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EMERGENCY SAFETY 1.Incident Name 2.Date/Time Prepared 3.Operational Period 4.Attachments:Attach MSDS for each <br /> and RESPONSE PLAN Chemical: <br /> 5.Organization IC/UC: Safety: Entry Team: Backup Team: Decon Team: <br /> Div/Group Supv: <br /> 6.a.Physical Hazards and 6.b. Confined Space❑Noise❑Heat Stress❑ Cold Stress❑Electrical❑Animal/Plant/Insect❑Ergonomic❑Ionizing Rad❑ <br /> Protection Sli s/Tri s/Falls❑ Struck by❑Water❑Violence❑Excavation❑Biomedical waste and/or needles❑Fati ue❑ Other(s ecif ) <br /> 6.c. 6d Entry 6.e. 6f 6g.Shoes 6.h. 6i. 6j. 61.Work/ 6.m. 6.n.Signs 6.p.Fall 6.q. 6.r. 6.s. 6.t. <br /> Tasks &Controls Permit Ventilate Hearing (type) Hard Clothing Life Rest(hrs) Fluids & Protect Post Flash Work Other <br /> Protection Hats (cold wx) Jacket (amt/time) Barricade Guards Protect Gloves <br /> 7.a. Agent 7.b.Hazards 7.c.Target Organs 7.d.Exposure Routes 7.f.PPE 7.g.Type of PPE <br /> Explosive❑ Radioactive❑ Eyes❑ Nose❑ Skin❑Ears❑ Inhalation ❑ Face Shield❑ <br /> Flammable❑ Carcinogen❑ Central Nervous System❑ Absorption ❑ Eyes❑ <br /> Reactive❑ Oxidizer❑ Respiratory❑ Throat❑ Ingestion ❑ Gloves❑ <br /> Biomedical❑ Corrosive❑ Lungs❑ Heart❑ Liver❑ Injection ❑ Inner Suit❑ <br /> Toxic❑ Specify Other: ❑ Kidney❑ Blood❑ Lungs❑ Membrane ❑ Splash Suit❑ <br /> Circulatory❑ Gastrointestinal❑ ❑ Level A Suit❑ <br /> Bone❑ Other Specify: ❑ SCBA❑APR[—] <br /> SAR❑ <br /> Cartridges❑ <br /> Fire Resistance❑ <br /> 8.Instruments: 8.a.Action 8.b.Chemical Name(s): 8.c. 8.d.Odor 8.e.Ceiling/ 81 8.g.Flash Pt/ 8.h.Vapor 8.i.Vapor 8.j.Specific 8.1. <br /> Levels LEL/UEL Thresh IDLH STEL/TLV Ignition Pt Pressure Density Gravity Boiling <br /> % PPM F or C (mm) Pt F or C <br /> 02❑ <br /> CGI❑ <br /> Radiation❑ <br /> Total HCs❑ <br /> Colorimetric❑ <br /> Thermal❑ <br /> Other❑ <br /> ICS-208-CG SSP-A Page 1 (rev 9/06): Page of <br />