(NAME OF COMPANY)

Contractor Health

and

Safety Plan (HASP) Template

Job Title

Building Number

Job/Req/PO No.

Contract No.

Signature/Date: Date:

Contractor Health and Safety Representative/Designee

Signature/Date: Date:

BNL Department/Division Work Control Manager/Coordinator

Signature/Date: Date:

BNL Safety Engineer

Signature/Date: Date:

BNL Contract Technical Representative

# Section 1: COMPLIANCE LETTER

######## COMPANY LETTERHEAD

Date:

Brookhaven National Laboratory\
Bldg.\
Upton, N.Y. 11973

Attn: *(Insert name of BNL contact)*

*(Insert title)*

Re: Contract No

Job Title:

Job No:

Bldg. No:

Dear: *(Insert name of BNL contact)*

In conformance with the requirements of the contract documents for the
above project, the following information is submitted on our company\'s
safety program:

-   Copy of the company's record of injuries and accidents (OSHA 300
    logs)

-   Insurance experience modification rate for the past two years

-   Environmental compliance records (if applicable) for past five
    years, including fines, Administrative Consent Orders, and Notices
    of Violations.

We understand that Brookhaven National Laboratory is an ISO 14001
Registered Organization. All work must conform to the applicable
requirements of this program***. (Insert Company Name)*** its employees
and subcontractors must follow the BNL requirements listed in its
Standards Based Management System (SBMS) <https://sbms.bnl.gov/>
pertaining to: [Integrated Safety
Management](https://sbms.bnl.gov/SBMSearch/ProgDesc/ISM/ISM_PD.cfm?ProgdescID=4)
(5 Core Functions), [Work Planning and Control for
Operations](https://sbms.bnl.gov/sbmsearch/subjarea/109/109_SA.cfm?parentID=109),
Emergency Response/Spill Response, Waste Management (radiological,
hazardous, mixed, medical, industrial), Chemical Handling and Use (RCRA,
OSHA), Land Use Restrictions (Wetlands, Pine Barrens, Endangered
Species), Liquid Effluents.

***(Insert Company Name)*** its employees and subcontractors must comply
with the applicable requirements established in the SBMS
<https://sbms.bnl.gov/>. Environment, Safety and Health Standards of the
SBMS are located at:
<https://sbms.bnl.gov/SBMSearch/LD/ld08/ld08t011.htm>

for review and use. Where the requirements specified in the BNL
Standards Manual and the SBMS exceed the requirements of the OSHA
standards, the BNL requirements must take precedence.

BNL must provide all appropriate permits required by these standards***.
(Insert Company Name)*** must verify that these permits are current for
the scope of work and updated, with appropriate approvals, to reflect
any changes to the scope of work.

This letter also certifies that ***(Insert Company Name)*** is aware of,
understands and must comply with the safety regulations of the OSHA
Standard 29 CFR 1926 and 29 CFR 1910.

In addition, ***(Insert Company Name)*** understands that the BNL ES&H
Standards Manual and the Standards Based Management System (SBMS) is
available, on line, for our review and use and we must comply with
applicable safety requirements for this project.

Yours truly,

Signature

Title

**(COMPANY LETTERHEAD)**

# Section 2: STATEMENT OF ACCIDENT PREVENTION PROGRAM

Re: Contract No

Job Title:

Job No:

Bldg. No:

Project Superintendent:

Phone Numbers: On Site Off Site:

[Policy Statement]{.underline} A safe and healthful place of employment
is a basic right of every working person. Exposure to unsafe conditions,
no matter who created them, is unacceptable. Therefore, accident
prevention measures must be integrated with all operating functions.

A safe and healthful place of employment can exist and be maintained
only if both supervisory and non-supervisory personnel participate in
and support the safety and health program by working with whoever is
designated as being responsible for overseeing safe and health
conditions on the job site. Employees should report all unsafe
conditions to the Safety Representative.

For each jobsite there must be a Safety Representative.

Name:

Phone Nos. Jobsite Office:

Cell/Pager Alternate

[The Safety Designee must implement the Accident Prevention Program and
must:]{.underline}

1.  Prior to the start of work each day on a jobsite, evaluate the site
    for any unsafe conditions at the jobsite and take appropriate steps
    to eliminate employee exposure.

2.  Prior to the initiation of any work by employees, evaluate the
    hazards of that work, and instruct the employees as to site and
    job-specific hazards. As jobs change, site and job-specific
    instructions must also change.

