CONSTRUCTION SAFETY MANAGEMENT MANUAL

Copyright 2004 by Lovell Safety Management Company, LLC All rights reserved. Printing in United States of Ameri a. !o part of this man"al may be reprod" ed, stored in retrieval system, or transmitted in any form by any means, ele troni , me hani al, photo opying, re ording or other#ise, #itho"t the prior #ritten permission of Lovell Safety Management Company, LLC. $% eption is made for p"r hasers of the man"al, #ho may reprod" e the material for "se internal to their organi&ation.

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PL$AS$ '$A( ) '$M*+$ ,$-*'$ US.!/ 01.S P*L.C2 This program is designed to provide the user with information on establishing an effe tive !afet" Management Program to help prevent ostl" wor# related in$uries and to support omplian e with O!%A wor#pla e safet" regulations& This safety & health program a ! all the atta"hme ts are ot "ompa y spe"ifi"# It is the employer$s respo si%ility to e s&re that the appropriate "ha ges are ma!e to this poli"y to %etter refle"t the spe"ifi"s of the operatio # Yo&$ll ee! to go thro&gh the poli"y a ! the appli"a%le atta"hme ts a ! ma'e them more "ompa y spe"ifi" %y i serti g yo&r "ompa y ame (here appropriate a ! the ames of employees i "harge of impleme ti g )ario&s aspe"ts of the poli"y# RE*LACE T+E *+RASE YOUR COM*ANY NAME (ith yo&r o( "ompa y ame The pra ti e of o upational safet" and health and its related regulator" programs are onstantl" under review and hange& Additionall"' there are signifi ant differen es in professional interpretation of regulator" standards and pertinent o upational safet" and health information& (n order to prevent ostl" wor# related in$uries and o upational illnesses with the resulting wor#er)s ompensation insuran e laims' all emplo"ees must be properl" trained and held a ountable for safet"& Emplo"ees must understand all #nown ha*ards presented in their wor# environment and be able to respond appropriatel" to unplanned ha*ards' whi h ma" arise& The responsibilit" for ompl"ing with regulator" re+uirements and sta"ing urrent with regulator" issues resides with the emplo"er& This publi ation is not intended to ta#e the pla e of legal or professional assistan e& (f legal advi e or other e,pert assistan e is re+uired with regard to a spe ifi issue onfronting an emplo"er' then the servi es of a ompetent professional should be sought a ordingl"& No representation an be made or responsibilit" ta#en b" the publisher regarding the ompleteness' a ura "' or ontinued validit" of the information in this publi ation& This program does not address ever" item in -. C/R 0.-1' nor is it intended to address motor arrier safet" regulations' environmental safet" regulations' or lo al odes and ordinan es& The manual addresses several areas related to the prevention of wor#pla e in$uries and a idents fa ed b" emplo"ers engaged in 2general industr"2 operations& (t is ver" important to understand that under /ederal 3aw "ou are responsible for omplian e with all standards and regulations of -. C/R 0.-1' whi h appl" to "our wor# areas and operations& All emplo"ers are en ouraged to obtain and be ome familiar with' a op" of the O!%A 4eneral (ndustr" !afet" and %ealth !tandards' -. C/R 0.-1' published b" both the U&!& 4ovt& Printing Offi e and several private printing firms& The O!%A web page is also a ver" valuable resour e5 www.osha.gov
Lo)ell Safety Ma ageme t Co#, LLC -./ Mai!e La e, NYC -0012 Safety 3epartme t 4 .-.560752277

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CONSTRUCTION SAFETY MANUAL TA8LE OF CONTENTS Se"tio s 0&6 Corporate Constru tion !afet" Program Corporate Management Poli " Corporate !afet" Responsibilit" !uperintendent !afet" Responsibilit" !uperintendent7/oreman Responsibilit" Emplo"ee Responsibilit" 8is iplinar" Poli " Pro edures -&0 Emplo"ee 8is iplinar" A tion /orm New Emplo"ee Training 9&0 New Emplo"ee !afet" Orientation Che #list Competent Person 8esignation :&0 Competent Person Memorandum :&O!%A Competent Person !afet" Committee ;&0 !afet" Committee Meeting Agenda ;&Appointment to Our !afet" Committee ;&9 !afet" Committee Minutes A ident (nvestigation Re ord#eeping =O!%A 966 3og> !ub ontra tor Complian e ?&0 !afet" Memorandum ?&!ample 3etter to !ub ontra tors ?&9 Poli ies and Pro edures for Contra tor Coordination ?&: Complian e A tion !heet ?&; Multi@Emplo"er !ite A Pre@Bob %a* om Che #list Toolbo, Meetings .&0 Bobsite !afet" Meeting Report

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/irst Aid Re+uirements 06&0 Poli " !tatement 06&- Che #list for Reviewing Cloodborne Pathogens Program !uperintendents7/oreman !elf (nspe tions 00&0 8ail" Bobsite !afet" Che #list Management Audit Che #list Pro$e t !ite !pe ifi !afet" Program 8rug and Al ohol Poli ies (n ident (nvestigation /orms 0;&0 !upervisorDs (nvestigation E Report of (n ident 0;&- A ident Report %a*ards !pe ifi Poli ies @ Atta hed Power Tolls Ele tri al !afet" /all Prote tion Residential /all Prote tion ! affolds 3adders7!tairwa"s Tren hing7E, avation Confine !pa e Entr" Cranes7Rigging /ire Prote tion7Eva uation Felding Material %andling Respirator" Prote tion PPE !teel Ere tion 3ead O upational %ealth %a*ard Communi ation

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Atta hments@ 3ovell !afet" Tool Co, !afet" Tal#s.

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COR*ORATE MANAGEMENT *OLICY STATEMENT

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CORPORATE MANA4EMENT PO3(CY !TATEMENT The personal safet" and health of ea h emplo"ee of our organi*ation is of primar" importan e& Fe believe that our emplo"ees are our most important assets and that their safet" at the wor#site is our greatest responsibilit"& The prevention of o upationall" indu ed in$uries and illnesses is of su h onse+uen e that it will be given pre eden e over operating produ tivit" whenever ne essar"& Management will provide all me hani al and ph"si al fa ilities re+uired for the personal safet" and health of ea h of its emplo"ees& To be su essful' su h a program must embod" the proper attitude toward in$ur" and illness prevention on the part of orporate management' supervisors' and emplo"ees& (t also re+uires ooperation in all safet" and health matters' not onl" between orporate management' supervisor and emplo"ees' but also between ea h emplo"ee and their fellow wor#ers& Our on ern for safet" and health of all human beings is dail"' even hourl"& Fe e,pe t ever" person who ondu ts the affairs of our ompan"' no matter in what apa it" the" fun tion' to a ept this on ern and its responsibilit"& Emplo"ees are e,pe ted to use the safet" e+uipment provided& Rules of ondu t and rules of safet" and health must be observed& !afet" e+uipment annot be abused or destro"ed& Cooperation between our emplo"ees and management in the observan e of this poli " will ensure safe@wor#ing onditions' will help result in a ident@free performan e and will wor# to our mutual advantage& (t will also assist in redu ing wor#ers) ompensation osts =dire t osts> and redu e $obsite down time' material loss and regulator" agen " fines =indire t osts>& Management has the authorit" to pro ure the ne essar" resour es to e,e ute the ob$e tives of our ompan")s safet" and health program& Fe will hold managers' supervisors and emplo"ees a ountable for meeting their responsibilities so that essential tas#s will be performed&

