<table>
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="8">ILR/Work Order #:      </td>
<td colspan="13">Tracking #:      </td>
<td colspan="6">Account # : 7610</td>
</tr>
<tr class="even">
<td colspan="15"><p id="work-requester" class="heading">Work Requester:
    </p></td>
<td colspan="6"><p id="deptgroup" class="heading">Dept/Group:
     </p></td>
<td colspan="3"><p id="ext." class="heading">Ext.     </p></td>
<td colspan="3"><p id="date" class="heading">Date:      </p></td>
</tr>
<tr class="odd">
<td colspan="24"><p
id="other-contact-person-if-different-from-requester"
class="heading">Other Contact Person (If different from Requester) :
     </p></td>
<td colspan="3"><p id="ext.-1" class="heading">Ext.     </p></td>
</tr>
<tr class="even">
<td colspan="27"><strong><u>Description of Work:</u></strong>     </td>
</tr>
<tr class="odd">
<td colspan="27">     </td>
</tr>
<tr class="even">
<td colspan="27">     </td>
</tr>
<tr class="odd">
<td colspan="27">     </td>
</tr>
<tr class="even">
<td colspan="27">     </td>
</tr>
<tr class="odd">
<td colspan="5">Building:      </td>
<td colspan="5">Room:      </td>
<td colspan="10">Equipment:      </td>
<td colspan="7">Start Date:      </td>
</tr>
<tr class="even">
<td colspan="27"><p id="hazard-analysis" class="heading">HAZARD
ANALYSIS</p></td>
</tr>
<tr class="odd">
<td colspan="27"><strong>RADIATION CONCERNS</strong></td>
</tr>
<tr class="even">
<td colspan="4"> NONE</td>
<td colspan="5"> Activation</td>
<td colspan="10"> Airborne</td>
<td colspan="6"> Contamination</td>
<td colspan="2"> Radiation</td>
</tr>
<tr class="odd">
<td colspan="27"> Other:      </td>
</tr>
<tr class="even">
<td colspan="27"><p id="safety-concerns-none" class="heading">SAFETY
CONCERNS: NONE</p></td>
</tr>
<tr class="odd">
<td colspan="8"> Adding/Removing Walls or Roof</td>
<td colspan="13"> Excavation (ES&amp;H 1.18.0)</td>
<td colspan="6"> Noise</td>
</tr>
<tr class="even">
<td colspan="8"> Asbestos</td>
<td colspan="13"> Flammable (ES&amp;H 4.10.2)</td>
<td colspan="6"> Non-ionizing Radiation</td>
</tr>
<tr class="odd">
<td colspan="8"> Biohazard</td>
<td colspan="13"> Fumes/Mist/Dust</td>
<td colspan="6"> Oxygen Deficiency</td>
</tr>
<tr class="even">
<td colspan="8"> Chemicals</td>
<td colspan="13"> Heat/Cold Stress (ES&amp;H 2.5.0)</td>
<td colspan="6"> Penetrating Fire Wall</td>
</tr>
<tr class="odd">
<td colspan="8"> Confined Space (ES&amp;H 2.2.4)</td>
<td colspan="13">Hydraulic</td>
<td colspan="6"> Pressurizing Systems (ES&amp;H 1.4.1)</td>
</tr>
<tr class="even">
<td colspan="8"> Corrosive</td>
<td colspan="13"> Lasers (ES&amp;H 2.3.1)</td>
<td colspan="6"> Rigging/Critical Lift (ES&amp;H 1.6.0)</td>
</tr>
<tr class="odd">
<td colspan="8"> Cryogenics (ES&amp;H 5.1.0)</td>
<td colspan="13"> Lead</td>
<td colspan="6"> Toxic</td>
</tr>
<tr class="even">
<td colspan="8"> Electrical (ES&amp;H 1.5.0)</td>
<td colspan="13"> Magnetic Field</td>
<td colspan="6"> Vacuum</td>
</tr>
<tr class="odd">
<td colspan="8"> Elevated Work</td>
<td colspan="13"> Material Handling (ES&amp;H 1.6.0)</td>
<td colspan="6"> Other      </td>
</tr>
<tr class="even">
<td colspan="27"><p id="environmental-concerns-none"
class="heading">ENVIRONMENTAL CONCERNS: NONE</p></td>
</tr>
<tr class="odd">
<td colspan="12"><p> Haz/Rad Material will be released to the air via
a</p>
<p>new/modified ventilation system, hood or stack.</p>
<p>(ES&amp;H 6.1.4 and 6.1.5) Notify Project Engineer, E.P.O.
