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CG ICS SSP: Emergency 1.Incident Name 2.Date/Time Prepared 3. Operational 4. Site Supervisor/Leader 5.Location of Site Safety&Response Plan Period 1910.120 Compliance Checklist(Form A) 6.a. Cite: 1910.120 6.b.Requirement(sections that duplicate or explain are omitted) 6.c.ICS Form 6.d. Check 6.e.Comments 1 Is the plan in writing? SSP-A ❑ 1 Is the plan available for inspection by employees? N/A ❑ Performance based (q)(2)(i) Does the plan address pre-emergency planning and SSP-A ❑ coordination? (ii) Does it address personnel roles? SSP-A ❑ (ii) Does it address lines of authority? SSP-A ❑ (ii) Does it address communications? SSP-A ❑ (iii) Does it address emergency recognition? SSP-A ❑ (iii) Does it address emergency revention? SSP-A ❑ iv Does it identify safe distances? SSP-A ❑ iv Does it address places of refuge? SSP-A ❑ v Does it address site security and control? SSP-A ❑ vi Does it identify evacuation routes? SSP-A ❑ vi Does it identify evacuationprocedures? SSP-A ❑ vii Does it address decontamination? SSP-A ❑ viii Does it address medical treatment and first aid? SSP-A ❑ ix Does it address emergency alerting procedures? SSP-A ❑ ix Does it address emergency response procedures SSP-A ❑ x Was the response critiqued? N/A ❑ Performance based xi Does it identify Personal Protection Equipment? SSP-A ❑ xi Does it identify emergency equipment? SSP-A ❑ (q)(3)(ii) All the hazardous substances identified to the extentpossible? N/A ❑ Performance based (ii) All the hazardous conditions identified to the extentpossible? N/A ❑ Performance based (ii) Was site analysis addressed? N/A ❑ Performance based (ii) Were engineering controls addressed? N/A ❑ Performance based (ii) Were exposure limits addressed? N/A ❑ Performance based (ii) Were hazardous substance handling procedures addressed? N/A ❑ Performance based (iii) Is the PPE appropriate for the hazards identified? N/A ❑ Performance based (iv) Is respiratory rotection worn when inhalation hazards resent? N/A ❑ Performance based (v) Is the buddy system used in the hazard zone? N/A ❑ Performance based (vi) Are backup personnel on standby? N/A ❑ Performance based (vi) Are advanced first aid support personnel standing by? N/A ❑ Performance based (vii) Has the ICS designated safety official been identified? SSP-A ❑ (vii) Has the Safety Official evaluated the hazards? N/A ❑ Performance based (viii) Can the Safety Official communicate with IC immediately? N/A ❑ Performance based (ix) Are appropriate decontamination procedures implemented? N/A ❑ Performance based ICS-208-CG SSP-J rev 9/06 Page of