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FJVSAFr. <br /> Safe Work Assessment & Permit (SWAP) — V For Safety <br /> This form must be filled out daily prior to any work in the field and reviewed with all project personnel in a daily safety brief. <br /> I understand the hazards and will utilize the controls as noted above. (all EnSafe personnel and subcontractors) <br /> Subcontractors must provide their own job hazard analysis tool to validate their tasks and controls. Subcontractors signing this document merely verify that they <br /> participated in the EnSafe T3 safety process <br /> Name Signature Company Name Signature Company <br /> Comments: <br /> Update SWAP as needed throughout the day. Keep focused on Recognizing Hazards and Reducing Risk! V <br /> Common Hazards(For reference only) Control Identification Process <br /> Animals snakes etc. Machine (unguarded) <br /> Asbestos Manual liftingeve Hierarchy o Controls <br /> Chemical Exposures Moving equipment forklift, crane I Physically remove <br /> Elimination <br /> Combustible Material Noise the hazard <br /> Distractions Other client activities Substitution Replace <br /> Dust Other contractors L <br /> I the haaard <br /> Energized circuits Pinch Points <br /> Engineering IWJate PaPteFall from heights Poison tants(Ivy, oak, sumac fe hazard <br /> Flammable substances Poor body positioning <br /> Hand or Power tools Radiation _I Change the way <br /> Ignition sources Sharp/rough edges,etc. people work <br /> Inclement weather Temperature extremes II Protect the worker with <br /> Insects(Wasps,spiders,ticks Traffic - i Personal Protective Equipment <br /> Lead Trapped pressure �atr <br /> eRective <br /> Lifting/hoistingLifting/hoisting equipment Underground/overhead utilities <br /> Limited communication Walking surfaces(Slippery/uneven) <br /> This section is to be completed by the Project Manager when present. If a project manager is not on site, this section may be left blank. <br /> Project Managers: Use this portion of the SWAP to observe an activity using the T 3 process. Record what is being observed below then <br /> compare your observations to what is noted in the tasks, hazards, and controls. <br /> Task being observed: <br /> Hazards observed: <br /> Controls observed: <br /> T3 Questions <br /> Was the task observed included on the SWAP? Yes No <br /> Were all observed hazards identified on the SWAP? Yes No <br /> Were the controls properly used and effective? Yes No <br /> Were the results of this T3 process discussed with the employee(s)? Yes No <br /> Discussion Output(s)/Actions: <br /> Manager's Name and Signature: <br /> ✓ Return completed form to your Project Manager or save in Project File <br /> ✓ Emergency Contact Info: Corporate Health and Safety: 901-937-4255 or 724-470-4481; Corporate HR: 800-588-7962 <br /> Please see the reverse side for more information V. 08/01/2018 <br />