UFC 4-150-07
19 June 2001
Figure 4-1 Safety Plan Format
1.
Proposed Project: __________________________________________
a)
Description: _______________________________________________
______________________________________________________________
b)
Project Site/Diagrams: _______________________________________
c)
Dates/Times of Operation: ____________________________________
d)
Project Personnel: __________________________________________
e)
Safety Coordinators: _________________________________________
2.
Preliminary Hazard Analysis:
a)
List hazards, triggering events, and estimate seriousness:___________
______________________________________________________________
b)
Assign Risk Assessment Code (based on hazard severity and mishap
probability): _______________________________________________
c)
Hazard Control Mechanisms/Safety Measures (attach SOPs): _______
_______________________________________________________________
3.
Training and Medical Surveillance (list project personnel, their training, medical
surveillance dates and signatures): ___________________________________
________________________________________________________________
4.
Hazardous Waste Operations and Emergency Response (describe applicable
HW operations and emergency plans):_________________________________
________________________________________________________________
5.
Personal Protective Equipment (list all PPE to be used for each task): _
________________________________________________________________
6.
Medical surveillance (list personnel who have had the required medical
surveillance exams for each task):____________________________________
________________________________________________________________
7.
Industrial hygiene (identify requirements for air, personnel and environmental
monitoring):______________________________________________________
________________________________________________________________
8.
Site control measures (identify any site control measures instituted):____
________________________________________________________________
9.
General information:__________________________________________
10.
Phone contacts:______________________________________________
11.
Emergency contacts:__________________________________________
4-3
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