Form Preview Example

Site Safety and Health Plan ICS-208-CG (rev 9/06)

Incident Name:

Date/Time Prepared:

Operational Period:

Purpose. The ICS Compatible Site Safety and Health Plan is designed for safety and health personnel that use the Incident Command System (ICS). It is compatible with ICS and is intended to meet the requirements of the Hazardous Waste Operations and Emergency Response regulation (Title 29, Code of Federal Regulations, Part 1910.120). The plan avoids the duplication found between many other site safety plans and certain ICS forms. It is also in a format familiar to users of ICS. Although primarily designed for oil and chemical spills, the plan can be used for all hazard situations.

Questions on the document should be addressed to the Coast Guard Office of Incident Management and Preparedness (G-RPP).

Table of Forms

FORM NAME	FORM #	USE	REQUIRED	OPTIONAL	ATTACHED
Emergency Safety and Response	A	Emergency response phase (uncontrolled)	X
Plan

Site Safety Plan	B	Post-emergency phase (stabilized, cleanup)	X
Site Map	C	Post-emergency phase map of site and hazards	X
Emergency Response Plan	D	Part of Form B, to address emergencies	X
Exposure Monitoring Plan	E	Exposure monitoring Plan to monitor exposure	X
Air Monitoring Log	E-1	To log air monitoring data	X*
Personal Protective Equipment	F	To document PPE equipment and procedures	X*
Decontamination	G	To document decon equipment and procedures	X*
Site Safety Enforcement Log	H	To use in enforcing safety on site		X
Worker Acknowledgement Form	I	To document workers receiving briefings		X
Form A Compliance Checklist	J	To assist in ensuring HAZWOPER compliance		X
Form B Compliance Checklist	K	To assist in ensuring HAZWOPER compliance		X
Drum Compliance Checklist	L	To assist in ensuring HAZWOPER compliance		X
Other:

* Required only if function or equipment is used during a response

This Page Intentionally Left Blank

EMERGENCY SAFETY

1. Incident Name

2. Date/Time Prepared

3. Operational Period

4. Attachments: Attach MSDS for each

and RESPONSE PLAN

Chemical:

5. Organization IC/UC:

Safety:

Entry Team:

Backup Team:

Decon Team:

Div/Group Supv:

6.a. Physical Hazards and

6.b. Confined Space

Noise

Heat Stress

Cold Stress

Electrical

Animal/Plant/Insect

Ergonomic

Ionizing Rad

Protection

Slips/Trips/Falls

Struck by

Water

Violence

Excavation

Biomedical waste and/or needles

Fatigue

Other (specify)

6.c.

6d Entry

6.e.

6f.

6g. Shoes

6.h.

6i.

6j.

6l. Work/

6.m.

6.n. Signs

6.p. Fall

6.q.

6.r.

6.s.

6.t.

Tasks & Controls

Permit

Ventilate

Hearing

(type)

Hard

Clothing

Life

Rest (hrs)

Fluids

Protect

Post

Flash

Work

Other

Protection

Hats

(cold wx)

Jacket

(amt/time)

Barricade

Guards

Protect

Gloves

7.a. Agent

7.b. Hazards

7.c. Target Organs

7.d. Exposure Routes

7.f. PPE

7.g. Type of PPE

Explosive

Radioactive

Eyes

Nose

Skin

Ears

Inhalation

Face Shield

Flammable

Carcinogen

Central Nervous System

Absorption

Eyes

Reactive

Oxidizer

Respiratory

Throat

Ingestion

Gloves

Biomedical

Corrosive

Lungs

Heart

Liver

Injection

Inner Suit

Toxic

Specify Other:

Kidney

Blood

Lungs

Membrane

Splash Suit

Circulatory

Gastrointestinal

Level A Suit

Bone

Other Specify:

SCBA

APR

SAR

Cartridges

Fire Resistance

8. Instruments:

8.a. Action

8.b. Chemical Name(s):

8.c.

8.d. Odor

8.e. Ceiling/

8.f.

8.g. Flash Pt/

8.h. Vapor

8.i. Vapor

8.j. Specific

8.l.

Levels

LEL/UEL

Thresh

IDLH

STEL/TLV

Ignition Pt

Pressure

Density

Gravity

Boiling

Ppm

(F or C)

(mm)

Pt F or C

CGI

Radiation

Total HCs

Colorimetric

Thermal

Other

ICS-208-CG SSP-A Page 1 (rev 9/06): Page

EMERGENCY SAFETY and

1. Incident Name

2. Date/Time Prepared

3. Operational Period

4. Attachments: Attach MSDS for each Chemical

RESPONSE PLAN (Cont)

9. Decontamination:

Suit Wash

Bottle Exchange

SCBA/Mask Rinse

Intervening Steps

Specify:

Instrument Drop Off

Decon Agent: Water

Outer Suit Removal

Inner Glove Removal

Outer Boots/Glove Removal

Other

Inner Suit Removal

Work Clothes Removal

Suit/Gloves/Boot Disposal

Specify:

SCBA/Mask Removal

Body Shower

10. Site Map. Include: Work Zones, Locations of Hazards, Security Perimeter, Places of Refuge, Decontamination Line, Evacuation Routes, Assembly Point, Direction of North

Attached,

Drawn Below:

11.a. Potential Emergencies:

11.b. Evacuation Alarms:

11.c Emergency Prevention and Evacuation Procedures:

Fire

Horn

# Blasts

Safe Distance:

Explosion

Bells

#Rings

Other

Radio Code

Other:

12. a. Communications:

12.b. Command #:

12.c. Tactical #:

12.d. Entry #:

Radio Phone

Other

13.a. Site Security:

13.b. Procedures:

13.c. Equipment:

Personnel Assigned

14.a. Emergency Medical:

14.b. Procedures:

14.c Equipment:

Personnel Assigned

15. Prepared by:

16. Date/Time Briefed:

ICS-208-CG SSP-A Page 2.