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CORPORATE MANA4EMENT !A/ETY RE!PON!(C(3(T(E! Eliminate potential ha*ards b" providing appropriate safeguards' personal prote tive e+uipment and safe wor# tas#s& Provide ne essar" personal prote tive e+uipment and enfor e its use and are& Provide effe tive training' whi h is re+uired b" the 2standards2' as a minimum for the emplo"ees& Ce ome familiar and ompl" with appli able O!%A standards =-. C/R 0.06' 4eneral (ndustr"' and 0.-1' Constru tion> and ma#e opies of medi al re ords as well as all safet" and health programs available for emplo"ees to review& Review' onsider for approval' and e,e ute appropriate a tion on safet" poli ies developed b" safet" ommittees or safet" dire tor& Ensure a high level of produ tivit" and safet" performan e and hold pro$e t management staff a ountable& Assign an individual=s> G ompetent personH the authorit" for the implementation of the safet" program at ea h wor#site&

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!A/ETY 8(RECTOR RE!PON!(C(3(T(E! Monitor supervisor" management and emplo"ee a tivit" to ensure that the orporate programs are arried out in a timel" manner& !hall oordinate safet" information between pro$e ts7shops to assure that all pro$e ts will benefit from ea h other)s efforts& Coordinate all safet" a tivities in luding $obsite inspe tions' and distribution of safet" materials& Perform $obsite inspe tions periodi all" and follow up orre tive a tions& Maintain all a ident re ords and omplete all re+uired O!%A forms& Anal"*e a ident re ords and show trends& Promote safet" edu ation on all levels& Periodi all" review safet" rules and standards with emplo"ees to ompan" is meeting its goals and ob$e tives& onfirm that the

Review with supervisors how to handle emergen " pro edures at ea h $obsite lo ation& Confirm that all re+uired signs are posted' and bulletin boards are maintained in lear and legible ondition& Confirm emplo"er is enfor ing omplian e with all appli able federal' state' and lo al regulations& Provide a regular report to upper management on the results of the safet" program&

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!UPER(NTEN8ENT7/OREMAN RE!PON!(C(3(T(E! Inow safet" rules and wor# pra ti es that appl" to the wor# "ou supervise& Ta#e a tion to onfirm that all emplo"ees in "our harge understand the safet" rules that appl" to them& Alwa"s ta#e immediate a tion to orre t safet" rule violations& Unsafe a ts or pro edures annot be tolerated& Prevent bad wor# habits from developing& You are responsible to ma#e dail" observations of emplo"ees to ensure that the" perform their wor# safel"' and ontinue this observation regularl" on e safe wor#ing habits are established& Ta#e a tion to orre t or ontrol ha*ardous onditions within "our wor# areas& (f it is be"ond "our ontrol' remove the emplo"ee until the ondition is safe& Eliminate unsafe onditions and prevent an a ident& En ourage wor#ers to report unsafe onditions or pro edures& 3isten to "our wor#ers and don)t ta#e their safet" omplaints lightl"& No $ob should pro eed when a +uestion of safet" remains unanswered& !ee# advi e from "our pro$e t manager when ne essar"& !et a good e,ample& 8emonstrate safet" in "our own wor# habits and personal ondu t& Alwa"s wear personal prote tive e+uipment in areas where personal prote tive e+uipment is re+uired& Train "our emplo"ees on the proper safet" pro edures to follow' in luding the use of additional safeguards su h as ma hine guards and personal prote tive e+uipment& (nvestigate and anal"*e ever" a ident' however slight' that o urs to an" of "our emplo"ees& Control the auses of minor in idents to help avoid future rippling a idents& Complete and file a report on ea h and ever" in ident and a ident that o urs at "our $obsite& (f "ou have +uestion or re+uire reporting forms' onta t "our pro$e t manager& Condu t wee#l" safet" toolbo, meetings& Ma#e safet" suggestions& !erve on safet" ommittee' if re+uested& Ta#e an a tive part and parti ipate in safet" meetings& Non@ omplian e of these rules as well as other federal and7or state laws or regulations ma" be legal violations sub$e t to ivil and7or riminal penalties&

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EMP3OYEE RE!PON!(C(3(T(E! Fhenever "ou are involved in an a ident that results in personal in$ur" or propert" damage' no matter how slight' the a ident must be reported to "our supervisor or other management personnel prior to the end of the wor# shift& 4et first aid promptl"& Report an" ondition or pra ti e "ou thin# might e+uipment immediatel" to "our supervisor& ause in$ur" and7or damage to

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8o not operate an" e+uipment' whi h' in "our opinion' is not in a safe ondition& Report immediatel" the ondition that "ou believe is unsafe to "our foreman& All pres ribed safet" e+uipment and personal prote tive e+uipment must be used when re+uired and must be maintained in good wor#ing ondition& (t is "our personal responsibilit" to use su h e+uipment& The use of re+uired personal prote tive e+uipment is a non@negotiable item& Obe" all safet" rules' government regulations' signs' mar#ings' and instru tions& Ce parti ularl" familiar with the rules and regulations that appl" dire tl" to "ou in the area in whi h "ou wor#& (f "ou don)t #now' as "our foreman& Fhen lifting' use the approved lifting te hni+ue' i&e& bend "our #nees' grasp load firml"' #eep load lose to "ou' and then raise the load #eeping "our ba # as straight as possible& Alwa"s get help with heav" or aw#ward loads& 8o not engage in horsepla"J avoid distra ting othersJ be ourteous to fellow wor#ers& Alwa"s use the right tools and e+uipment for the $ob& Use them safel" and onl" when authori*ed& (f "ou are not familiar with the safe wa" to use a parti ular tool or pie e of e+uipment' as# "our supervisor& Fhen using "our own tools on the $ob site' ma#e sure all guards' ground pins' et &' are in pla e& 4ood house#eeping must alwa"s be pra ti ed& Return all tools' e+uipment' materials' et &' to their proper pla es when "ou are finished with them& Ieep floors lean and passagewa"s lear& Poor house#eeping wastes time' energ"' and material' and often results in in$ur"& The use of drugs and7or into,i ating beverages on the $obsite is forbidden& Ceing under the influen e of al ohol or drugs when on the $obsite is ine, usable& .mmediate dis harge for being "nder the infl"en e and3or "sing dr"gs or al ohol may be instit"ted.

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Additional appropriate dis iplinar" a tion will be ta#en for the following offenses5 a& b& & d& /ighting @ no matter what the ause& (nsubordinate ondu t or refusal to follow dire tions& /alse statement' su h as in$ur" laims& Other inappropriate behavior in luding' but not limited to' failure to obe" safet" rules&

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3oose lothing and $ewelr" annot be worn when operating ma hiner" and e+uipment& Proper wor# shoes shall be worn at all $obsites& Open toed shoes and snea#ers will not be permitted to be worn at an" $obsite& (f "ou are observed wearing open toed shoes or snea#ers' "ou will not be permitted to wor# until "ou return with proper footwear& 8o not handle hemi als unless "ou have been trained in the safe handling pro edure& %ardhats and e"e prote tion shall be worn at all times& Read' understand and follow the guidelines set forth in the material safet" data sheets =M!8!> pertaining to "our wor#& Complian e with safet" and health rules and regulations is a ondition of emplo"ment&

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( have read the above poli ies and understand that ooperation between emplo"ees and management will ensure safe@wor#ing onditions' will help result in in$ur" free performan e and will wor# to our mutual advantage& Corporate Ma ageme t as of5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Safety 3ire"tor as of5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK S&peri te !e t9Forema as of5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Employee as of5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK b"5 b"5 b"5 b"5

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8(!C(P3(NARY PO3(CY PROCE8URE! All emplo"ees are e,pe ted to ompl" with $obsite rules and regulations' and to follow established operating pro edures set forth b" this ompan"& Liolations will not be tolerated and superintendent7foreman will be held a ountable for the ondu t of their emplo"ees& !uperintendents and foremen are re+uired to ta#e a tion when a violation is observed& (mmediate a tion to ontrol or eliminate a ha*ard is re+uired& (n the event a violation is observed' the following pro edures have been established to pla e an emplo"ee on noti e& Noti eM /irst Offense A tion A written warning addressed to the emplo"ee and a op" pla ed in the emplo"ee)s file referen ing the violation and warning' in luding date and time& A written warning addressed to the emplo"ee with referen e to the violation in luding date and time of the o urren e& A op" of this warning will be given to the emplo"ee' the union shop steward' and another op" will be pla ed in the emplo"ee)s file& A written warning similar to the se ond noti e will be prepared and distributed in the same manner& This warning will be followed b" a meeting with the emplo"ee' union shop steward' foreman and7or pro$e t manager and senior management to determine whether the emplo"ee will be suspended without pa" or terminated depending upon the nature of the violation& Termination&

