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/SYMPTOMSPERSONAL PROTECTIVE EQUIPMENT
FUNCTION / RESPIRATORY / DERMAL / ACCESSORIESENTRY
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 / ACTIONSITE 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: ______