(rev 9/06): Page

EMERGENCY SAFETY AND RESPONSE PLAN (ICS-208-CG SSP-A)

Purpose: The Emergency Safety and Response Plan provides the Safety Officer and ICS personnel a plan for safeguarding personnel during the initial emergency phase of the response. It is only used during the emergency phase of the response, which is defined as a situation involving an uncontrolled release. It is also intended to meet the requirements of the Hazardous Waste Operations and Emergency Response (HAZWOPER) regulation, Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer or his/her designated staff starts the Emergency Site Safety and Response Plan. They initially address the hazards common to all operations involved in the response (initial site characterization). Outside support organizations must be contacted to ensure the plan is consistent with other plans (local, state, other federal plans). Form ICS-208-CG SSP-G need not be completed if this form is used. When the operation proceeds into the post-emergency phase (site stabilized and cleanup operations begun) forms ICS-208-CG SSP-B and ICS-208-CG SSP-G should be used. For large incidents, the Emergency Site Safety and Response Plan complements the Incident Action Plan. For smaller incidents, the Emergency Site Safety and Response Plan complements ICS-201.

Distribution: The Emergency Safety and Response Plan completed by the Safety Officer is forwarded to the Planning Section Chief. Copies are made and attached to the Assignment List(s) (ICS Form 204). The Operations Section Chief, Directors, Supervisors or Leaders get a copy of the plan. They must ensure it is available on site for all personnel to review. The Safety Officer is responsible for ensuring that the Emergency Site Safety and Response Plan properly addresses the hazards of the operation. The Safety Officer accomplishes this through on site enforcement and feedback to the operational units.

		Instructions:
Item #	Item Title	Instructions
1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Attachments	Enter attachments. Material Safety Data Sheets are mandatory under 1910.120. Safe Work Practices may
		also be attached.
5	Organization	List the personnel responsible for these positions. IC and Safety Officer are mandatory.
6	Physical Hazards &	Check off the physical hazards at the site. Identify the major tasks involved in the response (skimming,
	Protection	lightering, overpacking, etc.). Check off the controls that would be used to safeguard workers from the
		physical hazards for each major task.
7	Chemical/Agent	List the chemicals involved in the response. Chemicals may be listed numerically. Check off the hazards,
		potential health effects, pathway of dispersion, and exposure route of the chemical. Numbers corresponding
		to the chemical may be entered into the check blocks to differentiate. Check off the PPE to be used.
		Identify the type of PPE selected (for example: gloves: butyl rubber).
8	Instruments	Indicate the instruments being used for monitoring. List the action levels adjacent to the instruments being
		used. Identify the chemicals being monitored (2). List the physical parameters of the chemicals. Use a
		separate form for additional chemicals monitored.

EMERGENCY SAFETY AND RESPONSE PLAN (FORM ICS-208-CG SSP-A) (Instructions Continued)

9	Decontamination	Check off the decontamination steps to be used. Numbers may be entered to indicate the preferred sequence.
		Identify any intervening steps necessary on the form or in a separate attachment.
10	Site Map	Draw a rough site map. Ensure all the information listed is identified on the map.
11	Potential	Identify any potential emergencies that may occur. If none, so state. Check off the appropriate alarms that
	Emergencies	may be used. Identify emergency prevention and evacuation procedures in the space provided or on a
		separate attached sheet.
12	Communications	Indicate type of site communications (phone, radio). Indicate phone numbers or frequencies for the
		command, tactical and entry functions.
13	Site Security	Identify the personnel assigned. Identify security procedures in the space provided or on a separate attached
		sheet. Identify the equipment needed to support security operations.
14.	Emergency Medical	Identify the personnel assigned. Identify emergency medical procedures in the space provided or on a
		separate attached sheet. Identify the equipment needed to support security operations.
15.	Prepared by:	Enter the name and position of the person completing the worksheet.
16.	Date/time briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SITE	1.	Incident Name	2.	Date/Time Prepared	3.	Operational Period		4. Safety Officer (include method of
SAFETY PLAN (SSP)								contact)
HAZARD
ID/EVAL/CONTROL
5. Supervisor/Leader	6.	Location and Size of Site	7.	Site Accessibility	8.	For Emergencies Contact:		9. Attachments: Attach MSDS for each
			Land Water Air					Chemical
			Comments:

10.a.	10.b.		10.c. Potential Injury & Health		10.d. Exposure		10.e.
Job Task/Activity	Hazards*		Effects		Routes		Controls: Engineering, Administrative, PPE

Inhalation

Absorption

Ingestion

Injection

Membrane

		Inhalation
		Absorption
		Ingestion
		Injection
		Membrane

		Inhalation
		Absorption
		Ingestion
		Injection
		Membrane

		Inhalation
		Absorption
		Ingestion
		Injection
		Membrane

		Inhalation
		Absorption
		Ingestion
		Injection
		Membrane

11. Prepared By:	12. Date/Time Briefed:	*HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen Deficiency,	ICS-208-CG SSP-
		Ionizing Radiation, Biological, Biomedical, Electrical, Heat Stress, Cold Stress,	B (rev 9/06):
		Ergonomic, Noise, Cancer, Dermatitis, Drowning, Fatigue, Vehicle, & Diving	B (rev 9/06):
			Page	of

SITE SAFETY PLAN (FORM ICS-208-CG SSP-B)

Purpose: The Site Safety Plan provides the Safety Officer and ICS personnel a plan for safeguarding personnel during the post-emergency phase of an incident. The post-emergency phase is when the situation is stabilized and cleanup operations have begun. ICS-208-CG SSP-B is intended to meet the requirements of the Hazardous Waste Operations and Emergency Response (HAZWOPER) regulation, Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer or his/her designated staff starts the Site Safety Plan. They initially address the hazards common to all operations involved in the response (initial site characterization). The plan is then reproduced and as a minimum sent to ICS Group/Division Supervisors. They amend it according to unique job or on-scene hazards with support from the Safety Officer and/or his/her staff (detailed site characterization). The plan is continuously updated to address changing conditions. During the first hours of the response, where most response functions are in the emergency phase, the Safety Officer may chose to use the Emergency Safety and Response Plan (ICS-208-CG SSP-A) in place of the Site Safety Plan. For large incidents, ICS-208-CG SSP-B compliments the Incident Action Plan (IAP). For smaller incidents, ICS-208-CG SSP-B compliments ICS Form 201. The Safety Officer is encouraged to use the HAZWOPER Compliance Checklist (Form ICS-208-CG SSP-K) to ensure the IAP and the 201 address the requirements and all other pertinent ICS forms (203, 205, 206, etc.) are completed.