(ES&amp;H</p>
<p>Services)</p></td>
<td colspan="15"><p> New Haz/Rad Material will be released via the
liquid</p>
<p>effluent system to the sewage system or an impoundment</p>
<p>(ES&amp;H 6.1.2 and 6.1.3). Notify Regulatory Compliance Engineer,
E.P.O.</p>
<p>(ES&amp;H Services) for permit</p></td>
</tr>
<tr class="even">
<td colspan="12"> Acutely hazardous chemical</td>
<td colspan="15"> Other      </td>
</tr>
<tr class="odd">
<td colspan="27"><strong>WASTE GENERATED</strong></td>
</tr>
<tr class="even">
<td> NONE</td>
<td colspan="6"> Clean Waste</td>
<td colspan="2"> PCB</td>
<td colspan="8"> Hazardous Waste</td>
<td colspan="8"> Radioactive Waste</td>
<td colspan="2"> Mixed Waste</td>
</tr>
<tr class="odd">
<td colspan="27"><strong>WORK CONTROLS</strong></td>
</tr>
<tr class="even">
<td colspan="6"> NONE</td>
<td colspan="7"> Containment</td>
<td colspan="9"> IH Survey</td>
<td colspan="5"> Scaffolding (Req. Inspection)</td>
</tr>
<tr class="odd">
<td colspan="6"> Back-up Person/Watch</td>
<td colspan="7"> Exhaust Ventilation</td>
<td colspan="9"> Lockout/Tagout (ES&amp;H 1.5.1)</td>
<td colspan="5"> Time Limit</td>
</tr>
<tr class="even">
<td colspan="6"> Barricades</td>
<td colspan="7"> HP Coverage</td>
<td colspan="9"> Postings/Warning Signs</td>
<td colspan="5"> Other Terminate wires</td>
</tr>
<tr class="odd">
<td colspan="27"><strong>WORK PRACTICE PROTECTIVE
EQUIPMENT</strong></td>
</tr>
<tr class="even">
<td colspan="6"> NONE</td>
<td colspan="7"> Ear Plugs</td>
<td colspan="5"> Gloves</td>
<td colspan="5"> Lab Coat</td>
<td colspan="4"> Safety Glasses</td>
</tr>
<tr class="odd">
<td colspan="6"> Coveralls</td>
<td colspan="7"> Ear Muffs</td>
<td colspan="5"> Goggles</td>
<td colspan="5"> Respirator</td>
<td colspan="4"> Safety Harness</td>
</tr>
<tr class="even">
<td colspan="6"> Disposable Clothing</td>
<td colspan="7"> Face Shield</td>
<td colspan="5"> Hard Hat</td>
<td colspan="5"> Shoe Covers</td>
<td colspan="4"> Safety Shoes</td>
</tr>
<tr class="odd">
<td colspan="27"><p id="permits-required" class="heading">PERMITS
REQUIRED</p></td>
</tr>
<tr class="even">
<td colspan="8"><p id="none" class="heading"> NONE</p></td>
<td colspan="11"><p id="diggingcore-drilling-esh-1.18.0"
class="heading"> Digging/Core Drilling (ES&amp;H 1.18.0)</p></td>
<td colspan="8"><p id="impair-fire-protection-sys.-esh-4.2.0"
class="heading"> Impair Fire Protection Sys. (ES&amp;H 4.2.0)</p></td>
</tr>
<tr class="odd">
<td colspan="8"> Confined Space Entry (ES&amp;H 2.2.4)</td>
<td colspan="11"> Electrical Working Hot (ES&amp;H 1.5.0)</td>
<td colspan="8"> Rad Work Permit (BNL RadCom Manual)</td>
</tr>
<tr class="even">
<td colspan="14"> Cutting/Welding (ES&amp;H 4.3.0)</td>
<td colspan="13"> Dept/Div Specific Permit      </td>
</tr>
<tr class="odd">
<td colspan="27"><strong>DOSIMETRY/MONITORING</strong></td>
</tr>
<tr class="even">
<td colspan="2"> NONE</td>
<td colspan="9"> Noise Survey/Dosimeter</td>
<td colspan="9"> Passive Vapor Monitor</td>
<td colspan="6"> Self-reading Dos.</td>
<td> TLD</td>
</tr>
<tr class="odd">
<td colspan="2"> Heat Stress Mon.</td>
<td colspan="9"> O<sub>2</sub>/Combustible Gas</td>
<td colspan="9"> Real Time Monitor</td>
<td colspan="6"> Sorbent Tube/Filter</td>
<td> Other</td>
</tr>
<tr class="even">
<td colspan="27"><p id="job-hazard-category" class="heading">JOB HAZARD
CATEGORY</p>
<p><strong>NOTE:</strong> Based on analysis above, the Walk-down Team
determines the job hazard category:</p></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>ES&amp;H Risk Level :</strong></td>
<td colspan="13"><blockquote>
<p> <strong>LOW</strong> <strong>MODERATE</strong>
<strong>HIGH</strong></p>
</blockquote></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Complexity Level :</strong></td>
<td colspan="13"><blockquote>
<p> <strong>LOW</strong> <strong>MODERATE</strong>
<strong>HIGH</strong></p>
</blockquote></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Work Coordination :</strong></td>
<td colspan="13"><blockquote>
<p> <strong>LOW</strong> <strong>MODERATE</strong>
<strong>HIGH</strong></p>
</blockquote></td>
<td colspan="11">Job Safety Analysis (JTA) Required? Yes No</td>
</tr>
</tbody>
</table>