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CG ICS SSP: 1910.120 1.Incident Name 2.Date/Time Prepared 3. Operational 4. Site Supervisor/Leader 5.Location of Site <br /> COMPLIANCE Period <br /> CHECKLIST(Form B) <br /> 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 <br /> 1910.120 b 1 ii A Organizational structure? 203 ❑ <br /> B Comprehensive workplan? IAP ❑ Incident Action Plan <br /> C Site Safety Plan? SSP-B ❑ <br /> D Safety and health training program? N/A ❑ Responsibility of each employer <br /> E Medical surveillance program? N/A ❑ Responsibility of each employer <br /> F Employer SOPs? N/A ❑ Responsibility of each employer <br /> G Written program related to site activities? N/A ❑ <br /> b 1 iii Site excavation meets shored or slope requirements in 1926? N/A ❑ <br /> b 2 i D Lines of communication? 201 203 205 ❑ <br /> b 3 iv Training addressed? N/A ❑ Responsibility of each employer <br /> (y)-(vi) Information and medical monitoring addressed? N/A ❑ Responsibility of each employer <br /> (b)4(i) Site Safety Plan kept on site? N/A ❑ <br /> (ii)(A) Safety and health hazard analysis conducted? N/A ❑ <br /> B Properly trained employees assigned to right'obs? N/A ❑ <br /> C Personnel Protective Equipment issues addressed? SSP-F ❑ <br /> E Frequency and types of air monitoring addressed? SSP-E ❑ <br /> F Site control measures in lace? SSP-B ❑ <br /> G Decontamination procedures in lace? SSP-G ❑ <br /> H Emergency Response Plan in lace? SSP-D ❑ <br /> I Confined space entry procedures? SSP-B ❑ <br /> J Spill containment program SSP-B ❑ <br /> (iii) Pre-entry briefings conducted? SSP-I ❑ <br /> iv Site Safety Plan effectiveness evaluated? SSP-H ❑ <br /> (c)(1) Site characterization done? N/A ❑ <br /> (c)(2) Preliminary evaluation done by qualifiedperson? N/A ❑ <br /> (c)(3) Hazard identificationperformed? SSP-B ❑ <br /> c 4 i Location and size of site identified? SSP-B ❑ <br /> (ii) Response activities,job tasks identified? SSP-B ❑ <br /> (iii) Duration of tasks identified? SSP-B ❑ Operational period <br /> iv Site topography and accessibility addressed? SSP-C ❑ <br /> v Health and safety hazards addressed? SSP-B ❑ <br /> vi Dispersion pathways addressed? SSP-B ❑ <br /> vii Status and capabilities of medical emergency response teams? 206 ❑ <br /> c 5 i iv Chemical protective clothing addressed and properly selected? SSP-F ❑ <br /> (ii) Respiratory rotection addressed? SSP-B and F ❑ <br /> (iii) Level B used for unknowns? N/A ❑ <br /> ICS-208-CG SSP-K (rev 9/06): Page 1. Page of <br />