!e ond Offense

Third Offense

/ourth Offense

M Fithin an" onse utive 0- month period& M This poli " is in effe t unless there is a poli " in our labor7management agreement& The above pro edure has been prepared so that there is no +uestion about how violations of rules' regulations' and pro edures will be handled b" management and so that emplo"ees will #now what to e,pe t if the" do not ompl" with the established rules' regulations' and pro edures& Management #nowledge of unsafe behavior and la # or appropriate do umented dis ipline ma" be a violation of federal' state laws and regulations&

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Employee 3is"ipli ary A"tio Form Pro$e t5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK !hop5 KKKKKKKKKKKKKKKKKKKKKKKKK 8ate5 KKKKKKKKKKKKKKKK 8a"5 KKKKKKKKKKKKKKKKK Time5 KKKKKKKKKKKKKKKK

Emplo"ee Name5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK !uperintendent5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK /oreman5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK -st :iolatio

8es ription5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK Emplo"ee !ignature5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK . ! :iolatio 8es ription5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK Emplo"ee !ignature5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 1r! :iolatio 8es ription5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK Emplo"ee !ignature5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK

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;th :iolatio <TERMINATION=

F(T%(N A 0- MONT% PER(O8

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NEF EMP3OYEE TRA(N(N4 All new emplo"ees will be trained b" a member of the management staff prior to starting wor#& The 2New Emplo"ee !afet" Orientation Che #list2 shall be used b" trainers =managers' superintendents' foremen' safet" dire tors> as a reminder of the items that must be reviewed with the emplo"ee& All items must be initialed or identified as not appli able& The he #list must be signed b" the emplo"ee and the management representative after the orientation is omplete& This form will be given to the pro$e t manager or home offi e and #ept in the emplo"ee)s personnel file&

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Ne( Employee Safety Orie tatio Che"'list (nstru tions To Management5 (nitial ea h item as "ou dis uss it with the emplo"ees& This he #list must be ompleted before the emplo"ee starts wor#& (tem 0& -& Emplo"ee re eived Compan" !afet" Program KKKKKKKKKKKKKKK Review5 N !afet" and %ealth Poli " KKKKKKKKKKKKKKK N Emplo"ee 4eneral !afet" and %ealth Rules KKKKKKKKKKKKKKK N 8is iplinar" Poli " and Pro edures KKKKKKKKKKKKKKK 9& (nstru t5 N %ow to report unsafe onditions KKKKKKKKKKKKKKK N Fhat to do in the event of an in$ur" on the $ob KKKKKKKKKKKKKKK N !tate when and where safet" tool bo, meetings are KKKKKKKKKKKKKKK N %ardhats' wor# boots' safet" glasses7goggles mandator" KKKKKKKKKKKKKKK =Personal prote tive e+uipment is not negotiable> N E,plain /ire Eva uation7Emergen " Plan KKKKKKKKKKKKKKK N Proper lifting te hni+ues and importan e of ba # fitness KKKKKKKKKKKKKKK N Review O!%A %a*ard Communi ation Poli " and provide training KKKKKKKKKKKKKKK :& Other =Please 3ist> KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKK Completed

( a #nowledge that information on the above sub$e ts was furnished to me during m" orientation and that ( understand this information Emplo"ee !ignature Management !ignature

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KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 8ate 8ate

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK

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COMPETENT PER!ON 8E!(4NAT(ON (t is the responsibilit" of top management to appoint an individual as a ompetent person who is apable of identif"ing e,isting and predi table ha*ards in the surroundings or wor#ing onditions whi h are unsanitar"' ha*ardous' or dangerous to emplo"ees' and who has authori*ation to ta#e prompt orre tive measures to eliminate them& There is the possibilit" that more than one ompetent person ma" be ne essar"' depending on the range of ha*ards on the pro$e t' the si*e of the pro$e t' and the distan e between operations on a pro$e t&

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Compete t *erso List 0.-1&-6 0.-1&90.-1&;9 0.-1&10.-1&060 0.-1&069 0.-1&-;0 0.-1&9;: 0.-1&:6: 0.-1&:;0 0.-1&;60.-1&;;6 0.-1&1;6 0.-1&1;0 0.-1&1;0.-1 !ubpart P App A 0.-1 !ubpart P App C 0.-1&<6; 0.-1&<;0.-1&?66 0.-1&?69 0.-1&?;6 0.-1&?;. 0.-1&.66 0.-1&06;9 0.-1&0616 0.-1&0060 0.-1&00-< 4eneral safet" and health provisions 8efinitions (oni*ing radiation 3ead %earing prote tion Respirator" prote tion Rigging e+uipment for material handling Felding' utting' and heating in wa" of preservative Firing design and prote tion ! affolding 8efinitions appli able to fall prote tion Cranes and derri #s ! ope' appli ation' and definitions appli able to e, avations 4eneral re+uirements Re+uirements for prote tive s"stems !oil lassifi ation !loping and ben hing Re+uirements for lift@slab operations Colting' riveting' fitting@up' and plumbing@up Underground onstru tion Compressed air Preparator" operations @ demolition Me hani al demolition Clasting and use of e,plosives 3adders Training re+uirements @ stairwa"s E ladders Asbestos Cadmium

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Compete t *erso Memora !&m

TO5 /ROM5 8ATE5 !UCBECT5 Competent !afet" Person

Lia this memo' we appoint KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK as our 2Competent !afet" Person2 a ording to the provisions of -. C/R 0.-1 in the area=s> of5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK& %e7she has the authorit" to orre t all ha*ards or to remove wor#ers from the ha*ardous e,posure if the ha*ards annot be immediatel" orre ted&

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK !ignature of Owner7Manager

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O!%A COMPETENT PER!ON Pro$e t5 8ate5 Trade5 Compan" Name5

Address5

Telephone O

Offi e5 Cell7Pager5

Onsite !ite !afet" Representative 7 Competent Person J The following person has been designated as the on site safet" representative for the above named ompan"& The named individual hereb" de lares that the" posses the edu ation and e,perien e ne essar" to enable him 7 her to re ogni*e safet" ha*ards and has the authorit" to ta#e prompt orre tive measures for their s ope of wor# on this pro$e t& Name5 !ignature5

YOUR COMPANY NAME

;&6

!A/ETY COMM(TTEE The development and implementation of a safet" ommittee is an e, ellent te hni+ue in the monitoring of "our safet" program& (t will reate a ountabilit" throughout the organi*ation& Mem%ership< (t is most appropriate to appoint members from top management' the personnel dire tor' one or more pro$e t managers' superintendents' foreman' and shop steward or #e" emplo"ee& Meeti gs9Mi &tes< The safet" ommittee should meet on a pre@s heduled monthl" basis' at a regular time and pla e& Minutes from these meetings should be #ept on file for review b" management' and insuran e representatives& The agenda for the safet" ommittee meetings will in lude items that relate to the safet" and health of "our emplo"ees& !afet" ommittee minutes will be distributed to ompan" management' $obsite management and safet" staff& Committee Goals< Our ommittee is e,pe ted to provide solutions to wor#site safet" and health problems& To do so' the ommittee must be aware of problems' serve as a hannel of information from emplo"ees to management' and ma#e positive re ommendations for orre tive a tion&

