Instructions

All blocks must be completed or addressed. Enter an "N/A" in blocks or
sections where the information does not apply. Enter an "Unknown" in
blocks or sections where the information is not known.

**1. ORGANIZATION/AGENCY INFORMATION/POINT OF CONTACT**

Enter the month, day, year, and time. Use 24-hour (military) time, for
example, 0816 for 8:16 a.m. and 2115 for 9:15 p.m. Enter the name of the
individual filling out the form. This may be the dispatcher or an agency
submitter.

Enter the name of the agency/business/institution or organization who
has responsibility for the work/project, e.g., Acme Drilling Co., Field
Services, Cultural Resources.

Enter the name of the person at the agency/business/institution or
organization who is the point of contact for field workers and is
knowledgeable of their location. This individual may be contacted to
initiate emergency notifications. This name may be the same as the work
leader in the field.

**2. FIELD WORK INFORMATION**

Enter date when field work is to be started and to be completed on the
INL. Enter those times that are not part of the normal 4x10 work
schedule, Monday -- Thursday.

3.  **COMMUNICATION SOURCES**

Enter the name of the person acting as the work leader for those
performing work in the field. Each work group shall have a designated
work leader who can be contacted in an emergency event. If there is only
one person doing the work, that individual's name will be listed as the
work leader. Enter the radio net or talk group name or alias for use in
contacting the field workers, e.g., F Net, "Ln/Crew." Enter the phone
number of phones used in the field, i.e., a cell phone or SMR phone
number. Enter the INL Paging System number of the work leader or
individual performing field work. Enter types and number(s) of any other
field communication equipment if not previously listed.

4.  **TRAINING INFORMATION**

If the answers are YES, this indicates the workers have been issued
security badges and have completed Blue Card/Orange Card training and
received an ordnance briefing. If the answers are NO, forward to the CFA
EM Planner. The Organization/Agency POC will be notified of this
requirement.

5.  **WORK ACTIVITY INFORMATION (optional)**

Enter a brief description of the type of field work being performed on
the INL, e.g., well drilling, environmental study, air monitoring. This
information is optional.

6.  **SPECIFIC WORK LOCATION**

Record the grid number where the work will be performed, using the INL
Grid Map as reference. Use the INL Grid Map Link to determine the grid
numbers. Record an estimated distance of the work from the affected
facilities.

7.  **VEHICLE INFORMATION (optional)**

Record the type, make, and color of the vehicle being used by the field
workers. This information is optional.