Distribution: The initial Site Safety Plan completed by the Safety Officer is forwarded to the Planning Section Chief. Copies are made and attached to the Assignment List(s) (ICS Form 204). The Operations Section Chief, Directors, Supervisors or Leaders get a copy and make on site amendments specific to their operation. They must also ensure it is available on site for all personnel to review. The Safety Officer provides personnel from his/her staff to assist in the detailed site characterization. The Safety Officer is responsible for ensuring that the Site Safety Plan for each assignment properly addresses the hazards of the assignment. The Safety Officer must ensure that the safety plans on site are consistent. The Safety Officer accomplishes this through on site enforcement and feedback to the operational units.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Group/Division Supv	The Supervisor/Leader who receives this form will enter their name here.
	Strike Team/TF Leader
6	Location & size of site	Enter the geographical location of the site and the approximate square area.
7	Site Accessibility	Check the block(s) if the site is accessible by land, water, air, etc.
8	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
9	Attachments	Enter attachments. Material Safety Data Sheets are mandatory under 1910.120. Safe Work Practices may
		also be attached.

10	Job/Task Activity	Enter Job/Task & Activities, list hazards, list potential injury and health effects, check exposure routes
		and identify controls. If more detail is needed for controls, provided attachments.
11	Prepared by	Enter the name and position of the person completing the worksheet.
12	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP: SITE MAP		1.	Incident Name	2.	Date/Time Prepared	3. Operational	4.	Safety Officer (include method of contact)
						Period

5. Supervisor/Leader		6.	Location and Size of Site	7.	Site Accessibility	8. For Emergencies	9.	Include:
				Land Water Air		Contact:	- Work Zones		- Locations of Hazards
				Comments:			- Security Perimeter		- Places of Refuge
							- Decontamination Line		- Evacuation Routes
10. Sketch of Site:
Attached.	Drawn Here

11. Prepared By:	12. Date/Time Briefed:	HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen	ICS-208-CG SSP-C
		Deficiency, Ionizing Radiation, Biological, Biomedical, Electrical,	ICS-208-CG SSP-C
			(rev 9/06):
		Heat Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis,	(rev 9/06):
		Drowning, Fatigue, Vehicle, & Diving	Page	of

SITE MAP FOR SITE SAFETY PLAN (ICS-208-CG SSP-C)

Purpose: The Site Map for the Site Safety Plan is required by Title 29 Code of Federal Regulations Part 1910.120. It provides in 1 place a visual description of the site which can help ICS personnel locate hazards, identify evacuation routes and places of refuge.

Preparation: The Site Map for the Site Safety Plan can be completed by the Safety Officer, his/her staff or by ICS field personnel (Group Supervisors, Task Force/Strike Team Leaders) working at a site with unique and specific hazards. One or several maps may be developed, depending on the size of the incident and the uniqueness of the hazards. The key is to ensure that the workers using the map(s) can clearly identify the work zones, locations of hazards, evacuation routes and places of refuge.

Distribution: This form must be located with the Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	Location & size of	Enter the geographical location of the site and the approximate square area.
	site
7	Site Accessibility	Check the block(s) if the site is accessible by land, water, air, etc.
8	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
9	Include	Ensure the map includes the listed items provided in this block.
10	Sketch of Site	Sketch of site for work. May attach map or chart.
10	Prepared by	Enter the name and position of the person completing the worksheet.
11	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP:		1.	Incident Name		2.	Date/Time Prepared		3. Operational Period	4.	Safety Officer (include method of contact)
EMERGENCY
RESPONSE PLAN
5.	Supervisor/Leader	6.	Location and Size of Site		7.	For Emergencies Contact:			8.	Attachments: INCLUDE ICS FORM 206 and
									EMT Medical Response Procedures

9.	Emergency Alarm (sound	10. Backup Alarm (sound and			11. Emergency Hand Signals			12. Emergency Personal Protective Equipment Required:
and location)		location)

13. Emergency Notification Procedures				14. Places of Refuge (also see site map			15. Emergency Decon and Evacuation			16. Site Security Measures
				form 208B)			Steps

17. Prepared By:	18. Date/Time Briefed:	HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen	ICS-208-CG SSP-D
		Deficiency, Ionizing Radiation, Biological, Biomedical, Electrical, Heat	(rev 9/06)
		Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis, Drowning,	(rev 9/06)
			Page	of
		Fatigue, Vehicle, & Diving	Page	of
		Fatigue, Vehicle, & Diving

EMERGENCY RESPONSE PLAN (ICS-208-CG SSP-D)

Purpose: The Emergency Response Plan provides information on measures to be taken in the event of an emergency. It is used in conjunction with the Site Safety Plan (Form ICS-208-CG SSP-B). It is also required by Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Safety Officer, his/her staff member or the Site Supervisor/Leader prepares the Emergency Response Plan. A copy of the Medical Plan (ICS Form 206) must always be attached to this form.