3.  Hold weekly safety meetings with all employees. These meetings may
    be in the form of one-on-one contacts or group meetings.

4.  Inspect the jobsite regularly. This may be performed as a separate
    inspection or while the Safety Representative is engaged in other
    supervisory duties. Such inspections must be documented, noting
    discrepancies and corrective actions taken. Include a descriptive
    outline of the program for frequent and regular inspections and
    reporting of jobsite conditions. The program must include the person
    responsible for conducting inspections, the frequency of
    inspections, reporting unsafe acts or conditions, and taking
    corrective action to prevent or control the unsafe act or condition.
    Daily inspections should be performed and documented by the safety
    representative or designee during active work, periodically during
    shutdowns to maintain site barriers, etc., and when mandated by
    adverse weather conditions.

5.  Insure that first aid and emergency services are available when
    required. Brookhaven National Laboratory (BNL) must provide
    emergency services, fire, medical, and spill response, for any
    emergencies arising while on the Laboratory property. BNL must
    provide emergency medical transportation. All personnel must use the
    BNL emergency phone number 2222 or 911 (from any BNL phone) or
    344-2222 (from a pay phone or cellular phone) and immediately notify
    the BNL Project Person in the event of any emergency. Minor injuries
    must be those that are treatable by first aid only, all other
    injuries must be reported to and treated by BNL\'s Medical Clinic or
    BNL emergency services personnel.

6.  Investigate all accidents or near accidents and take appropriate
    steps to eliminate the cause of the accident before work is resumed.
    All such incidents must be reported immediately to the BNL Project
    Manager.

7.  Utilize a safety and health checklist during the evaluation of the
    jobsite with the understanding that any unsafe conditions, not
    covered by the checklist, must be corrected.

8.  Periodically review and update the checklist with items that were
    originally not included, but identified during the worksite
    inspections.

9.  Inform all employees of the location and availability of the
    company\'s WRITTEN HAZARD COMMUNICATION PROGRAM, which is required
    to be on the jobsite, and which must include copies of all MATERIAL
    SAFETY DATA SHEETS (MSDS) for hazardous materials used on the
    jobsite by the Company.

10. Make readily available for all employee copies of 29 CFR 1910.20,
    Employee Access to Exposure and Medical Records (which includes
    Material Safety Data Sheets and other exposure records).

11. Conduct annual training for employees concerning who is the person
    responsible for keeping these records and that the employees or
    their authorized representatives have the right to have access to
    them.

12. Ensure that all personnel on the job site wear appropriate personal
    protective.

[Safety Representative Training and Qualifications]{.underline}

I certify that the Safety Representative is trained and knowledgeable in
the Environment, Safety & Health requirements of the project for which
he or she must be responsible. Attached is a copy of that individual's
training completion certificate.

Acceptable training and qualifications include certificates of
completion for formal classroom and hands-on training, as applicable,
in:

Additional training may be required for specific hazards, as dictated by
the scope of work, such as:

-   Lockout/Tagout (LOTO)

-   Working on live electrical circuits

-   Excavations

-   Confined spaces

-   Material handling/forklift operation/rigging

-   Fall protection

-   Respirators

-   Hazardous chemicals

-   Lead, asbestos

-   Radiation

Company Owner/President/CEO Date

**(COMPANY LETTERHEAD)**

# Section 3: CONTRACTOR/SUBCONTRACTOR RESPONSIBILITIES

The following summarizes the responsibilities of the ***(Insert Company
Name)*** as prime contractor and any subcontractors hired by the
contractor in the course of this project:

**[CONTRACTOR RESPONSIBILITIES:]{.underline}**

-   Immediately rectify any and all conditions that are found to be
    unsafe and/or unsanitary.

-   Issue a "Stop Work" order for those events, which pose an imminent
    danger to personnel, environment, or equipment. All Stop Work orders
    will be reported to the BNL Project Manager.

-   Report any unsafe conditions to project personnel and send all
    copies of safety inspections to Brookhaven National Laboratory Plant
    Engineering Division

-   A follow-up report must be issued detailing the action taken to
    rectify any and all inadequacies.

-   Coordination of activities with Subcontractors must take place to
    ensure work proceeds in accordance with applicable safety
    requirements.

-   Project Personnel and Subcontractors must be notified of any
    recognized hazards, potential problem areas and safety requirements.

-   Coordination of all pertinent certifications, training and record
    keeping must take place and their accessibility for review made
    available.

**[SUBCONTRACTOR RESPONSIBILITIES:]{.underline}**

-   Subcontractors must retain full responsibility for the safety of
    his/her personnel.

