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project Name; <br /> Location: <br /> Date: <br /> F`IEY.D CHANGE REQUEST <br /> SUE SAFETY REVIEW-- CHANGES AND OVERALL EVALUATION <br /> (To Be Completed For Each Fi leld Change In Plan) <br /> Was the Safety Plan Followed as presented Yes No <br /> Describe,in detail,all changes to the Safety Plan <br /> Reason for changes +' <br /> Follow-up, Review and Evaluation Prepared by Date <br /> DMpline <br /> Approved by: Site Manager Date <br /> Site Safety Otfieer Date <br /> Approved by: Office Health&Safety Supervisor Date <br /> Evaluation of Site Safety Pian <br /> Was the Safety Plan adequate? Yes No <br /> What changes would you reoommend? <br /> ROUX ASSOCIATES M HM1051EFMMM <br />