Distribution: This form must be located with Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	Location & size of	Enter the geographical location of the site and the approximate square area.
	site
7	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
8	Attachments	Enter attachments. ICS Form 206 must be included.
9	Emergency Alarm	Enter a description of the sound of the emergency alarm and it’s location.
10	Backup Alarm	Enter a description of the sound of the emergency alarm and it’s location.
11	Emergency Hand	Enter the emergency hand signals to be used.
	Signals
12	Emergency Personal	Enter the emergency personal protective equipment that may be needed in the event of an emergency.
	Protective
	Equipment Required
13	Emergency	Enter the procedures for notifying the appropriate personnel and organizations in the event of an emergency.
	Notification
	Procedures
14	Places of Refuge	Enter by name the place of refuge personnel can go to in the event of an emergency.
15	Emergency Decon &	Enter emergency decontamination steps and evacuation procedures.
	Evacuation Steps
16	Site Security	Enter site security measures needed for emergencies.
	Measures
17	Prepared by	Enter the name and position of the person completing the worksheet.
18	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP: Exposure

1. Incident Name

Date/Time

3. Operational Period:

4. Safety Officer (Method of Contact):

Monitoring Plan

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

Method:

Compliance

Dermal Exposure Monitoring

Assess current

Biological Monitoring:

Manufacturer:

PPE adequacy

Blood

Collecting Media:

Validate

Urine

Charcoal Tube

engineering controls

Other

Last Mfr

Silica Gel

Monitor IDLH

Obtain bulk samples

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

Last Mfr

Silica Gel

Monitor IDLH

Obtain bulk samples

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

Last Mfr

Silica Gel

Monitor IDLH

Obtain bulk samples

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

Last Mfr

Silica Gel

Monitor IDLH

Obtain bulk samples

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.

Page

EXPOSURE MONITORING PLAN (FORM ICS-208-CG SSP-E)

Purpose: The Exposure Monitoring Plan provides plan of monitoring conducted during an incident. The plan is a supplement to the Site Safety Plan (ICS-208-CG SSP-B). It is only required when performing monitoring operations.

Preparation: The Safety Officer, his/her staff member or the Site Supervisor/Leader prepares the Exposure Monitoring Plan. If there is a decision not to monitor during a response, the reasons must be stated clearly in the Site Safety Plan (ICS-208-CG SSP-B).

Distribution: This form must be located with Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Specific Task /	Enter specific task or operation.
	Operation
6	Survey Location	Enter the location to be monitored.
7	Survey Date/Time	Enter the date/time for the monitoring teams to survey.
8	Monitoring	Enter/Check the monitoring method to be used.
	Methodology
9	Direct-Reading	Enter the instrument model, manufacturer, last calibration date.
	Instrument
10	Air Sampling	Enter Air Sampling analysis method
11	Hazards to Monitor	Enter the hazards to monitor
12	Monitoring Duration	Enter duration of monitoring
13	Reasons to Monitor	Enter Reasons to Monitor
14	Laboratory Support for	Enter Laboratory Support needed for analysis of samples
	Analysis
15	Prepared by	Enter the name and position of the person completing the worksheet.
16	Date/Time Briefed	Enter the date/time the document was briefed to the appropriate workers and by whom.
17	Safety Officer Review	The Safety Officer must review and sign the form.

CG ICS SSP: AIR	1. Incident Name	2. Date/Time	3. Operational Period	4. Safety Officer (include method of contact)
MONITORING LOG		Prepared
5. Site Location	6. Hazards of Concern	7. Action Levels (include references):		8. Weather:
				Temperature:	Precipitation:
				Wind:
				Relative Humidity:
				Cloud Cover:
9.a. Instrument, ID Number	9.b. Monitoring Person Name(s)	9.c. Results (units)	9.d. Location	9.f. Time	9.g. Interferences and
Calibrated? Indicate below.					Comments
















10. Safety Officer Review:		Potential Health Effects: Bruise/Lacerations, Organ Damage, Central			ICS-208-CG SSP-E-1
		Nervous System Effects, Cancer, Reproductive Damage, Low Back			ICS-208-CG SSP-E-1
					(rev 9/06):
		Pain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, Bone			(rev 9/06):
		Breaks, & Eye Burning			Page	of

DAILY AIR MONITORING LOG (FORM ICS-208-CG SSP-E-1)

Purpose: The Exposure Monitoring Log provides documentation of air monitoring conducted during a spill. The log is a supplement to the Site Safety Plan (ICS-208-CG SSP-B). It is only required when performing air monitoring operations. The information used from the log can help update the Site Safety Plan.

Preparation: Persons conducting monitoring complete the Daily Air Monitoring Log. Normally these are air monitoring units under the Site Safety Officer. If there is a decision not to monitor during a spill, the reasons must be stated clearly in the Site Safety Plan (ICS-208-CG SSP-B).

Distribution: The Daily Air Monitoring Log when completed is copied and forwarded to the Site Safety Officer who must review and sign the form. The original form must be available on site, readily available and briefed to all impacted ICS personnel.

Instructions:

Item #	Item Title	Instructions
1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Location & size of site	Enter the geographical location of the site and the approximate square area.
6	Hazards of Concern	Enter the hazards being monitored.
7	Action Levels	Enter the action levels/readings for the monitoring teams.
8	Weather	Enter weather information. Ensure units of measure are listed.
9	Air Monitoring Data	Enter the instrument type and number, persons monitoring, results with appropriate units, location of
		reading, time of reading and interferences and comments.
10	Safety Officer Review	The Safety Officer must review and sign the form.

CG ICS SSP:	1.	Incident Name	2. Date/Time Prepared		3. Operational	4.	Safety Officer (include method of contact)
PERSONAL					Period
PROTECTIVE
EQUIPMENT
5. Supervisor/Leader	6.	Location and Size of Site		7. Hazards Addressed:		8.	For Emergencies Contact:

9. Equipment:

10. References Consulted:

11. Inspection Procedures:

12. Donning Procedures:

13. Doffing Procedures:

14.Limitations and Precautions (include maximum stay time in PPE):

15. Prepared By:	16. Date/Time Briefed:	Potential Health Effects: Bruise/Lacerations, Organ Damage, Central	ICS-208-CG SSP-F:
		Nervous System Effects, Cancer, Reproductive Damage, Low Back	(Rev 9/06)
		Pain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, Bone	(Rev 9/06)
			Page	of
		Breaks, Eye Burning	Page	of
		Breaks, Eye Burning

PERSONAL PROTECTIVE EQUIPMENT (ICS-208-CG SSP-F)

Purpose: The Personal Protective Equipment form is a list of personal protective equipment to be used in operations. The listing of personal protective equipment is required by Title 29 Code of Federal Regulations Part 1910.120.

