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ENSAFE <br /> mem- <br /> Safe Work Assessment & Permit (SWAP) — V For Safety <br /> This form must be filled out dail rior to any work in the field and reviewed with all project personnel in a daily safety brief. <br /> Project Information <br /> Project/Client Name: SWAP Date: <br /> Location or Address: Site Emergency#: <br /> General Description of Today's Work: Project#: <br /> If any work involves confined spaces,excavations,LOTO,energized circuits,chemical exposure,or working at unguarded heights>4', <br /> contact the Corporate Health and Safety Manager or Senior Safety PM unless an approved HASP is in place. <br /> Prior to performing any task,you must Think Things Through. Each time you 73"a task,you improve your ability to identify hazards, <br /> implement the correct controls, which reduces the risk of an incident. <br /> T3 each task using the following questions. What hazards exist or actions taken could result in someone: <br /> 1. Being struck by or striking against something? 5. Straining or overexerting themselves? <br /> 2. Being caught in or between two or more objects? 6. Coming into contact with any harmful substances? <br /> 3. Slipping, tripping, or falling on the same level? 7. Injuring another person? <br /> 4. Falling from an elevated height? 8. Causing damage to equipment or materials? <br /> NOTE: Controls must be s ecific using the hierarchy of controls: Eliminate,Substitute,Engineer,Administrative,or Personal Protective Equipment See reverse. <br /> Task 1: <br /> Hazard: Hazard: Hazard: Hazard: <br /> Control 1: Control 1: Control 1: Control 1: <br /> Control 2: Control 2: Control 2: Control 2: <br /> Control 3: Control 3: Control 3: Control 3: <br /> Task 2: <br /> Hazard: Hazard: Hazard: Hazard: <br /> Control 1: Control 1: Control 1: Control 1: <br /> Control 2: Control 2: Control 2: Control 2: <br /> Control 3: Control 3: Control 3: Control 3: <br /> Task 3: <br /> Hazard: Hazard: Hazard: Hazard: <br /> Control 1: Control 1: Control 1: Control 1: <br /> Control 2: Control 2: Control 2: Control 2: <br /> Control 3: Control 3: Control 3: Control 3: <br /> List specific PPE: Eye/Face: Head: Hands: Hearing: <br /> Foot: ResoiratoLyn Bod : Other: <br /> THE LOCATION WHERE THE WORK IS TO BE DONE HAS BEEN EXAMINED AND NECESSARY PRECAUTIONS TAKEN FOR THE WORK. <br /> I certify that the above-listed project has been evaluated for hazards and personal protective measures assigned and communicated with all EnSafe personnel <br /> -on the jobsite. Changes in scope of work or work conditions may require the modification of existing SWAP or creation of a new SWAP. <br /> SWAP Leader: Name: Signature: <br /> Please see the reverse side for more information V. 08/01/2018 <br />