Site Specific Safety Plan - Smith & Associates

Complete the below form and include as much information as possible.

Name *

First

Last

Company Name *

Email *

Phone Number *

Estimated Project Start Date *

Please allow up to 2 weeks for the completion of the SSSP.

Type of Contractor *

Project Name:

Job Number:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Project Scope/Description *

General Contractor: Outline entire scope of work. Subcontractor: Only outline scope of work that will be performed.

*Add the scope of work and description that you would like included within the SSSP

Responsibilities

Please list at least one and up to 4 different Roles along with Contact Information and Responsibility.

How many Roles would you like to add? *

Role #1 *

Person #1 *

Contact Information #1 *

Responsibility #1 *

Role #2

Person #2

Contact Information #2

Responsibility #2

Role #3

Person #3

Contact Information #3

Responsibility #3

Role #4

Person #4

Contact Information #4

Responsibility #4

Name of Person to Report Injuries To *

Phone Number of Person to Report Injuries To *

Project Site Emergency Phone Number *

Evacuation Assembly Area: *

Attach map with project evacuation assembly areas with supporting documents below.

Identified Site Hazards: *

Please enter none or n/a if not applicable.

Types of Mobile Equipment *

Please enter none or n/a if not applicable.

Where will master Safety Data Sheets be located: *

Please enter none or n/a if not applicable.

Is there a potential exposure to powerlines? *

What is the voltage? Select Voltage (nominal, kV, alternating current) *

The value that follows "to" is up to and includes that value. For example, over 50 to 200 means up to and including 200kV.

How was voltage determined or who provided voltage information? *

What is the distance from the work to the powerlines? *

You indicated there is work in close proximity to powerlines. Has the power company or electrical system operator been notified and approved one of the following: • De-energized the lines • Relocated the lines • Or installed protective coverings • Additional OSHA approval?

Please upload approval documentation with the support documents at the end of the form.

Will scaffolding be used? *

What type of scaffolding will be used: *

Will there be work over or near water where the danger of drowning exists? *

Work with a potential for falling into water.

Will employees be required to be transported to the work location by means of van, bus, helicopter, boat, etc.? *

Will there be exposures to falls 6ft or greater? *

Where Personal Fall Arrest Systems are used as fall protection, fall rescue plans and tie off points must be established in compliance with §1670

Will there be hot work? *

What type of Hot Work? *

Will you be working in Confined Spaces *

Location of Parking Areas *

Location of Eating Areas *

Location of Smoking Area(s) or Rules (No Smoking): *

Required PPE other than work boots, hard hats and safety glasses or other PPE requirements *

Rules for Cell Phone Use *

Location of landline and if there are any protocols for dial out *

Are there any restricted areas/Restricted Area Locations? *

Location of First Aid Supplies *

Location of Fire Extinguishers *

Location of Eyewash Stations *

Are there client specific requirements required? *

Working with client name / agency:

Number of Support Documents to Upload

Maximum size of each file is 5 MB.

Note: When uploading procedures identify applicable work verses subcontracted work. If applicable the following types of documents will be needed: Submit applicable Safety Data Sheets, Drawings, Cover Page Photo, etc.

First Support Document