Preparation: The Personal Protective Equipment form is completed by the Site Safety Officer, or his/her staff. Personal protective equipment common to all ICS Operations personnel is addressed first. Jobs with unique personal protective equipment requirements (fall protection) are addressed next. When the form is delivered on site, the ICS Director, Supervisor, or Leader may amend the list to ensure personnel are adequately protected from job hazards. It must be completed prior to the onset of any operations, unless addressed elsewhere by Standard Operating Procedures.

Distribution: This form must be located with Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	Location & size of site	Enter the geographical location of the site and the approximate square area.
7	Hazard(s) Addressed:	Enter the hazards that need to be safeguarded.
8	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
9	Equipment	List the equipment needed to address the hazards. If pre-designed Safe Work Practices are used, indicate here
		and attach to form.
10	References consulted	List the references used in making the selection for PPE.
11	Inspection Procedures	Enter the procedures for inspecting the Personal Protective Equipment prior to donning. If pre-designed Safe
		Work Practices are used, indicate here and attach to form.
12	Donning Procedures	Enter the procedures for putting on the PPE. If pre-designed Safe Work Practices are used, indicate here and
		attach to form.
13	Doffing Procedures	Enter the information for removing the PPE. If pre-designed Safe Work Practices are used, indicate here and
		attach to form.
14	Limitations and	List the limitations and precautions when using PPE. Include the maximum time to be inside the PPE, Heat
	Precautions	Stress concerns, psychomotor skill detraction and other factors.
15	Prepared by	Enter the name and position of the person completing the worksheet.
16	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP:		1.	Incident Name	2.	Date/Time Prepared	3. Operational	4.	Safety Officer (include method of contact)
DECONTAMINATION						Period

5.	Supervisor/Leader	6.	Location and Size of Site	7.	For Emergencies Contact:		8.	Hazard(s) Addressed:

9.	Equipment:								10. References Consulted:

11. Contamination Avoidance Practices: 12. Decon Diagram: Attached, Drawn below

13. Decon Steps

14. Prepared By:	15. Date/Time Briefed:	Potential Health Effects: Bruise/Lacerations, Organ Damage, Central	ICS-208-CG SSP-G
		Nervous System Effects, Cancer, Reproductive Damage, Low Back	ICS-208-CG SSP-G
			(rev 9/06):
		Pain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, Bone	(rev 9/06):
		Breaks, Eye Burning	Page	of

DECONTAMINATION (ICS-208-CG SSP-G)

Purpose: The Decontamination form provides information on how workers can avoid contamination and how to get decontaminated. It is a supplemental form to the Site Safety Plan.

Preparation: The Decontamination Form can be completed by the Site Safety Officer, a member of his/her staff or by the Group/Division Supervisor, Task Force/Strike Team Leader on the site

Distribution: This form must be located with Site Safety Plan (ICS-208-CG SSP-B). It therefore follows the same distribution route.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	Location & size of site	Enter the geographical location of the site and the approximate square area.
7	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
8	Hazard(s) Addressed:	Enter the hazards that need to be safeguarded.
9	Equipment	Enter the decontamination equipment needed for the site. If pre-designed Safe Work Practices are used,
		indicate here and attach to this form.
10	References consulted	List the references used in making the selection for PPE.
11	Contamination	Enter procedures for personnel to avoid contamination. If pre-designed Safe Work Practices are used,
	Avoidance Practices	indicate here and attach to form.
12	Decon Diagram	Draw a diagram for the decontamination operation. If pre-designed Safe Work Practices are used, indicate
		here and attach to form.
13	Decon Steps	List the decontamination steps.
14	Prepared by	Enter the name and position of the person completing the worksheet.
15	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP:	1. Incident Name	2. Date/Time Prepared	3. Operational Period	4. Safety Officer (include method of contact)
ENFORCEMENT LOG
5. Supervisor/Leader	6. For Emergencies Contact:			7. Attachments:

				8.e. Safety Plan	8.f. Signature of
8.a. Job Task/Activity	8.b. Hazards	8.c. Deficiency	8.d. Action Taken	Amended?	Supervisor/Leader










9. Prepared By:	10. Date/Time Briefed:	HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, Oxygen			ICS-208-CG SSP-H
		Deficiency, Ionizing Radiation,	Biological, Biomedical, Electrical, Heat		ICS-208-CG SSP-H
		Deficiency, Ionizing Radiation,	Biological, Biomedical, Electrical, Heat		(rev 9/06):
		Stress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis, Drowning,			(rev 9/06):
		Fatigue, Vehicle, & Diving			Page	of

SITE SAFETY ENFORCEMENT LOG (ICS-208-CG SSP-H)

Purpose: The Site Safety Plan Enforcement Log is used to help enforce safety during an incident.

Preparation: The Safety Officer and/or his/her staff complete the Site Safety Plan Enforcement Log. The log is completed as Safety personnel are on scene reviewing the site. It should be completed at a minimum once per day. The number of enforcement logs to be completed depends on the size of the incident. Enough should be completed to ensure that site safety is being adequately enforced.

Distribution: The Site Safety Plan enforcement log when completed is delivered to the Safety Officer. The Safety Officer can use the form to amend the Site Safety Plan (ICS-208-CG SSP-A or B).

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
7	Attachments	List any attached supporting documentation.
8 a	Job/Task Activity	Enter only those Job Task/activities for which a deficiency is noted.
8 b	Hazards	Enter the hazard not being sufficiently addressed.
8 c	Deficiency	Enter the deficiency.
8 d	Action Taken	Enter the corrective action taken to address the deficiency.
8 e	Safety Plan Amended?	Enter whether the on site safety plan was amended.
8 f	Signature of	Ensure the Supervisor/Leader signs the form to acknowledge the deficiency.
	Supervisor/Leader
9	Prepared by	Enter the name and position of the person completing the worksheet.
10	Date/Time Briefed:	Enter the date/time the document was briefed to the appropriate workers and by whom.