YOUR COMPANY NAME

Safety Committee Meeti g Age !a Topi s for dis ussion and a tion at safet" meetings will in lude5 0& Review a ident investigation reports and determine if appropriate orre tive a tion was ta#en to prevent similar o urren es in the future& (f not' re ommendations will be submitted to management for their onsideration and subse+uent a tion& Prepare and review ompan" safet" and health rules and pro edures for the purpose of #eeping the safet" and health program up to date and effe tive& Review potential ha*ards that are reported and re ommend to management wa"s and means to ontrol or eliminate ha*ards that ould lead to a idents or propert" damage& Promote safet" and health a tivities& Review the need for emplo"ee training and edu ation and ma#e re ommendations to management& Ma#e periodi over@sight $obsite inspe tions to ensure that ha*ards are not being overloo#ed b" the superintendent or foreman' and to ensure that orre tive a tion is ade+uate and ta#en in a timel" manner& Review a ident statisti s for the purpose of identif"ing high a ident $obsites' problem foremen' trends' et & Cased on findings' ma#e re ommendations to management&

-& 9& :& ;& 1&

<&

YOUR COMPANY NAME

Appoi tme t to O&r Safety Committee

To5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKK

8ate5

Our safet" ommittee an be a valuable asset to help us provide a safe and healthful pla e to wor#& (ts effe tiveness depends on the #nowledge' e,perien e' ooperation and level of ommitment of ea h safet" ommittee member& Fe have made the following appointments to this ommittee and re+uest that the Chairman all its first meeting within thirt" da"s in a ordan e with the en losed listing of responsibilities of the ommittee&

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Chairman KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK !e retar" KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK

The above appointments ta#e effe t immediatel"' and will remain in effe t until hanged in writing&

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK Name5 Title5

YOUR COMPANY NAME

Safety Committee Mi &tes Members Present5 KKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKK Members E, used5 KKKKKKKKKKKK Members Absent5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKK 3o ation5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Meeting 8ate5

Minutes Prepared b"5 KKKKKKKKKKKKKKKKKKKKKKK Ne,t Mtg& 8ate5

Topi 8ate

!ummar" of 8is ussion

A tion Re+uired7 Assigned To

8ue

5 To be returned to Chairperson when 2A tion2 is ompleted&

YOUR COMPANY NAME

1&6

ACC(8ENT (NLE!T(4AT(ON Ea h superintendent and foreman will ma#e a do umented report of ever" in ident' even those without in$ur"' within twent"@four =-:> hours of the o urren e& Reports are to be ompleted as soon as possible to avoid hanges in ph"si al onditions and witness reports& Note5 An" a ident that auses a fatalit" or three or more emplo"ees to be hospitali*ed must be reported to O!%A within eight hours of the in ident& A ident reports highlight problem areas& Through the use of good reports' a ident patterns an be dete ted and resour es dire ted toward prevention& A ident reports ma#e e, ellent training tools& The ause and effe t of a idents an be reviewed at safet" meetings& !uperintendents and foremen will be trained in a ident investigation te hni+ues& @ @ @ @ @ @ @ A ident investigation is a management fun tion that must be e,e uted at the superintendent7foreman level& All a idents7in idents must be investigated regardless of the e,tent of the in$ur" or damage& Emplo"ees will never be allowed to fill out their own a ident investigation report& /o us must be fa t finding not fault finding& !uperintendents and foremen must identif" the unsafe a t or unsafe ondition& !uperintendents and foremen should provide re ommendations for orre tive a tion' bring it to top management)s attention and assure that it is a ted upon& !uperintendent7foreman will be provided with an a ident investigation #it' whi h must remain on site&

The forms at the end of this do ument will assist with in ident investigations&

YOUR COMPANY NAME

<&6

RECOR8IEEP(N4 Re ords must be maintained and #ept up to date b" the superintendent at ea h $obsite and7or home offi e& (f there is no superintendent' then this responsibilit" lies with the foreman& These re ords must be available for review at all times& The following re ords must be maintained& 0& -& 9& :& ;& 1& <& ?& .& 06& 00& 0-& 09& 0:& !upervisor)s (nvestigation and Re ord of (n ident O!%A 3O4 =form 966> http://www.osha.gov/recordkeeping/RKforms.html !elf (nspe tions 3og of Tool Co, Tal#s =in lude names and signatures of emplo"ees present> E+uipment Preventive Maintenan e %a*ard Communi ation Complian e Plan Material !afet" 8ata !heets Chemi al (nventor" 3ist Minutes of !afet" Committee Meetings O!%A Training Re+uirements Re ords O!%A Poster E,plaining Emplo"ee Rights http577www&osha&gov7Publi ations7poster&html A ident /orms @ Medi al Re ords Corporate !afet" Program Emergen " Phone Number 3ist

YOUR COMPANY NAME

L(((&

!UCCONTRACTOR COMP3(ANCE O!%A has larified their position with respe t to multi@emplo"er wor# sites b" identif"ing four different t"pes of emplo"ers& Exposing employers @ those whose emplo"ees are e,posed to ha*ards& Creating employers @ those who a tuall" reate ha*ards Controlling employers @ those who have the authorit" to ensure that ha*ards are orre ted Correcting employers @ those who are spe ifi all" responsible for orre ting ha*ards (n order to issue a itation for a wor#site ha*ard to one of these t"pes of emplo"ers' O!%A must prove that the emplo"er had #nowledge of the ha*ardous ondition' or ould have had su h #nowledge with the e,er ise of reasonable diligen e& As alwa"s' prevention is the first step in avoiding O!%A san tions& (t is imperative that YOUR COM*ANY NAME understand the rules and potential liabilities related to O!%A)s multi@emplo"er wor#site lause& Fe re+uire sub ontra tors to ompl" with O!%A standards& Contra tual agreements with sub ontra tors will state that the" must provide the following5 0& -& Certifi ate of (nsuran e %a*ard Communi ation Plan N Chemi al (nventor" 3ist N !pe ifi material safet" data sheets !afet" Program

9&

The following forms will assist in monitoring sub ontra tor omplian e with safet" poli ies and pro edures&

YOUR COMPANY NAME

Safety Memora !&m Contra tor KKKKKKKKKKKK Name5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 8ate5

!afet" Liolation 8es ription5

4ENERA3 CONTRACTOR !ignature5KKKKKKKKKKKKKKKKKKKKKKK !UCCONTRACTOR !ignature5KKKKKKKKKKKKKKKKKKKKKKK Noti e5 Controlling Emplo"er @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ E,posing Emplo"er @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Creating Emplo"er @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ Corre ting Emplo"er @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

8ate5 KKKKKKKKKKKK 8ate5 KKKKKKKKKKKK

YOUR COMPANY NAME

Sample Letter to S&%"o tra"tors

Re5 Bobsite !afet" 4entlemen73adies5 The personal safet" and health of ea h emplo"ee and wor#er on our pro$e ts is of primar" importan e& The prevention of o upationall" indu ed in$uries and illnesses is of su h onse+uen e that it should be given pre eden e over operating produ tivit" whenever possible& To the greatest degree possible' Compan" Management should provide all me hani al and ph"si al fa ilities re+uired for personal safet" and health& Therefore' if "our Compan" does not ompl" with our /ield Management on erning safet"' the following will o ur5 /irst Liolation5 !e ond Liolation5 Third Liolation5 Fritten Noti e Fe will withhold "our monthl" pa"ments until infra tion is orre ted& Your Compan" will $eopardi*e possible future sub ontra ts with our Compan"&

(f "ou have an" +uestions and7or omments please onta t the undersigned& Ler" trul" "ours'

