Ics 208 Hm Form – Fill Out and Use This PDF

SITE SAFETY AND

1.

Incident Name:

2.

Date Prepared:

3.

Operational Period:

CONTROL PLAN

Time:

ICS 208 HM

Section I. Site Information

4.

Incident Location:

Section II. Organization

5.

Incident Commander:

6.

HM Group Supervisor:

7.

Tech. Specialist - HM Reference:

8.

Safety Officer:

9.

Entry

Leader:

10.

Site Access Control Leader:

11.

Asst. Safety Officer - HM:

12.

Decontamination Leader:

13.

Safe Refuge Area Mgr:

14.

Environmental Health:

15.

16.

17.

Entry Team: (Buddy System)

18.

Decontamination Element:

Name:

PPE Level

Name:

PPE Level

Entry 1

Decon 1

Entry 2

Decon 2

Entry 3

Decon 3

Entry 4

Decon 4

Section III. Hazard/Risk Analysis

19.

Material:

Container

Qty.

Phys.

pH

IDLH

F.P.

I.T.

V.P.

V.D.

S.G.

LEL

UEL

type

State

Comment:

Section IV. Hazard Monitoring

20.

LEL Instrument(s):

21.

O2

Instrument(s):

22.

Toxicity/PPM Instrument(s):

23.

Radiological Instrument(s):

Comment:

Section V. Decontamination Procedures

24.

Standard Decontamination Procedures:

YES:

NO:

Comment:

Section VI. Site Communications

25.

Command Frequency:

26.

Tactical Frequency:

27.

Entry Frequency:

Section VII. Medical Assistance

28.

Medical Monitoring:

YES:

NO:

29. Medical Treatment and Transport In-place:

YES:

NO:

Comment:

ICS 208 HM

Page 1

3/98

Weather ❏ Command Post ❏

Zones ❏

Assembly Areas ❏

Escape Routes ❏

Other ❏

32. Modifications to Documented SOP s or Work Practices:

YES:

NO:

Comment:

Section XII.

Safety Briefing

34.

Asst. Safety Officer - HM Signature:

Safety Briefing Completed (Time):

35.

HM Group Supervisor Signature:

36. Incident Commander Signature:

ICS 208 HM

Page 2

3/98

Item Number

Item Title

Instructions

1.

Incident Name/Number

Print name and/or incident number.

2.

Date and Time

Enter date and time prepared.

3.

Operational Period

Enter the time interval for which the form applies.

4.

Incident Location

Enter the address and or map coordinates of the incident.

5 - 16.

Organization

Enter names of all individuals assigned to ICS positions. (Entries 5 &

8 mandatory). Use Boxes 15 and 16 for other functions: i.e. Medical

Monitoring.

17 - 18.

Entry Team/Decon

Enter names and level of PPE of Entry & Decon personnel. (Entries 1

Element

- 4 mandatory buddy system and back-up.)

19.

Material

Enter names and pertinent information of all known chemical

products.

Enter UNK if material is not known. Include any which

apply to chemical properties. (Definitions: ph = Potential for Hydrogen

(Corrosivity), IDLH = Immediately Dangerous to Life and Health,

F.P. = Flash Point, I.T. = Ignition Temperature, V.P. = Vapor Pressure,

V.D. = Vapor Density, S.G. = Specific Gravity, LEL = Lower Explosive

Limit, UEL = Upper Explosive Limit)

20 - 23.

Hazard Monitoring

List the instruments which will be used to monitor for chemical.

24.

Decontamination

Check NO

if modifications are made to standard decontamination

Procedures

procedures and make appropriate Comments including type of

solutions.

25 - 27.

Site Communications

Enter the radio frequency(ies) which apply.

28 - 29.

Medical Assistance

Enter comments if NO is checked.

30.

Site Map

Sketch or attach a site map which defines all locations and layouts of

operational zones. (Check boxes are mandatory to be identified.)

31.

Entry Objectives

List all objectives to be performed by the Entry Team in the

Exclusion Zone and any parameters which will alter or stop entry

operations.

32 - 33.

SOP s, Safe Work

List in Comments if any modifications to SOP s and any emergency

Practices, and

procedures which will be affected if an emergency occurs while

Emergency

personnel are within the Exclusion Zone.

Procedures

34 - 36.

Safety Briefing

Have the appropriate individual place their signature in the box once

the Site Safety and Control Plan is reviewed.

Note the time in box 34 when the safety briefing has been completed.

ICS 208 HM

Page 3

3/98