CG ICS SSP WORKER

1. Incident Name

2. Site Location:

3. Attachments:

ACKNOWLEDGEMENT FORM

4. Type of Briefing

5. Presented By:

6. Date Presented

7. Time Presented

Safety Plan/Emergency Response Plan

Start Shift

Pre-Entry

Exit

End of Shift

Specify Other:

8.a. Worker Name (Print)

8.b. Signature*

8.c. Date

8.d. Time

* By signing this document, I am stating that I have read and fully understand

ICS-208-CG SSP-I (rev 9/06): Worker Acknowledgement

the plan and/or information provided to me.

Page

WORKER ACKNOWLEDGEMENT FORM (ICS-208-CG SSP-I)

Purpose: The Worker Acknowledgement form is used to document workers who have received safety briefings.

Preparation: Those personnel responsible for conducting safety briefings complete this form initially. Once the briefings are completed, workers who were briefed print their name, sign, date and indicate the time of the briefing.

Distribution: This form is returned to the Safety Officer or designated representative at the end of each operational period.

Instructions:

Item

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Site Location	Indicate the location where the briefings are held.
3	Attachments	Indicate any attachments used as part of the briefings.
4	Type of briefing	Check the block next to the type of briefing.
5	Presented by	Enter the name of the person conducting the briefing.
6	Date Presented	Enter the date of the briefing.
7	Time Presented	Enter the time of the briefing.
8	Worker Name, Signature,	Workers receiving the briefing print their name, sign, date and enter the time they acknowledge the
	Date and Time	briefing.

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

(q)(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 prevention?

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 evacuation procedures?

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 extent possible?

N/A

Performance based

(ii)

All the hazardous conditions identified to the extent possible?

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 protection worn when inhalation hazards present?

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

Emergency Safety & Response Plan Compliance Checklist Form A (ICS-208-CG SSP-J)

Purpose: The Emergency Safety and Response Plan 1910.120 Compliance Checklist is to ensure that incident response operations are in compliance with Title 29, Code of Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response. It also identifies how form ICS- 208-CG SSP-J can be used to satisfy the HAZWOPER requirements. This checklist is an optional form.

Preparation: The Emergency Safety and Response Plan 1910.120 Compliance Checklist is completed by the Safety Officer or his/her staff as frequently as necessary whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan Enforcement Log (ICS-208-CG SSP-H). Many of the requirements are performance based and are best evaluated on scene by the Safety Officer or his/her staff.

Distribution: The Safety Officer should maintain The Emergency Safety and Response Plan (ERP) 1910.120 Compliance Checklist.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
5	Location of Site	Enter the site location.
6 a	Cites	These are the regulatory cites within 1910.120. The major headings are highlighted in bold.
		Informational cites or cites that are duplicative are not included.
6 b	Requirement	This lists the requirement in a question format. Some require documentation or some form of action.

6 c	ICS Form	Lists those requirements covered by ICS-208-CG SSP-A.
6 d	Check Block	Enter the check if the site satisfies the requirement.
6 f	Comments	This provides additional information on the requirement. The user may also enter comments.
7	Prepared by	Enter the name and position of the person completing the worksheet.

CG ICS SSP: 1910.120

1. Incident Name

2. Date/Time Prepared

3. Operational

4. Site Supervisor/Leader

5. Location of Site

COMPLIANCE

Period

CHECKLIST (Form B)

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

1910.120 (b)(1)(ii)(A)

Organizational structure?

203

(B)

Comprehensive workplan?

IAP

Incident Action Plan

(C)

Site Safety Plan?

SSP-B

(D)

Safety and health training program?

N/A

Responsibility of each employer

(E)

Medical surveillance program?

N/A

Responsibility of each employer

(F)

Employer SOPs?

N/A

Responsibility of each employer

(G)

Written program related to site activities?

N/A

(b)(1)(iii)

Site excavation meets shored or slope requirements in 1926?

N/A

(b)(2)(i)(D)

Lines of communication?

201 203 205

(b)3(iv)

Training addressed?

N/A

Responsibility of each employer

(v)-(vi)

Information and medical monitoring addressed?

N/A

Responsibility of each employer

(b)4(i)

Site Safety Plan kept on site?

N/A

(ii)(A)

Safety and health hazard analysis conducted?

N/A

(B)

Properly trained employees assigned to right jobs?

N/A

(C)

Personnel Protective Equipment issues addressed?

SSP-F

(E)

Frequency and types of air monitoring addressed?

SSP-E

(F)

Site control measures in place?

SSP-B

(G)

Decontamination procedures in place?

SSP-G

(H)

Emergency Response Plan in place?

SSP-D

(I)

Confined space entry procedures?

SSP-B

(J)

Spill containment program

SSP-B

(iii)

Pre-entry briefings conducted?

SSP-I

(iv)

Site Safety Plan effectiveness evaluated?

SSP-H

(c)(1)

Site characterization done?

N/A

(c)(2)

Preliminary evaluation done by qualified person?

N/A

(c)(3)

Hazard identification performed?

SSP-B

(c)(4)(i)

Location and size of site identified?

SSP-B

(ii)

Response activities, job tasks identified?

SSP-B

(iii)

Duration of tasks identified?

SSP-B

Operational period

(iv)

Site topography and accessibility addressed?

SSP-C

(v)

Health and safety hazards addressed?

SSP-B

(vi)

Dispersion pathways addressed?

SSP-B

(vii)

Status and capabilities of medical emergency response teams?

206

(c)(5)(i)(iv)

Chemical protective clothing addressed and properly selected?

SSP-F

(ii)

Respiratory protection addressed?

SSP-B and F

(iii)

Level B used for unknowns?