!afet" 8ire tor

YOUR COMPANY NAME

*oli"ies a ! *ro"e!&res for Co tra"tor Coor!i atio

0&

(t is our poli " that all persons on our $obsite are entitled to information regarding the hemi als to whi h the" are e,posed in their wor# areas and that our emplo"ees are entitled to information regarding he hemi als to whi h the" ma" be e,posed as the result of the wor# pro esses of other ontra tors& The %a*ard Communi ation Coordinator or his7her $obsite designee is responsible for the oordination of information between our organi*ation and an" other ontra tors on erning all aspe ts of this %a*ard Communi ation Program& Fhen the %a*ard Communi ation Coordinator or $obsite designee is informed that ontra tors will be on our site' he7she will advise them in person of5 an" hemi al ha*ards that ma" be en ountered in the normal ourse of their wor# on the siteJ our labeling s"stemJ the prote tive measures re+uired' the safe handling s"stemJ the prote tive measures re+uired' the sage handling pro edures ne essar" and our emergen " alarm s"stem=s>& (n addition' the %a*ard Communi ation Coordinator or designee will notif" these individuals of the lo ation and availabilit" of our material safet" data sheets& Ea h ontra tor bringing hemi als on site' must provide our %a*ard Communi ation Coordinator with the appropriate ha*ard information on these substan es' in luding labels used and the pre autionar" measures to be ta#en in wor#ing with those hemi als& The ontra tors must also inform the %a*ard Communi ation Coordinator or $obsite designee as to where on our $obsite the ontra tor will maintain a hemi al inventor" list and appropriate M!8! file& The %a*ard Communi ation Coordinator is also responsible for providing information to an" relevant parties about an" potentiall" ha*ardous substan es we ma" bring into an" $obsite at whi h we ma" wor# as ontra tors& The %a*ard Communi ation Coordinator or $obsite designee will use the he #list' whi h follows to implement the above poli "&

-&

9&

:&

;&

1&

YOUR COMPANY NAME

COMP3(ANCE ACT(ON !%EET Pro$e t@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ 8ate @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

CORRECTE8 T%E %APAR8!@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@ REMOLE8 EMP3OYEE! /ROM T%E %APAR8!@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

FR(TTEN NOT(CE !ENT @@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

YOUR COMPANY NAME

M&lti5Employer Site *re5>o% +a?"om Che"'list 8ate5 KKKKKKKKKKKKKKKKKKKKK Contra tor5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Phone O = >KKKKKKKKKKKKKKKK Main Offi e Conta t =Name>5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK On !ite Conta t =Name>5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Answer A33 Questions5 Fhere will Contra tor)s wor# be performedR KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K %ow will ontra tor)s wor#ers enter and leave premisesR KKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K Fe have dis ussed with the ontra tor our5 KKKKKKKKKK%a*Com Plan KKKKKKKKKK%a*Com Plan 3o ation KKKKKKKKKKM!8! /ile @@@@@@@@@@@@@3o #out7 Tagout KKKKKKKKKK3abeling !"stem KKKKKKKKKK!igns KKKKKKKKKKAlarm !"stem @@@@@@@@@@@@@ Confine spa e entr" program KKKKKKKKNo

%as the ontra tor wor#ed at this fa ilit" before5 KKKKKKKKYes Fhat ha*ards will ontra tor emplo"ees be e,posed toR

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K Fhat personal prote tive e+uipment will ontra tor needR KKKKKKKKKKgloves =t"pe> KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKrespirators with artridges for KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKair@line respirators forKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKhard hats KKKKKKKKKKsafet" glasses KKKKKKKKKKsplash goggles KKKKKKKKKKfa e shields KKKKKKKKKKaprons KKKKKKKKKKdust suits KKKKKKKKKKes ape pa #s KKKKKKKKKKear plugs KKKKKKKKKKear muffs KKKKKKKKKKother KKKKKKKKKKKKKKKKKKKKKK

YOUR COMPANY NAME

3ist spe ial e+uipment ontra tor will need5 KKKKKKKKKKventilation KKKKKKKKKKspe ial disposal methods

KKKKKKKKKKother KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Fhat ha*ardous materials will the ontra tor bring onto the wor#siteR +uantit"> =(ndi ate t"pe and

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K Fhere on site are ontra tor)s M!8!s availableRKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K 8oes the ontra tor have a %a*Com PlanR KKKKKKKKKKYes KKKKKKKKKKNo

(f "es' where is it lo atedRKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK (f "es' is a hemi al inventor" list in luded KKKKKKKKKKYes KKKKKKKKKKNo

8o an" of the ha*ardous materials the ontra tor will being onsite present a danger to our emplo"ees or fa ilit"R KKKKKKKKKKYes KKKKKKKKKKNo (f "es' what prote tive measures will be ta#en to prevent an unwanted in identR E,plain5KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK K

!igned5KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 8ate5KKKKKKKKKKKKKK %a*ard Communi ation Coordinator !ignature of Contra tor5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK

YOUR COMPANY NAME

.&6

TOO3 COS MEET(N4! Tool bo, tal#s of ; to 06 minutes must be held b" superintendents and7or foreman ea h wee#& Emplo"ees never re eive too mu h training' and therefore our ompan" relies upon $obsite management to provide ongoing and ontinuous emplo"ee training& The sub$e t to ea h training tal# should be hosen to relate to the t"pe of wor# that is being performed& !ome e,amples in lude5 N N N N N N The use of safet" glasses when using ir ular saws' grinders' table saws' radial arm saws' $a # hammers' power a tuated tools' et & The proper set up and use of ladders& %ard hats and wh" the" are ne essar"& A dis ussion of a re ent a ident and its ause=s>& A dis ussion of an old a ident& A dis ussion of dis iplinar" pro edures for failure to ompl" with safet" poli ies

A log of Tool Co, Tal#s must be #ept in a ordan e with the form that follows& One op" should be #ept b" $obsite management and the other #ept on the file in the home offi e b" $obsite lo ation&

YOUR COMPANY NAME

>o%site Safety Meeti g Report Bob 3o ation5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Meeting 8ate5 KKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKK Names of !ub ontra tors Present5 Number of Emplo"ees Present

KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK

Others Present5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK Topi s 8is ussed5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKK Remember @ An emplo"ee will better understand and retain a safet" message if "ou both show and tell the person& 3ead b" E,ample& KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKK !ignature Position 8ate (n attendan e at this meeting were5 KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK
YOUR COMPANY NAME

Main Offi e @ Original /ield

YOUR COMPANY NAME

@#

FIRST AI3 5 8LOO38ORNE *AT+OGENS The following are highlights of a Cloodborne Pathogens Program& Please refer to Corporate !afet" E %ealth Consultants) ,loodborne Pathogens Man"al for details on implementing a omplete program& Our ompan" will provide first aid supplies at ea h wor# lo ation and all personnel are to #now pro edures to follow in ase of an emergen "& 0& -& 9& Report all in$uries immediatel"' no matter how minor' to "our foreman and7or $obsite offi e& Emergen " phone numbers for fire' poli e and ambulan e will be posted& Please note that if an" emplo"ee renders first aid or uses a first aid #it to assist a o@wor#er =although su h a tion is not re+uired b" an"one)s duties> we would view this a tivit" as a 24ood !amaritan2 a t& Note5 /irst aid #its are to be approved b" a li ensed medi al do tor& (f there is a potential for death or serious ph"si al harm =i&e&5 stoppage of breathing and7or severe bleeding> and appropriate medi al attention is not available within 9@: minutes' then an emplo"er is re+uired to have a trained first aider on ea h shift&

:&

The atta hed draft poli " statement is to be used b" those who do not e,pe t an emplo"ee to assist o@wor#ers and who meet the 9@: minute medi al response re+uirement&

YOUR COMPANY NAME

To5 /rom5 !ub$e t5

All Emplo"ees

Assisting Co@For#ers (n Medi al Emergen ies

The poli " of this organi*ation is that we do not e,pe t' as part of an" emplo"ee)s duties' to assist a o@wor#er in a medi al emergen "& !in e appropriate medi al assistan e is available within a reasonable time b" alling the phone number posted at the $ob@site' emplo"ees are not re+uired to assist o@wor#ers& The use of the /irst Aid Iits that ma" be available within our organi*ation are for self@ help& That is' an emplo"ee who is in$ured ma" use the materials in the first aid #it for self@ administration& Please note that if an emplo"ee uses a first aid #it to assist a o@wor#er =although su h a tion is not re+uired b" an"one)s duties> we would view this a tivit" as a 24ood !amaritan2 a t&