-   Review possible safety hazards, work activities, etc., with his/her
    personnel.

-   Issue a "Stop Work" order for those events, which pose an imminent
    danger to personnel, environment, or equipment. All Stop Work orders
    will be reported to the contractor and the BNL Project Manager.

-   Ensure that his/her foreman and personnel understand all necessary
    precautions to be taken and ensures that these precautions are
    carried out.

-   Makes regular inspections of hand tools and equipment used in all
    phases of work

-   Immediately corrects any safety deficiencies when identified and/or
    notified.

-   Immediately informs the Contractor and Contractor Safety
    Representative of any and all unsafe conditions or activities.

***There must be an open and continuous line of communication***

***between the Contractor and Subcontractor***

***to discuss any unsafe acts or conditions***

***that arises or may arise in the course of this project.***

**(COMPANY LETTERHEAD)**

#  Section 4: SAFETY TRAINING AND COMMUNICATION

## TRAINING AND EDUCATION:

-   Safety oriented signs and posters must be properly posted and
    clearly visible at various locations around the job site.

-   The Safety Representative must ensure that all personnel and
    Subcontractors have been properly trained for the hazards
    anticipated on this project as specified in Section 15, "Phase
    Hazard Analysis".

-   All new personnel must be instructed in work-place safety policies,
    regulations and procedures for the project prior to the start of
    work, for one's own safety and the safety of all those working at
    the job site.

-   Avoiding potential hazardous situations during the activities
    planned for the workweek must be addressed at weekly toolbox talks
    or more frequently if necessary. Any new safety procedures and
    safety updates must be discussed at these talks; and a
    safety-conscious attitude must be emphasized and reinforced.

-   As each new phase of work begins, as specified in Section 15, "Phase
    Hazard Analysis", a safety awareness meeting must be held for all
    personnel and Subcontractors involved in that aspect of the work.

-   Proper steps must be taken to correct any and all offenders not
    practicing adequate safety procedures.

-   Incorrect safety procedure must be immediately indicated to the
    offender.

-   The Safety Representative must ensure that the offender has a clear
    understanding of the corrective action to take and the possible
    consequences if those measures are not followed.

-   Severe or repetitive safety violations must be cause for permanent
    removal from the job site.

-   The Safety Representative must possess on file any special training
    records and education documentation.

**(COMPANY LETTERHEAD)**

## 

## DRUG-FREE WORKPLACE POLICY STATEMENT

######### **Drug-Free Workplace:**

Policy Statement

The unlawful manufacture, distribution, dispensing, possession, or use
of a controlled substance is prohibited in the workplace. A single
violation of such prohibition must result in the offending individual
being removed from the job-site and recommendation of participation in
an approved drug abuse assistance or rehabilitation program, and/or
reporting to the civil authorities for criminal prosecution.

All employees must abide by the rules of this program, and must notify
the employer in writing of the employee\'s conviction under a criminal
drug statute for a violation occurring in the workplace no later than 5
days after such conviction.

Program Elements

Ongoing drug-free awareness training program includes:

1.  Mandatory participation by all employees.

2.  Classroom and/or toolbox discussions must include:

    -   The dangers of drug abuse in the workplace.

    -   Distribution and discussion of the Contractor\'s policy of
        maintaining a drug-free workplace.

    -   Any available drug counseling, rehabilitation, and employee
        assistance programs.

    -   The penalties that may be imposed upon employees for drug abuse
        violations occurring in the workplace.

3.  Intervention Procedures - employee and supervisor.

-   Identification - Signs and Symptoms

-   Corrective action

4.  Personnel actions - program enforcement, disciplinary options, and
    employee assistance.

-   Legal or criminal actions.

-   Disciplinary actions up to and including termination.

-   Drug abuse or rehabilitation program.

5.  Brookhaven National Laboratory\'s Contracting Officer must be
    notified in writing within 10 days after receiving notice of an
    employee\'s conviction under a criminal drug statute for a violation
    occurring in the workplace. Notification must include the position
    title of the employee and the appropriate personnel action to be
    taken within 30 days under the requirements of this program.

Company Owner/President/CEO

Date:

## DRUG-FREE WORKPLACE REQUIREMENTS -- TOOL BOX TALK

Project Title:

Location:

Date:

Instructor:

***(Insert Company Name)*** strictly prohibits the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance
including alcohol. A single violation of such prohibition must result in
the offending individual being removed from the job-site and
recommendation of participation in an approved drug abuse assistance or
rehabilitation program, and/or reporting to the civil authorities for
criminal prosecution.

