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' BROWN AND Attachment Site Safety and Health Plan ALDWELL Safet Plan Implementation Checklist Protect Name Protect Location (city and state) Date Name of Site Safety Coordinator Weather Conditions Protect Number ' BC Staff Present Name Office Indicate the status of each of the following 1 Is a copy of the Site Safety and Health Plan (SSHP) on site? ❑ YES ❑ NO ❑ NIA 2 Is the personal protective equipment required by the SSHP available and being used correctly? ❑ YES ❑ NO ❑ NIA 3 Have the work zones been delineated? ❑ YES ❑ NO ❑ NIA ' 4 Has a decontamination station been set up as required by the SSHP? ❑ YES ❑ NO ❑ NIA 5 Are the decontamination procedures being followed? ❑ YES ❑ NO ❑ NIA ' 6 Is access to the exclusion zone being controlled? ❑ YES ❑ NO ❑ NIA 7 Has the site activities briefing and tailgate safety meeting been provided? ❑ YES ❑ NO ❑ NIA Is the list of emergency telephone numbers posted at the support zone? ❑ YES ❑ NO ❑ NIA Are directions to nearest emergency medical assistance posted at support zone? ❑ YES ❑ NO ❑ NIA 10 Is emergency equipment available and functional, as required by the SSHP? ❑ YES ❑ NO ❑ NIA ' 11 Has the nearest toilet facility been identified or a portable facility been set up? ❑ YES ❑ NO ❑ NIA 12 Has an adequate supply of drinking water been provided? ❑ YES ❑ NO ❑ NIA 13 Has water for decontamination been provided? ❑ YES ❑ NO ❑ NIA ' 14 Have the instruments for environmental and exposure monitoring been calibrated and set up as required by the SSHP? ❑ YES ❑ NO ❑ NIA ' 15 Are the instruments being used properly and periodically checked during the shift for battery charge status? ❑ YES ❑ NO ❑ N/A 16 Have the trenches and excavations been clearly marked? ❑ YES ❑ NO ❑ N/A ' 17 Have trenches and excavations been shored or sloped as required by sod type and work activities? ❑ YES ❑ NO ❑ N/A 18 Are dust suppression measures being used? ❑ YES ❑ NO ❑ N/A ' 19 Is food and tobacco consumption being restricted to the support zone? ❑ YES ❑ NO ❑ N/A 20 Has a confined space been identified as part of this protect? ❑ YES ❑ NO ❑ N/A 21 Are the confined space entry procedures being correctly implemented? ❑ YES ❑ NO ❑ N/A ' 22 Has the work/rest cycle for the shift been established? ❑ YES ❑ NO ❑ N/A TIME ON (minutes) TIME OFF (minutes) 23 Has a shaded rest area been set up in the support zone? ❑ YES ❑ NO ❑ NIA iP1 NOTE: Place completed form in project file. HS-18 REV 06/98