YOUR COMPANY NAME

Che"'list For Re)ie(i g 8loo!%or e *athoge s *rograms For *rote"tio Of Collateral 3&ty First Ai!ers KKKKKKKKKK KKKKKKKKKK KKKKKKKKKK KKKKKKKKKK KKKKKKKKKK KKKKKKKKKK KKKKKKKKKK %as the %epatitis C La ination series =%CL> been offeredR (f the ompan" wishes to offer the %CL on a post first aid in ident basis' do the" meet all re+uirementsR %ave the re+uirements of Paragraph =d> of the standard been metR =This in ludes among other things5 PPE' Faste 8isposal and Cleanup>& Fas an e,posure determination performedR 8o the" have omplete training and medi al re ordsR 8oes the fa ilit" have a written e,posure ontrol planR %ave the proper follow up pro edures been established for e,posure in identsR

YOUR COMPANY NAME

S(&

!UPER(NTEN8ENT7/OREMEN !E3/@(N!PECT(ON (t is our poli " to redu e and eliminate ha*ard e,posures that an lead to emplo"ee in$ur" or propert" damage& !elf@inspe tion is one wa" to provide a safe wor#pla e for our emplo"ees& !uperintendents and foremen are re+uired to ma#e dail" visual inspe tions of their wor# areas and to test all e+uipment safet" devi es prior to the start of the wor# shift& Corre tive a tion must be provided immediatel" if an" ha*ards e,ist rear if an" safet" devi es are not fun tioning properl"& (f the e+uipment an not be repaired before being used so that it is safe to use' then it must be removed from servi e& !uperintendents =or other assigned management representatives> are re+uired to omplete a wee#l" inspe tion of the wor# site using the 24eneral (nspe tion /orm2 furnished b" our ompan"& All wor# areas in luding offi e areas will be inspe ted using this form& (f an" ha*ardous onditions are noted' orre tive a tion must be ta#en& (f the orre tive a tion is be"ond our authorit" and7or apabilit"' #eep all emplo"ees awa" from the ha*ardous ondition until it is orre ted or ontrolled& Notif" the pro$e t manager in writing to re+uest orre tive a tion& !uperintendents are e,pe ted to follow up on reported ha*ards to ma#e sure the" have been eliminated or ontrolled& All ompleted forms' signed and dated b" the superintendent where indi ated must be turned into the home offi e on or before the last wor# da" of ea h wee#& 3a # of appropriate inspe tions as well as falsifi ation of inspe tion forms is a violation of ompan" pro edure and ma" be a ivil and7or riminal violation of federal and7or state laws and7or regulations&

YOUR COMPANY NAME

3AILY >O8SITE SAFETY C+ECALIST Bob 3o ation5KKKKKKKKKKKKKKKKKKKKKBob O5KKKKKKKKKKKKKKKKKKK !igned C"5KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 8ate5 KKKKKKKKKKKKKKKK Performed b"5KKKKKKKKKKKKKKKKKKKKKKK A T A eptable U T Una eptable NA T Not Appli able

( understand that falsifi ation of this do ument ma" be a violation of federal' state and lo al laws& The ompleted form should be turned into the home offi e b" the end of ea h wee#& 3es"riptio A3MINISTRATI:E 0& -& 9& Bobsite !afet" E %ealth Poster 8ispla"ed O!%A 3og Maintained Emergen " Phone 3ist Posted Stat&s 3ate A%ate!

EM*LOYEE TRAINING 0& -& 9& :& ;& 1& <& ?& .& 06& All Emplo"ees Re eived %a*ard (dentifi ation Training All Emplo"ees Trained (n %a*Com All Emplo"ees Trained (n Appropriate /ire /ighting Response All Emplo"ees Trained in Eva uation Pro edures 3o #out7Tagout Pro edures /or Appropriate Emplo"ees Confined !pa e Training /or Appropriate Emplo"ees !tairwa" And 3adder Training /all Prote tion Training E+uipment Operator Training %a*ard !pe ifi Training =3EA8 ' A!CE!TO! 'ETC&>

SAFETY MEETINGS 0& -& 9& %eld Fee#l" !igned C" All (n Attendan e Cover Topi s Pertaining To Your Bob

YOUR COMPANY NAME

3es"riptio +ABAR3 COMMUNICATION 0& -& 9& :& ;& Fritten Program On !ite Chemi al (nventor" 3ist Posted M!8! !heets On /ile All 8rums E Containers 3abeled Emplo"ees Trained

Stat&s 3ate A%ate!

ELECTRICAL 0& -& 9& 4/C( (n Pla e Ele tri Cords (nspe ted @ No !pli es (n Cord Ele tri Power Tools (nspe ted

*ERSONAL *ROTECTI:E ECUI*MENT 0& -& 9& :& ;& 1& <& %ard %ats For# Area Prote tion' !ignage' and Refle tive Lests For#ing Near Traffi E"e Prote tion @ Chipping' Curning' Con & Et & Ear Prote tion Personal /lotation 8evi es E 3ife Rings For#ing Near Fater 4loves Used Proper For# !hoes =No !nea#ers or Open Toe !hoes>

TOOLS 0& -& 9& :& ;& 1& <& Tool Casings (n !afe Condition Firing /or All Power Tools (n !afe Condition Ele tri Tools 4rounded =Unless 8ouble (nsulated> E,tension Cords 4rounded And (n !afe Condition %ands Tools (n !afe Condition Tools !tored (n 8esignated 3o ation 3adders /ree Of Cra #s E 8amage

YOUR COMPANY NAME

3es"riptio CONFINE3 S*ACE 0& -& 9& :& Air Monitoring Power Lentilation !tand C"7Res ue Trained Person E+uipment E Ele tri al 3o #out7Tagout

Stat&s 3ate A%ate!

TRENC+ING & E@CA:ATION 0& -& 9& :& ;& !heeting Or Proper !loping Over ; /eet 3adder Ever" -; /eet Utilit" Compan" Notified (f Ne essar" Air Monitored (n Tren h E, avated Material !tored Min& - /eet /rom Tren h

SCAFFOL3ING O:ER -0 FEET 0& -& 9& :& ;& Top' Midrail E Toe boards Mudsills !upported On !olid Case Cross Cra ing Properl" (nstalled /ull" Plan#ed E Proper Overla"

LA33ERS 0& -& 9& :& ;& E,tended 91 (n hes Above 3anding !e ured @ Tied Off !olid Rungs @ No Cra #s (n Rungs Proper Angle @ 07: For#ing 3ength Of 3adder Provided At Crea#s (n Elevations 0.2 Or More

CRANES 0& -& 9& :& ;& 1& <& /ire E,tinguisher (n Cab Coom Angle (ndi ators For#ing Properl" 3oad Capa it" Charts (n Cab (nstru tions E Farnings Posted Annual (nspe tions On !ite %and !ignal Chart (n Lisible Liew Of Rigger - /eet Radius Carri ade Around !wing Radius Of Crane

YOUR COMPANY NAME

3es"riptio MAC+INERY 0& -& 9& :& ;& 1& <& ?& Point Of Operation 4uards (n Pla e Pulle" Celt Assemblies 4uarded 4ear Assemblies 4uarded !hafts 4uarded Are There An" Oil 3ea#s Two %and Controls For#ing Properl" (s Ele tri Firing (n !afe Condition 3o #out Poli " E Tag Pro edures Used

Stat&s 3ate A%ate!

DEL3ING ECUI*MENT AN3 O*ERATIONS 0& -& 9& :& ;& 1& O,"gen E A et"lene Felding E+uipment E+uipped Fith /lash Arrestors Compressed 4as C"linders !e ured Upright E Capped Fhen (n !torage C"linders Mounted On A Card Or !e ured (n An Upright Position (s O,"gen !eparated /rom /lammables And Combustibles C" At 3east -6) Or A ;) %igh Non@ Combustible Fall Fhen !tored 4as %oses And 4auges (n !afe Condition Proper E"e Prote tion Available And Used

FIRE *ROTECTION 0& -& 9& :& ;& 1& <& E,tinguishers Charged And A essible (f Available' !tandpipes' %oses' !prin#ler %eads And Lalves (n !afe Condition And A essible !tairs Clear And (n !afe Condition %ollow Pan !tairwa"s /illed E,its And E,it Paths Clearl" Mar#ed /lammables Properl" !tored =4asoline' Paint !olvents' A et"lene' Propane Tan#s' Et &> Eva uation Plan As Re+uired C" O!%A Available

YOUR COMPANY NAME

3es"riptio +OUSEAEE*ING 0& -& 9& :& ;& Aisles' !tairs E /loor /ree Of Obstru tions Materials !upplies !tored And Piled (n 8esignated Areas Regular Removal Of Trash E 8ebris Are All For# Areas 3ighted For# Areas Neat E Orderl"

Stat&s 3ate A%ate!

FALL *ROTECTION 0& -& 9& :& Perimeter Prote tion Top' Midrail E Toe board' Nets E7Or !tati 3ines /ull Arrest !"stems =%arness> On All Emplo"ees E,posed To /alls /loor Openings Properl" Prote ted

MATERIAL +AN3LING ECUI*MENT 0& -& 9& :& ;& 1& Carts (n !afe Condition Cart Fheels /ree E Rolling !moothl" %oist Opening E+uipped Fith Removable Railing %oist Cables E %oo#s (nspe ted Materials !e ured !ta #ed Emplo"ees Trained E7Or Certified To Operate E+uipment

RES*IRATORY *ROTECTION 0& -& 9& :& ;& 1& <& Respirators sele ted on the basis of ha*ards =spe ifi substan e and on entration> to whi h the wor#er is e,posed& E,posure assessment performed to ensure ma,imum use on entration of a respirator is not e, eeded& Emplo"ees instru ted and trained in proper use of respirators& Respirators regularl" leaned and disinfe ted& Respirators stored in a lean and sanitar" lo ation& Respirators inspe ted during leaning for worn or deteriorated parts& 8etermine if emplo"ees are ph"si all" able to perform the wor# and use the respirator" e+uipment& 8etermined b" a ph"si ian&

(t is ver" important to understand that "ou are responsible for all 2items2 and se tions of -. C/R 0.-1&

YOUR COMPANY NAME

MANAGEMENT AU3IT C+ECALIST Yes A& Ma ageme t Commitme t a ! Lea!ership 0& -& 9& :& ;& 1& C& Poli " statement5 goals established' issued and ommuni ated to emplo"ees Program reviewed annuall" Parti ipation in safet" meetings' inspe tions' agenda items in meetings Commitment of resour es is ade+uate !afet" rules and pro edures in orporated into the site operations Management observes safet" rules KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK No

Assig me t of Respo si%ilities 0& -& 9& !afet" designee on site' #nowledgeable and a ountable !upervisors =in luding foremen> safet" and health responsibilities understood Emplo"ees adhere to safet" rules KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK

C&

I!e tifi"atio a ! Co trol of +a?ar!s 0& -& 9& :& ;& 1& Periodi site safet" inspe tion program involves supervisors Prevention ontrols in pla e =PPE' maintenan e' and engineering ontrols' et &> A tion ta#en to address ha*ards !afet" ommittee where appropriate Te hni al referen es available Enfor ement pro edures b" management KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK

8&

Trai i g a ! E!&"atio 0& -& 9& !upervisors provided with basi training !pe iali*ed training provided when needed Emplo"ee training program e,ists' is ongoing and is effe tive KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK

E&

Re"or!'eepi g a ! +a?ar! A alysis 0& -& 9& Re ords maintained of emplo"ee illnesses' in$uries' and posted KKKKK KKKKK A ident investigations performed' determine auses and proposed orre tive a tion KKKKK KKKKK (n$uries' near misses and illnesses are evaluated for trends' similar auses and orre tive a tion initiated KKKKK KKKKK

YOUR COMPANY NAME

Yes /& First Ai! a ! me!i"al Assista "e 0& -& 9& /irst aid supplies and medi al servi es available Emplo"ees informed of medi al results Emergen " pro edures and training where ne essar"

No

KKKKK KKKKK KKKKK KKKKK KKKKK KKKKK

To determine the effe tiveness of our ompan")s safet" and health program' our safet" dire tor will omplete the self@evaluation re ommended b" O!%A& This information will be rated b" the home offi e and #ept on file& !uperintendent7foremen will be provided with a op" and are e,pe ted to orre t an" defi ien ies& Remember' the O!%A inspe tion an result in a review of defi ien ies' and where onditions warrant' a itation for one or more of the above standards& Annual ompletion of the self@ evaluation is re+uired b" our ompan"&

YOUR COMPANY NAME

S(((&

PROBECT !(TE !PEC(/(C !A/ETY PRO4RAM The owner' onstru tion manager or general ontra tor will ondu t a pre@bid meeting to dis uss and e,plain the pro$e t site safet" program& This program should in lude at minimum the following5 A& *&rpose Of The *la The purpose of this Constru tion !afet" and %ealth Plan is to establish pra ti es and pro edures to prote t onstru tion personnel and others during onstru tion on the site& C& Appli"a%ility The provisions of the plan are mandator" for ontra tors and sub ontra tors engaged in an" on@site onstru tion a tivities& C& Site 3es"riptio 0& -& 9& 8& Proposed Pro$e t !ite 8es ription and %istor" Ris# Evaluation

Emerge "y I formatio 0& Emergen " Conta ts N Poli e N /ire N Ambulan e

E&

Site Safety Dor' *la 0& -& 9& :& ;& 1& 8esignation of !ite !afet" Coordinator Re ord#eeping Responsibilities /irst Aid7Cloodborne Pathogens E, avation7Tren hing 8emolition Responsibilit" for /all Prote tion N 4uard Rails =top rail' mid rail' toe boards> N ! affolds N 3adders N !afet" Nets

YOUR COMPANY NAME

<& ?&

Responsibilit" for 3ead 8etermination and Abatement Personal Prote tive E+uipment N %ard %ats N 4loves N !afet" 4lasses74oggles N For# Coots N !afet" Celts and 3an"ards /ire Prote tion and Prevention N /ire E,tinguishers N !torage and Use of /lammable and Combustible 3i+uids Material %andling' !torage Use and 8isposal Tools @ %and Power Felding and Cutting N !torage and Use of O,"gen and A et"lene Tan#s Ele tri al N 4round /ault Cir uit (nterrupters %eav" E+uipment7/or# 3ifts Respirator" Prote tion Program

.&

06& 00& 0-& 09& 0:& 0;& /&

Safety Committee Meeti gs EMo thlyF N Evaluation of Program N Address !afet" Re ommendations7%a*ards N Review and 8is uss Up oming Constru tion

YOUR COMPANY NAME

S(L& 8RU4 AN8 A3CO%O3 PRO4RAM *oli"y Stateme t An" emplo"ee aught possessing or using drugs or oming to wor# under the influen e of drugs will be dis harged with pre$udi e or severel" dis iplined& An" emplo"ee who uses drugs on the $ob or wor#s under the influen e of drugs endangers himself7herself and other wor#ers& This ompan" will not tolerate drug use on the $ob& 8rug use is the dire t ause of thousands of deaths ever" "ear& 8rug use auses permanent brain damage and birth defe ts and usuall" leads to addi tion& (ntravenous drug use transmits A(8!' whi h is in urable and invariabl" fatal' as well as other serious diseases& Possession of drugs' no matter how small an amount' is a rime' punishable b" in ar eration& !ales of drugs or possession of a signifi ant +uantit" of drugs is a felon"&

YOUR COMPANY NAME

SL&

%APAR8 !PEC(/(C PO3(C(E! To further ensure the safet" of our emplo"ees and ensure omplian e with spe ifi re+uirements that ma" be mandated under lo al' state or federal regulations' YOUR COMPANY NAME has atta hed the following safet" and health plans' designed to address spe ifi ha*ards in the wor#pla e& These plans will be updated periodi all" as indi ated b" law and hanges in the operation5 A88 NEF =UP8ATE 3OLE33 %APAR8 !PEC(/(C PO3(C(E!> /A33 PROTECT(ON RE!(8ENT(A3 /A33 PROTECT(ON 3A88ER! 7 !TA(RFAY! TRENC%(N4 7 ESCALAT(ON E3ECTR(CA3 !A/ETY CRANE! AN8 R(44(N4 !CA//O38! FE38(N4 RE!P(RATORY PROTECT(ON POFER TOO3! PPE %APAR8 COMMUN(CAT(ON MATER(A3 %AN83(N4 OCCUPAT(ONA3 %EA3T%

ATTAC%MENT! 3OLE33 !A/ETY TOO3 COS !A/ETY TA3I!

YOUR COMPANY NAME

SU*ER:ISOR$S IN:ESTIGATION & RE*ORT OF INCI3ENT

YOUR COMPANY NAME

SU*ER:ISOR 5 3O NOT DRITE 8ELOD T+IS LINE 8ate Report Re eived b" !afet" Manager KKKKKKKKKKKKKKKKKKKKKKKKKK 8ate forwarded to %R KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK C@- CompletedKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 3ovell Notified KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK 3ovell !afet" Management Co&' 33CJ 0-; Maiden 3ane' NYC 0669?

O of 8a"s 3ost5 KKKKKKKKKKKKKKKKKKKKKKKKKKKK O!%A 3O4 OKKKKKKKKKKKKKKKKKKKKKKKKKK O!%A notifiedR =fatalit"' 9 hospitali*ations>5KKKKK C+ECA +ERE IF CONTINUE3 ON A33ITIONAL *AGES

ACCIDENT REPORT To Be Completed at Accident Scene Drivers Name ______________________________________ Plate Num er _______________________________________ GENERAL INSTRUCTIONS ! !. '. "#$P at the scene as %uickl& as possi le.

3.

,**1D4N# "*4N4 Instructions for Accident Dia ram

*.

$#<4R ;4<1*:4"

Driver ;eh. B' _________________________________ ,ddress______________________________________ Drivers :icense No. ____________________________

8ill dotted lines to correspond with road at accident site. "how position of all vehicles/ pedestrians etc. as follows: 9our vehicle

$#<4R $**(P,N#": $ther vehicle=s> successivel&. Pedestrian #raffic "ign @ A num ered ,. #raffic "ignal =indicate t&pe> 3. Name ______________ ,ddress ______________ Name ______________ ,ddress ______________

Protect the scene. (se warning devices. )et help from &standers. #urn off all engines. No smoking. )uard against fire. *heck for fuel or cargo leaks. ,ssist in-ured persons. Dont move them unless a solutel& necessar&. "ummon am ulance if needed. )et help. (se near & phone or send relia le passer &. Notif& terminal/ police and insurance compan& as instructed. )ive location and nature of accident accuratel&. 1dentif& &ourself and compan&. "how license/ registration and insurance card on re%uest. 34 *$(R#4$(". 5ake no statement a out accident e6cept to police or compan& and insurance compan& representative. 8ill out and check all applica le information on this form 348$R4 9$( :4,;4 #<4 "*4N4. D,#4/ #154/ P:,*4

$CN4R =18 N$# #<4 DR1;4R>: +. .. ,. Name ___________________________________

,ddress _____________________________________ ;4<1*:4: 5ake D 5odel _________________________________ #ag B and "tate_______________________________________ 1nsurance *o. ______________Polic& B_____________ 1NE(R14": NameD 1n-ur&_________________________________

0. 2.

7. ,.

Chere taken__________________________________ Date ________________#ime_________,5_____ P5______ 1n ________________________________________________ =*it& or #own> =*ount&> ="tate> $n________________________________________________ ="treet or <ighwa&> ,t_________________________________________________ ="treet ,ddress or 1ntersection> Distance and Direction from:_____________________________ $pen *ountr& Residential 3usiness?"hopping 5anufacturing?1ndustrial Not at 1ntersection "treet 1ntersection Drive or ,lle& *rosswalk #raffic *ontrol "top "ign :ight 9ield 3ridge?$verpass (nderpass Private propert& $ther off?street 9our ;eh. =B!> ________________ Direction of #ravel: $ther =B'> ______________________ $#<4R $**(P,N#": ,. 3. Name ______________ ,ddress _____________ Name ______________ ,ddress _____________ 1nsurance *o. ______________Polic& B____________ ____________________________________________ Driver ;eh. B+ ________________________________ ,ddress_____________________________________ Drivers :icense No. ___________________________

$pen =Descri e>__________________________________ $CN4R =18 N$# #<4 DR1;4R>: ,. $ther: _____________ ,ddress _____________________________________ Name ___________________________________ __________________________________________________ __________________________________________________ __________________________________________________

__________________________________________________

). PR$P4R#9 D,5,)4 Descri e damage to other vehicle: _________________ _____________________________________________ _____________________________________________ Descri e damage to &our vehicle: _________________ _____________________________________________ _____________________________________________

;4<1*:4: 5ake D 5odel ________________________________ #ag B and "tate_________________________________ 1nsurance *o. ______________Polic& B____________ 1NE(R14": NameD 1n-ur&_________________________________ Chere taken__________________________________ 1nsurance *o. ______________Polic& B____________

YOUR COMPANY NAME

D. P4D4"#R1,N ,*#1$N D4"*R134 ___________________________________ _____________________________________________ _____________________________________________ 1n-uredF______________________________________ _____________________________________________ _____________________________________________ 4. C1#N4""

*argo Damage: _______________________________ _____________________________________________ _____________________________________________

Persons seeing the accident will e of service to our driver & giving their names and addresses. N,54_______________________________________ ,DDR4"" ____________________ Phone__________ N,54_______________________________________ ,DDR4"" ____________________ Phone__________ :icense num er and descriptions of first vehicles at scene. _____________________________________________ _____________________________________________ 1nvestigating $fficer=s> Name_________________________

$ther Propert& Damage:_________________________ _____________________________________________ _____________________________________________ _____________________________________________ 1. C<,# <,PP4N4D <ow fast were &ou goingF ______5P< <ow far did &our at vehicle go after 1mpactF_____8t.

,t what distance did &ou first see dangerF _____8t. Chat was &our speed impaceF _____5P<

3adge___________________ Dept._______________ Police ReportB ________________________________ Name_________________________ 3adge___________________ Dept._______________ *itation: 9ou______________ $ther_______________ *itation: 9ou______________ $ther_______________ 8. R$,DC,9 *$ND1#1$N" ,ND *$N#R$:" Not Divided Divided :imited ,ccess No. of :anes ' + . 0 2 _______________________ ="pecif&> Ceather ____________ *ondition of road

Descri e in &our own words the circumstances of the accident: _____________________________________________ _____________________________________________ _____________________________________________ N$#4: #his report should e handwritten at scene. #urned into 3ranch/ signed and sent to 8leet 5anagement within '. hours. Driver________________________________________ "ignature _____________________________________________

#ime _______________ Dr& Cet "now #raffic "mooth $ther

1ce 5udd& $il&

YOUR COMPANY NAME