Counseling, rehabilitation, and assistance are available through this
company, for further information contact ***(Insert Company Employee
Assistance Representative\'s Name)*** or talk to your supervisor.

All employees must abide by the rules of this program and must notify
***(Insert Company Name)*** in writing of the employee\'s conviction
under a criminal drug statute for a violation occurring in the workplace
no later than 5 days after such conviction.

Personnel should be alert to abnormal behavior, and are required to
report their observations to the appropriate supervisory personnel.
Should the behavior create or have the potential to create a hazard to
personnel, property or the environment, personnel have the right to stop
work on that activity.

Substance and alcohol abuse must not be tolerated in the workplace. It
contributes to unsafe, unproductive work, and may result in adverse
action against you personally by company and legal authorities.

List of attendees:

  ----------------- ----------------- ----------------- -----------------
                                                        

                                                        

                                                        

                                                        

                                                        

                                                        
  ----------------- ----------------- ----------------- -----------------

#  Section 5: HAZARD COMMUNICATION

**[(INSERT COMPANY NAME)]{.underline}**

## SAMPLE HAZARD COMMUNICATION PROGRAM

1\. **[Purpose]{.underline}**

> The purpose of this hazard communication program is to inform
> ***(Insert Company Name)*** employees and all sub-contractor employees
> of known chemical hazards that may exist in the workplace.

2\. **[Application]{.underline}**

This program applies to chemicals known to be present in the workplace
in such a manner that employees may be exposed under normal conditions,
non-routine tasks, or foreseeable emergencies.

This hazard communication program relies on Material Safety Data Sheets
(MSDS) from suppliers for purposes of hazard determination.

3\. **[Program Summary]{.underline}**

> The major elements of this program are as follows:

a)  Labels and other forms of warning

b)  Material Safety Data Sheets (MSDS) from suppliers

c)  Employee information and training

d)  List of hazardous chemicals known to be present in the workplace

e)  Methods for informing employees of hazards of non-routine tasks

f)  Methods for informing contractor employers of hazards their
    employees may be exposed to while working for ***(Insert Company
    Name).***

4\. **[Labels and Other Forms of Warning]{.underline}**

Each container of hazardous chemicals must be labeled, tagged, or
otherwise marked with:

a)  The identity of the hazardous chemicals (or chemicals), and,

b)  Appropriate hazard warnings

Labels and other forms of warning must be legible and in English, and
must be prominently displayed or readily available in the work area
during each shift.

5\. **[Material Safety Data Sheet]{.underline}**

> A material safety data sheet (MSDS) must be kept for each hazardous
> chemical known to be present in the workplace.
>
> Material safety data sheets are kept ***(in, at, location)*** and are
> readily accessible by employees during each work shift.
>
> The ***(insert job title)*** is responsible for maintaining the MSDS
> in a complete and up-to-date manner.
>
> When work is shipped to customers, copies of MSDS for any known
> hazardous chemicals included as part of the products shipped must be
> passed along to the customer.

6\. **[Training & Information]{.underline}**

1.  All employees must be trained according to a written
    hazard-communication training plan that is part of the company\'s
    overall hazard communication program.

2.  Training must extend to non-routine tasks, as necessary, and to
    foreseeable emergencies.

3.  All employees must be trained on any revisions to this program.

7\. **[Revisions]{.underline}**

This program must be amended as changes in work operations, new
materials or processes, or new information dictate.

***[(INSERT COMPANY NAME)]{.underline}***

## HAZARD COMMUNICATION TRAINING PROGRAM

**[1. Initial Assignment Information and Training]{.underline}**

a.  The ***(insert job title)*** must train new employees in hazard
    communication and protection procedures as part of their general
    orientation before the new employees begin work.

b.  The ***(insert job title)*** is responsible for training affected
    employees whenever new hazardous chemicals are introduced into the
    workplace. This responsibility extends to provide additional
    training, as required, for existing employees reassigned into new
    positions.

c.  All current employees must be trained in the elements of ***(Insert
    Company Name)*** hazard communication program by ***(insert contract
    start date)*.**

**[2. Curriculum]{.underline}**

a.  All employees must be provided with the following information:

    1.  Employees must be informed that ***(insert company name)*** is
        required by law to have a chemical hazard communication program.

