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CG ICS SSP: Exposure 1. Incident Name 2. Date/Time 3.Operational Period: 4.Safety Officer(Method of Contact): Monitorin2 Plan I Prepared: 5. Specific 6. Survey 7. Survey 8.Monitoring 9.Direct- 10.Air Sampling 11. 12. 13.Reasons to 14.Laboratory Task/Operation Location Date/Time Methodology Reading Hazard(s) Monitoring Monitor Support for Instrument to Monitor Duration Analysis ❑Personal Breathing Zone Model: Sampling/Analysis ❑Regulatory ❑Area Air Monitoring Compliance EJ Dermal Exposure Monitoring Method: ❑ Assess current ❑Biological Monitoring: Manufacturer: PPE adequacy ❑Blood Collecting: ❑Validate ❑Urine ❑Charcoal Tube engineering controls ❑Other ❑Silica Gel ❑Monitor IDLH ❑Obtain bulk samples Last Mfr ❑37 mm MCE Filter Conditions ❑Other: Calibration Date: ❑37 mm PVC Filter ❑Other ❑Other: ❑Personal Breathing Zone Model: Sampling/Analysis ❑Regulatory ❑Area Air Monitoring Method: Compliance ❑Dermal Exposure Monitoring ❑Assess current ❑Biological Monitoring: Manufacturer: PPE adequacy ❑Blood Collecting Media: ❑Validate ❑Urine ❑Charcoal Tube engineering controls ❑Other ❑Silica Gel ❑Monitor IDLH ❑Obtain bulk samples Last Mfr ❑37 mm MCE Filter Conditions ❑Other: Calibration Date: ❑37 mm PVC Filter ❑Other ❑Other: ❑Personal Breathing Zone Model: Sampling/Analysis ❑Regulatory ❑Area Air Monitoring Method: Compliance ❑Dermal Exposure Monitoring ❑Assess current ❑Biological Monitoring: Manufacturer: PPE adequacy ❑Blood Collecting Media: ❑Validate ❑Urine ❑Charcoal Tube engineering controls ❑Other ❑Silica Gel ❑Monitor IDLH ❑Obtain bulk samples Last Mfr ❑37 mm MCE Filter Conditions ❑Other: Calibration Date: ❑37 mm PVC Filter ❑Other ❑Other: ❑Personal Breathing Zone Model: Sampling/Analysis ❑Regulatory ❑Area Air Monitoring Method: Compliance ❑Dermal Exposure Monitoring ❑Assess current ❑Biological Monitoring: Manufacturer: PPE adequacy ❑Blood Collecting: ❑Validate ❑Urine ❑Charcoal Tube engineering controls ❑Other ❑Silica Gel ❑Monitor IDLH ❑Obtain bulk samples Last Mfr ❑37 mm MCE Filter Conditions ❑Other: Calibration Date: ❑37 mm PVC Filter ❑Other ❑Other: 15.Prepared By: 16.Date/Time Briefed: HAZARD LIST:Potential Health Effects:Bruise/Lacerations,Organ Damage,Central Nervous System Effects,Cancer,Reproductive Damage,Low Back Pain,Temporary Hearing Loss,Dermatitis,Respiratory Effects,Bone Breaks, &Eye Burning 18. Safety Officer Review: Reporting_Monitoring results shall be logged in the ICS-208-CG SSP-E-1 form(Air Monitoring ICS-208-CG SSP-E Log)and attached as part of a current Site Safety Plan and Incident Action Plan. Significant (rev 9/06) Exposures shall be immediately addressed to the IC and General Staff for immediate correction. Pae of