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f, <br />w ectNamv. <br />Location: <br />Date., <br />e <br />15 1 DI P 1 1 1 <br />11 « . 1' • <br />(To Be Completed For Each Held Change In Plan) <br />Was the Safety Plan Followed as presented Yes No <br />Describe, In detail, all changes1 the is <br />Reason for changes t' <br />Follow-up, Review and Evaluation Prepared by <br />Date <br />Discipline <br />Approved by: Site -ManaW Date <br />Site Safety Officer Date <br />Approved by. Office Health & Safety Supervisor Date <br />Evaluation of Site Safety Plan <br />Was the Safety Planadequate? <br />What changes would you d? <br />ROUX ASSOCIATES M' <br />