    2.  Employees must be informed of the details of ***(Insert Company
        Name)*** chemical hazard communication program including:

        -   The location and ready availability of a list of all
            hazardous chemicals used by the company

        -   A list of all hazardous chemicals known to be present in the
            work area is kept at ***(insert location)*** and is
            available for review by employees during each work shift

        -   The location and ready availability of Material Safety Data
            Sheets (MSDS) for hazardous chemicals used within the
            company

        -   Specific operations or tasks in the employees\' work area
            that use hazardous chemicals

b.  All employees must receive training as follows:

    1.  Employees must be trained in methods and observations to detect
        the presence of hazardous chemicals.

    2.  Employees must be trained regarding the specific physical and
        health hazards of known hazardous chemicals in the employees\'
        work area.

    3.  Employees must be trained in protective measures including the
        use of personal protective equipment and protective measures
        implemented by ***(Insert Company Name)***, including work
        procedures.

    4.  Employees must be trained in understanding, interpreting and
        using hazard information provided on labels and in MSDS.

**[3. Training Program Completion]{.underline}**

All ***(insert company name)*** employees are required to successfully
complete the ***(Insert Company Name)*** hazard-communications training
program. Employees are required to follow safe and healthy work
practices as a condition of employment.

**[4. Non-Routine Tasks:]{.underline}**

Training for hazard protection during non-routine tasks is the
responsibility of the ***(insert supervisor or other job title)*** and
must be provided as needed.

**[5. Foreseeable Emergencies:]{.underline}**

Training for hazard protection during foreseeable emergencies (such as
fires, floods, spills, etc.) must be provided to all affected employees
as part of their general safety training.

**[6. Sub-Contractor Employees]{.underline}**

The employer of sub-contractors required to work on this project must be
informed of the hazard communication program. While the sub-contractor
is responsible for their own employees\' training, ***(Insert Company
Name)*** must attempt to answer sub-contractor employees\' questions
about workplace hazards.

The MSDS and list of hazardous materials must be available to
sub-contractor employees as well.

**[REFERENCES:]{.underline}**

29 CFR 1910.1200 -- Hazard Communications

## HAZARD COMMUNICATION TRAINING SESSION

## ACKNOWLEDGEMENT SHEET

LOCATION:

GIVEN BY:

JOBSITE:

DATE OF TRAINING SESSION:

-   I know where Material Safety Data Sheets for my work are kept.

-   I understand the safe work procedures and precautions to be taken
    when working with these products including use of protective
    equipment.

-   I know where emergency supplies are kept.

-   I know where the emergency phone number and Hazard Communication
    Information are posted.

-   I am aware that I may review copies of the hazardous chemical list,
    the company\'s written program, and Material Safety Data Sheets.

-   I will inform my supervisor upon discovery of any identified
    chemical hazards.

  ------------------------------------------------ ----------------------
  **NAME**                                         **DATE**

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    
  ------------------------------------------------ ----------------------

***(SAMPLE FORM)***

## LIST OF HAZARDOUS CHEMICALS KNOWN TO BE PRESENT

**NOTE:** Material Safety Data Sheet (MSDS) is on file for each
substance on this list.  Details of specific physical and health hazards
as well as protective measures can be found on the MSDS for individual
chemicals.

  ----------------------- ----------------------- -----------------------
  **Substance**           **Supplier/Source**     **Comments**

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   

                                                   
  ----------------------- ----------------------- -----------------------

(COMPANY LETTERHEAD)

# Section 6: EMERGENCIES: FIRE, MEDICAL AND ENVIRONMENTAL

[Hazard Control and Implementation Guidelines/Checklists:]{.underline}

The Safety Representative must assume responsibility and ensure that the
following guidelines/checklists are adhered to for the safeguard of all
personnel and the environment:

**A. FIRST AID AND MEDICAL ATTENTION:**

-   The Safety Representative must maintain a First Aid Kit on site.

-   For all injuries and illnesses, the Safety Representative must
    immediately report them to Brookhaven National Laboratory's Medical
    Clinic or BNL Emergency Services personnel for treatment at
    extension 2222 or 911. If calling from a phone not part of the BNL
    system, e.g., cellular phone, (631)344-2222 must be dialed.

> **(Notification of the injury must also be made to the Brookhaven
> Laboratory Project Engineer.)**

-   The Safety Representative must ensure that all personnel are
    properly trained on site and facility-specific information.

-   Only qualified BNL Emergency Services Division personnel must
    provide emergency services and medical transportation.

    B.  **FIRE PROTECTION AND PREVENTION:**

-   Fire extinguishers must be provided at strategic locations around
    the job and free access to all fire hydrants of the job site must be
    maintained.