<table>
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<col style="width: 8%" />
<col style="width: 1%" />
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="48"><p><em><strong>Submit completed form to the Central
Facilities Area (CFA) Alarm Center Dispatcher by one of the following
methods:</strong></em></p>
<p><em><strong>FAX 526-6791, Mail Stop 4108, or Telephone 526-2212.
Instructions on page 1.</strong></em></p></td>
</tr>
<tr class="even">
<td colspan="27" rowspan="4"><ol type="1">
<li><p><strong>ORGANIZATION/ AGENCY INFORMATION/POINT OF
CONTACT:</strong></p></li>
</ol></td>
<td colspan="20"></td>
<td rowspan="2"></td>
</tr>
<tr class="odd">
<td>Date:</td>
<td colspan="10">     </td>
<td colspan="3">Time:</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="6">Recorded by:</td>
<td colspan="13">     </td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="20"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4">Submitter’s Name:</td>
<td colspan="23">     </td>
<td colspan="9">Representing (Org):</td>
<td colspan="11">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="18">Organization Point(s) of Contact (POC) Name(s):</td>
<td colspan="29">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="9">POC Work Phone Number:</td>
<td colspan="5">     </td>
<td colspan="12">POC Other Phone/Radio Net:</td>
<td colspan="6">     </td>
<td colspan="11">POC INL Pager:</td>
<td colspan="4">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="48"></td>
</tr>
<tr class="even">
<td colspan="48"><strong>2. FIELD WORK INFORMATION:</strong></td>
</tr>
<tr class="odd">
<td colspan="48">Work Schedule</td>
</tr>
<tr class="even">
<td rowspan="3"></td>
<td colspan="2">Start Date:</td>
<td colspan="10">     </td>
<td></td>
<td colspan="3" rowspan="3"></td>
<td colspan="5">Start Date:</td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="3" rowspan="3"></td>
<td colspan="5">Start Date:</td>
<td colspan="7">     </td>
<td></td>
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2">End Date:</td>
<td colspan="10">     </td>
<td></td>
<td colspan="5">End Date:</td>
<td colspan="7">     </td>
<td colspan="2"></td>
<td colspan="5">End Date:</td>
<td colspan="7">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td colspan="14"></td>
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="6">24-Hour operation?</td>
<td colspan="6"> YES</td>
<td colspan="9"> NO</td>
<td colspan="4"></td>
<td colspan="10">Work on back shifts?</td>
<td colspan="7"> YES</td>
<td colspan="6"> NO</td>
</tr>
<tr class="even">
<td colspan="7">Expected work hours:</td>
<td colspan="40">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="48"></td>
</tr>
<tr class="even">
<td colspan="48"><strong>3. COMMUNICATION SOURCES:</strong></td>
</tr>
<tr class="odd">
<td colspan="6">Work Leader name:</td>
<td colspan="20">     </td>
<td colspan="14">Number of workers in group:</td>
<td colspan="7">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="6">Radio net/talk group:</td>
<td colspan="9">     </td>
<td colspan="8">Field phone number:</td>
<td colspan="10">     </td>
<td colspan="11">INL pager number:</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11">Other communications methods:</td>
<td colspan="36">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="48"></td>
</tr>
<tr class="odd">
<td colspan="48"><strong>4. TRAINING INFORMATION:</strong></td>
</tr>
<tr class="even">
<td colspan="48">Have all workers received: (If answer is NO see
instructions)</td>
</tr>
<tr class="odd">
<td colspan="14">Security Badge?</td>
<td colspan="12"> YES</td>
<td colspan="22"> NO</td>
</tr>
<tr class="even">
<td colspan="14">Current blue card/orange card training?</td>
<td colspan="12"> YES</td>
<td colspan="22"> NO</td>
</tr>
<tr class="odd">
<td colspan="14">Ordnance briefing?</td>
<td colspan="12"> YES</td>
<td colspan="22"> NO</td>
</tr>
<tr class="even">
<td colspan="47"><strong>5</strong><strong>. WORK ACTIVITY
INFORMATION:</strong> <em><strong>(optional)</strong></em></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="46"><strong>     </strong></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="46"><strong>     </strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="48"></td>
</tr>
<tr class="even">
<td colspan="48"><strong>6. SPECIFIC WORK LOCATION:</strong></td>
</tr>
<tr class="odd">
<td colspan="8">INL grid map number:</td>
<td colspan="11">     </td>
<td colspan="13">INL Grid Map Link:</td>
<td colspan="16"><a
href="../../../../../../../../projects/ep/Field%20Work%20Form">\\Fsisc1\projects\ep\Field
Work Form</a></td>
</tr>
<tr class="even">
<td colspan="10">Is work area within 3 miles of:</td>
<td colspan="6"> TAN</td>
<td colspan="4"> NRF</td>
<td colspan="4"> INTEC</td>
<td colspan="4"> RTC</td>
<td colspan="9"> RWMC</td>
<td colspan="8"> FMC</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="5">If YES, how close?</td>
<td colspan="42">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="48"></td>
</tr>
<tr class="odd">
<td colspan="48"><strong>7. VEHICLE INFORMATION:</strong>
<em><strong>(optional)</strong></em></td>
</tr>
<tr class="even">
<td colspan="2">Make:</td>
<td colspan="11">     </td>
<td colspan="9">Type:</td>
<td colspan="8">     </td>
<td colspan="10">Color:</td>
<td colspan="7">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="48"></td>
</tr>
</tbody>
</table>