • Radio frequency or road signage changes
  • Blast zones
  • Visitors to the site

Date / Changes to Plan/Action Taken / Communicated To / Initial

frm_xWorkplaceSafetyPlan.docPage 1 of 1

Revised: May 12, 2015