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7/29/2019 7t Intergration of Exposure
1/13
ERHMS
http://www.osha.gov/oilspills/gulf-operations-ppe-matrix.pdfhttp://nrt.org/production/NRT/NRTWeb.nsf/AllAttachmentsByTitle/SA-1049TADFinal/$File/TADfinal.pdf?OpenElementhttp://nrt.org/production/NRT/NRTWeb.nsf/AllAttachmentsByTitle/SA-1049TADFinal/$File/TADfinal.pdf?OpenElementhttp://nrt.org/production/NRT/NRTWeb.nsf/AllAttachmentsByTitle/SA-1049TADFinal/$File/TADfinal.pdf?OpenElementhttp://nrt.org/production/NRT/NRTWeb.nsf/AllAttachmentsByTitle/SA-1049TADFinal/$File/TADfinal.pdf?OpenElementhttp://www.osha.gov/oilspills/gulf-operations-ppe-matrix.pdf7/29/2019 7t Intergration of Exposure
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Staging Area Information Check List
Staging Location:
(Insert County/Parish,
State)
Date:
NIOSH Personnel:
Number of Workers:
Type of Workers:
VOO, On-shore, Off-shore
Number of collected
surveys:
Describe Work Tasks:
Workshift time/duration:
Module Training required
Personal ProtectiveEquipment Required
Safety Concerns observed:
Top Safety Concerns
observed by Safety Officer
(Identify Safety Officers)
Decon in Use
Describe Medical Support
Heat Stress Coordinator
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Staging Area Information Check List
Heat Stress Program
Details
(Shade provided, time
on/off)
Hot Zones
Hot Zone Markings
Safety Briefings ( yes/no
when
Specific Messages during
briefing
Hygiene Logistics
(hand washing stations,
etc)
Consumables provided to
workforce at staging
area?
(food, water, Gatorade,
etc.)
Workforce Organization
(buddy system, etc.)
Pre-employee medical
screening
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Staging Area Information Check List
Description of Site
Issues Observed: :
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General InformatIonName: Job title:
Process description: Length of process:
Dept: Line: Location:
Potential exposures:
Sampling conducted: Heat stress Dermal/surface Other:
Worker
observation
Form
HETA #
Date:
Sequence #
Page
1
(See
Back)
respIratory protectIon
Mnf: Model:
Respirator use:Mandatory Voluntary
Is employee in a written respiratory protection program?
Yes No
Correct type of respirator forexposures?
Yes No Worn correctly? Yes No
Respirator condition
Frequency of use: Changeout frequency
Employees judgment ofeffectiveness:
Company name:
Completed by:
Air SAmpling informAtion
Sample #
Sampling media
Pump #
Type
Start time
Stop time
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protective clothing / gloveSType (gloves,
coveralls, etc)
Mnf
Model
Material
Available but not
worn
Changeout freq.
Condition Good Fair Poor Good Fair Poor Good Fair Poor
Description
Other PPE
Uncovered skin
(Check all thatapply)
Arms
Hands
Wrist
Neck
Face Legs Other:
notes
Page
2
Worker
observation
Form
enGIneerInG controls
Task/Process
Type (LEV,enclosure,etc)
Mnf
Model
Description
Judgment ofeffectiveness
Effective Ineffective Effective Ineffective Effective Ineffective
If ineffective,why?
Furtherevaluationneeded?
Yes No Yes No Yes No
HearInG protectIon
Type: Plugs Muffs Available but not worn
Mnf: Model: NRR:
Use:
Mandatory
Voluntary Worn correctly?
Yes
NoIs employee in a written hearing conservation program? Yes No Dont know
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Chemical form
solid
liquid/pourliquid/spray
Other
inhalation
potential
himed
low
Dermal
Potential
hiMed
lo
duration
(hrs/day)
if indoors,
ventilation:
nonegeneral
local exhaust
Comments
Oil
Dispersant
Cleaner
other
(Specify)
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PPE Type In use? Replacement
Frequency
Type Other Info Provided by Use is
Safety
glasses No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Goggles No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Gloves No
Yes
As nec Daily
Task Other
Short Long Employer
Employee
Required
Voluntary
Respirator No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Safety
shoesNo
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Hard hat No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
HearingProtection
NoYes
As nec Daily Task Other
EmployerEmployee
Required Voluntary
Face
ShieldNo
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Tyvek or
TychemNo
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Rubber
BootsNo
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Slicker
Suit (rain)No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Other No
Yes
As nec Daily
Task Other
Employer
Employee
Required
Voluntary
Clothing No Yes Type
Shirt No Yes Long sleeve Short sleeve
Pants No Yes Long Short
Head covering No Yes
Protective sleeves No Yes
Apron No Yes
Waders No Yes
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Item No Yes Comments
Shower facilities on site
Handwash facil ities onsi te
Emergency eyewash onsite
Adequate sanitary facilit ies
Access t o air condition area for breaks
Shaded work area
Shaded break area
Do workers eat, drink, or smoke in work area?
Adequate water provided?
MSDS readily availablenon-English, as needed
Unlabelled chemical containers?
Facilities for first aid?
Procedures for medical emergencies?
Decon of clothing
Decon of tools?
What is the average number of hours worked per day?
What is the maximum number of hours worked per day?
Is there a work/rest regimen? No Yes minutes on minutes off
Check if any evidence of the following.
snakes wild animals mosquitoes ticks all igators
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1. Incident Name 2. Date Prepared 3. Time Prepared
4. Unit Name/Designators 5. Unit Leader (Name and Position) 6. Operational Period (Date/Time)
7. Personnel Roster Assigned
NAME ICS POSITION HOME BASE
8. ACTIVITY LOG (CONTINUE ON REVERSE)
TIME MAJOR EVENTS
9. Prepared By:
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ICS 204 8/96
3. Incident Name 4. Operational Period (Date/Time)
1. Branch 2. Division/Group
5. Operations Personnel
6. Resources Assigned This Period
Strike Team/Task Force/Resource
IdentifierLeader Phone
# of
Pers.
Drop Off
Point/Time
Pick Up
Point/Time
7. Assignments
8. Special Instructions/Safety Message
11. Approved By: (Planning Section Chief) Date/Time ApprovedPrepared By
Div./Group/Unit
Tactical
Command
Local
Repeat
Function Freq. System Chan.
Support
Local
Repeat
Function Freq. System Chan.
Ground-To-Air
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ICS 208 HM Page 1 3/98
SITE SAFETY ANDCONTROL PLAN
ICS 208 HM
1. Incident Name: 2. Date Prepared: 3. Operational Period:Time:
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)
Name: PPE Level
18. Decontamination Element:
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
type
Qty. Phys.
State
pH IDLH F.P. I.T. V.P. V.D. S.G. LEL UEL
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: