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2 Organizational Chart
3 Risk Assessment
8 Resources
9 Auditing System
11 Contact Details
Company Name:
Address:
Client Name:
Circle/Cluster Work Location:
Description Of The Work :
Email ID’s and Contact numbers to be included in the organizational chart for each member.
Mandatory to mention person responsible for health and safety of your organization , with contact details.
3. Risk Assessment
If available - submit the same
(Is risk assessment carried out for all field activities ? -
If not, refer the following format
Risk assessment leader:
Risk assessment team members:
Date of risk assessment / review date:
Severity Index
RISK MATRIX
Very Likely - 5 5 10 15 20 25
PROBABILITY
Likely - 4 4 8 12 16 20
Possible - 3 3 6 9 12 15
Unlikely - 2 2 4 6 8 10
Very Unlikely- 1 1 2 3 4 5
1 2 3 4 5
Negligible Slight Moderate High Very High
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4. Work at Height Plan
2.
3.
4.
Type of tower(s)
Task
Hazards associated with W@H
Fall protection equipment required
Equipment provided to teams
Supervision process
Other Controls to ensure safety of teams
5. Standard Operating Procedures (Medical, Training, Equipment, etc)
Measures/Procedures/Requirements Schedule /
Responsibility (SPOC)
Physical & Psychological Fitness Describe the measures to be taken/procedures to be followed to ensure that the
workmen performing work at elevated heights are physically & psychologically fit
of Workmen Working At Height to perform the work:
Training Requirements for Workmen Define the training requirements / program / plan for workmen who will be working
Working at Height and other activities at elevated heights and other safety topics
Awareness and communication process What are different methodologies being followed for awareness and
for safety communication on safety
PPE / Fall protection equipment - List & describe the procedures/methods/requirements for ensuring that the fall
Inspection testing & maintenance. protection equipment is safe to use.
6.1. Personal Protective Equipment Requirements (These are the minimum requirements)
Hard Hat
Gum Boots
Safety Shoes
Gloves
Safety Goggles
Dust Mask
Hearing Protection
Reflective Jacket
Other
PPE Procurement Plan:
(How org identify PPE requirement for employees, what standard of the product being followed, distribution mechanism,
periodic inspection process, responsibilities of inspection, records of issuing PPEs, etc.)
7. Health and Safety Reporting System-
For Reporting of incident / safety hazards / unsafe activities / unsafe conditions
(Include flowchart of reporting system of your organization)
8. RESOURCES (MANPOWER)
1. H&S Coordinator
2. Manager
3. Engineer
4. Technician
5. Rigger
6. Helper
MATERIAL (TOOLS & EQUIPMENTS) SAFETY
Describe tools and tackles, lifting tackles, ropes, slings, pulleys, etc. in use by team and safety measures needed for it
1 Electrical tools
2 Hand tools
4 Ropes, pulleys
5 Others
9. Auditing and Inspection System
Number of first aid boxes carried by team (one box per team)
1. EHS Coordinator
2. HR
3. Head of Organisation
(MD/CEO..)
4. Other SPOC