N/A

ICS-208-CG SSP-K (rev 9/06): Page 1. Page

CG ICS SSP: 1910.120	1. Incident Name	2. Date/Time Prepared	3. Operational Period
COMPLIANCE
CHECKLIST Form B (cont)
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

1910.120 (c)(6)(i)	Monitoring for ionization conducted?		SSP-E
(ii)	Monitoring conducted for IDLH conditions?		SSP-E
(iii)	Personnel looking out for dangers of IDLH environments?		N/A
(iv)	Ongoing air monitoring program in place?		SSP-E
(c)(7)	Employees informed of potential hazard occurrence?		SSP-B
(c)(8)	Properties of each chemical made aware to employees?		SSP-B
(d)(1)	Appropriate site control procedures in place?		IAP, SSP-B
(d)(2)	Site control program developed during planning stages?		IAP, SSP-B
(d)(3)	Site map, work zones, alarms, communications addressed?		IAP, SSP-B
(g)(1)(i)	Engineering, admin controls considered?		SSP-B
(iii)	Personnel not rotated to reduce exposures?		N/A
(g)(5)(i)	PPE selection criteria part of employer’s program?		N/A		Responsibility of employer
(ii)	PPE use and limitations identified?		SSP-F
(iii)	Work mission duration identified?		SSP-F
(iv)	PPE properly maintained and stored?		N/A		Responsibility of employer
(vi)	Are employees properly trained and fitted with PPE?		N/A		Responsibility of employer
(vii)	Are donning and doffing procedures identified?		SSP-F
(viii)	Are inspection procedures properly identified?		SSP-F
(ix)	Is a PPE evaluation program in place?		SSP-F
(h) (3)	Periodic monitoring conducted?		SSP-E
(k)(2)(i)	Have decontamination procedures been established?		SSP-G
(ii)	Are procedures in place for contamination avoidance?		SSP-G
(iii)	Is personal clothing properly deconned prior to leaving the		SSP-G
	site?
(iv)	Are decontamination deficiencies identified and corrected?		SSP-H
(k)(3)	Are decontamination lines in the proper location?		SSP-C
(k)(4)	Are solutions/equipment used in decon properly disposed of?		N/A
(k)(6)	Is protective clothing and equipment properly secured?		N/A
(k)(7)	If cleaning facilities are used, are they aware of the hazards?		N/A
(k)(8)	Have showers and change rooms provided, if necessary?		N/A
(l)(1)(iii)	Are provisions for reporting emergencies identified?		SSP-D
(iv)	Are safe distances and places of refuge identified?		SSP-B and C
(v)	Site security and control addressed in emergencies?		SSP-D
(vi)	Evacuation routes and procedures identified?		SSP-D
(vii)	Emergency decontamination procedures developed?		SSP-D
(ix)	Emergency alerting and response procedures identified?		SSP-D
(x)	Response teams critiqued and followup performed?		SSP-H
(xi)	Emergency PPE and equipment available?		SSP-D
		ICS-208-CG SSP-K (rev 9/06): Page 2. Page				of

CG ICS SSP: 1910.120	1. Incident Name	2. Date/Time Prepared		3. Operational Period
COMPLIANCE
CHECKLIST Form B (cont)
6.a. Cite:	6.b. Requirement(sections that duplicate or explain are omitted)			6.c. ICS	6.d. Check	6.e. Comments
				Form
1910.120 (l)(3)(i)	Emergency notification procedures identified?			SSP-D
(ii)	Emergency response plan separate from Site Safety Plan?			SSP-D
(iii)	Emergency response plan compatible with other plans?			SSP-D
(iv)	Emergency response plan rehearsed regularly?			SSP-D
(v)	Emergency response plan maintained and kept current?			SSP-H
1910.165 (b)(2)	Can alarms be seen/heard above ambient light and noise			N/A
	levels?
(b)(3)	Are alarms distinct and recognizable?			N/A
(b)(4)	Are employees aware of the alarms and are they accessible?			SSP-D
(b)(5)	Are emergency phone numbers, radio frequencies clearly			206
	posted?
(b)(6)	Signaling devices in place where there are 10 or more workers?			IAP
(c)(1)	Are alarms like steam whistles, air horns being used?			IAP
(d)(3)	Are backup alarms available?			IAP
(m)	Are areas adequately illuminated?			IAP
(n)(1)(i)	Is an adequate supply of potable water available?			IAP
(ii)	Are drinking water containers equipped with a tap?			IAP
(iii)	Are drinking water containers clearly marked?			IAP
(iv)	Is a drinking cup receptacle available and clearly marked?			IAP
(n)(2)(i)	Are non-potable water containers clearly marked?			IAP
(n)(3)(i)	Are their sufficient toilets available?			IAP
(n)(4)	Have food handling issues been addressed?			IAP
(n)(6)	Have adequate wash facilities been provided outside hazard			IAP
	zone?
(n)(7)	If response is greater than 6 months, have showers been			IAP
	provided?
7. Prepared By:			ICS-208-CG SSP-K (rev 9/06): Page 3.			Page	of
			ICS-208-CG SSP-K (rev 9/06): Page 3.			Page	of

HAZWOPER 1910.120 COMPLIANCE CHECKLIST FORM B (ICS-208-CG SSP-K)

Purpose: The HAZWOPER 1910.120 Compliance Checklist is to ensure that incident response operations are in compliance with Title 29, Code of Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response. It also identifies how other ICS forms can be used to satisfy the HAZWOPER requirements. This is an optional form.

Preparation: The HAZWOPER 1910.120 Compliance Checklist is completed by the Safety Officer or his/her staff as frequently as necessary whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan Enforcement Log (ICS- 208-CG SSP-H). The Site Safety Plan Forms (A-G) best meet some of the requirements. The Incident Action Plan is suited to address other requirements, and the Safety Officer should ensure the IAP addresses them. Other requirements are performance based and are best evaluated on scene by the Safety Officer or his/her staff.

Distribution: The HAZWOPER 1910.120 Compliance Checklist should be maintained by the Safety Officer.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time	Enter date (month, day, year) prepared.
	Prepared
3	Operational Period	Enter the time interval for which the assignment applies.
4	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
5	Location of Site	Enter the site location.
6.a.	Cites	These are the regulatory cites within 1910.120. The major headings are highlighted in bold. Informational
		cites or cites that are duplicative are not included.
6.b.	Requirement	This lists the requirement in a question format. Some require documentation or some form of action.

6.c.	ICS Form	Lists those ICS Forms that cover the requirement. IAP designations means it should be covered in IAP, it
		does not guarantee it is covered. The Safety Officer must ensure this.
6.d.	Check Block	Enter the check if the site satisfies the requirement.
6.e.	Comments	This provides information on where else the requirement may be met. The user may also enter comments.
7	Prepared by	Enter the name and position of the person completing the worksheet.

CG ICS SSP: 1910.120	1. Incident Name	2. Date/Time Prepared	3. Operational		4. Safety Officer (include method of contact)
DRUM COMPLIANCE			Period
CHECKSHEET
5. Supervisor/Leader	6. Location and Size of Site	7. For Emergencies Contact:			8. Note: tanks and vaults should also be treated in the
					same manner as described below [1910.120(j)(9)].
					Many can also pose confined space hazards.

9.a. Cite: 1910.120 (Cites
that duplicate or explain		9.b. Requirement				9.c. Check	9.d. Comments
requirements are omitted)
(j)(1)(ii)	Drums meet DOT, OSHA, EPA regs for waste they contain, including shipment?
(iii)	Drums inspected and integrity ensured prior to movement?
(iii)	Or drums moved to an accessible location (staging area) prior to movement?
(iv)	Unlabelled drums treated as unknown until properly identified and labeled?
(v)	Site activities organized to minimize drum handling?
(vi)	Employers properly warned about the hazards of moving and handling drums?
(vii)	Suitable overpack drums are available for addressing leaking and ruptured drums?
(viii)	Leaking materials from drums properly contained?
(ix)	Are drums that cannot be moved, emptied of contents with transfer equipment?
(x)	Are suspect buried drums surveyed with underground detection system?
(xi)	Are soil and covering material above buried drums removed with caution?
(xii)	Is the proper extinguishing equipment on scene to control incipient fires?
(j)(2)(i)	Are airlines on supplied air systems protected from leaking drums?
(ii)	Are employees at a safe distance, using remote equipment, when handling explosive drums?
(iii)	Are explosive shields in plane to protect workers opening explosive drums?
(iv)	Is response equipment positioned behind shields when shields are used?
(v)	Are non-sparking tools used in flammable or potentially flammable atmospheres?
(vi)	Are drums under extreme pressure opened slowly & workers protected by shields/distance?
(vii)	Are workers prohibited from standing and working on drums?
(j)(3)	Is the drum handling equipment positioned and operated to minimize sources of ignition?
(j)(5)(i)	For shock sensitive drums, have all non-essential employees been evacuated?
(ii)	For shock sensitive drums: is handling equipment provided with shields to protect workers?
(iii)	Are alarms that announce start/finish of explosive drum handling actions in place?
(iv)	Are continuous communications in place between the drum handling site & command post?
(v)	Are drums under pressure properly controlled for prior to handling?
(vi)	Are drums containing packaged laboratory wastes treated as shock sensitive?
(j)(6)(i)	Are lab packs opened by trained and experienced personnel?
(ii)	Are lab packs showing crystallization treated as shock sensitive?
(j)(8)(ii-iii)	Are drum staging areas manageable with marked access and egress?
(iv)	Is bulking of drums conducted only after drum contents have been properly identified?
10. Prepared By:				Form SSP-L (rev 9/06) Page				of
				Form SSP-L (rev 9/06) Page				of

HAZWOPER 1910.120 DRUM COMPLIANCE CHECKLIST (ICS-208-CG SSP-L)

Purpose: The HAZWOPER 1910.120 Drum Compliance Checklist is to ensure that incident response operations are in compliance with Title 29, Code of Federal Regulations Part 1910.120, Hazardous Waste Operations and Emergency Response whenever drums are encountered during an incident. This is an optional form.

Preparation: The HAZWOPER 1910.120 Drum Compliance Checklist is completed by the Safety Officer or his/her staff as frequently as necessary whenever the Safety Officer wants to ensure regulatory compliance. It is best used in conjunction with the Site Safety Plan Enforcement Log (ICS- 208-CG SSP-H). The Site Safety Plan Forms (A-G) best meet some of the requirements. Other requirements are performance based and are best evaluated on scene by the Safety Officer or his/her staff.

Distribution: The HAZWOPER 1910.120 Drum Compliance Checklist should be maintained by the Safety Officer.

Instructions:

Item #

Item Title

Instructions

1	Incident Name	Print the name assigned to the incident.
2	Date/Time Prepared	Enter date (month, day, year) prepared.
3	Operational Period	Enter the time interval for which the assignment applies.
4	Safety Officer	Enter the name of the Safety Officer and means of contact.
5	Supervisor/Leader	The Supervisor/Leader who receives this form will enter their name here.
6	Location & size of	Enter the geographical location of the site and the approximate square area.
	site
7	For Emergencies	Enter the name and way to contact the individual who handles emergencies.
	Contact
8	Note	Tanks and vaults should also be treated in the same manner as described in the checklist (1910.120((j)(9)).
9.a.	Cites	These are the regulatory cites within 1910.120. The major headings are highlighted in bold. Informational
		cites or cites that are duplicative are not included.
9.b.	Requirement	This lists the requirement in a question format. Some require documentation or some form of action.

9.c.	Check Block	Enter the check if the site satisfies the requirement.

9.d.	Comments	This provides information on where else the requirement may be met. The user may also enter comments.
10	Prepared by	Enter the name and position of the person completing the worksheet.

Question	Answer
Form Name	Site Safety Health Plan Form
Form Length	32 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	8 min
Other names	health ans safety plan for event management, ics 208 cg, sample occupational health and safety plan, site safety plan pdf

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