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-   Fire protection equipment must be provided during any activity that
    may pose a fire hazard, i.e. welding, flame cutting, etc., and there
    must be one fire extinguisher for each operation.

-   ***(Insert Company Name)*** must provide Fire protection equipment
    (one fire extinguisher for each 1,500 sq. ft. of floor space).

-   All necessary permits, i.e. welding, cutting, etc., must be obtained
    and a fire watch program must be in effect as needed.

-   There must be one fire watch with no other duties assigned per open
    flame operation.

-   In the case of any fire Project Engineer must be notified.

-   Within 72 hours of an emergency incident, the Safety Representative
    must submit a written report to Brookhaven National Laboratory
    project engineer and the report must include the following
    information:

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-   Type of fire

-   Cause of fire

-   Planned remedial action to prevent any future occurrences

-   Nature and outcome of any and all injuries not only personnel, but
    also to equipment and the project itself

**C. ENVIRONMENTAL PROTECTION:**

-   The use of containment for spill intervention must be implemented
    when applicable.

-   There must be proper storage and handling of hazardous materials
    (all MSDS sheets inclusive).

-   There must be proper documentation of operations, maintenance and
    repair of equipment.

-   Leaking or loose fluid retention systems must be intercepted via
    documented daily equipment inspection.

-   Concrete or blacktop must be used as surface for overnight storage
    of vehicles.

-   ***(Insert Company Name)*** must remove all unused chemicals.

> ***In the case of a fire, medical emergency, spill response or any
> other arising***
>
> ***emergency, the BNL Emergency Services Division must be immediately
> contacted***

***by dialing the following number(s):***

-   ***Dial 2222 or 911 from any BNL phone***

-   ***Dial (631)344-2222 from a phone not part of the BNL system***

> ***(i.e. cellular phone or other outside lines)***
>
> *Immediate notification must be made to the BNL Plant Engineering
> Division in the event of a fire or any other emergency after notifying
> BNL Emergency Services Division at*

***Ext.2222 or if calling from a phone not part of the BNL system, (631)
344-2222.***

(COMPANY LETTERHEAD)

# Section 7: EXCAVATIONS

## SAMPLE COMPETENT PERSON QUALIFICATION SUBMISSION FOR EXCAVATIONS

*\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_* is the
designated competent person responsible for

excavation safety on Job Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Bldg #:
\_\_\_\_\_\_\_\_\_\_ Job #: \_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is trained
and knowledgeable in excavation hazards, hazards, OSHA excavation safety
standards, and safe working requirements.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is capable of
identifying excavation hazards and has authority

to take all precautions necessary to protect personnel, property and the
environment from harm.

The competent person must be responsible for:

-   Implementing the project-specific excavation plan

-   Making frequent daily inspections to verify proper implementation

-   Taking all precautions necessary, up to and including work stoppage

-   Advising BNL and workers on any approved changes to the excavation
    plan

-   Briefing workers on project-specific excavation hazards

-   Securing and clearly making the area during working and non-working
    hours

-   Disciplining violators up to and including termination

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Company Owner/President/CEO Date

## EXCAVATION PLAN

-   The proposed method to prevent undermining existing structures and
    to protect personnel from potential cave-ins is described below

-   The soil for this project is type ***(specify type A, B, or C),***
    and all cave-in protection must conform to the applicable OSHA
    requirements.

-   Methods intended for supporting existing utilities and maintaining
    surface appurtenances such as roadways, sidewalks, and other
    anticipated encumbrances is briefly described below.

-   A contingency plan for notifying the project engineer upon suspicion
    or discovery of any contaminated soils, live munitions or other
    materials must be implemented.

-   For excavations 5 ft. or deeper or where there is a risk of cave-in,
    where sloping is to be used as cave-in protection, the slopes must
    be no greater than one to one and one-half, rise to run, or
    approximately 34 degrees from the horizontal.

-   Satisfactory lumber/timber must be used, i.e. badly cracked/broken
    timber must not be used for bracing or support of excavations.

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-   An adequate number of ladders must be present in the excavation for
    access. OSHA requires no more than 25 feet of lateral travel between
    ladders.

-   Excavated materials must be placed away from excavation cut in order
    to decrease additional loading on the support system as well as
    decreasing potential for excavated material to slough off into the
    cut.

-   Daily inspections must be done by the superintendent/foreman to
    monitor the condition of the support system.

-   A plan for proper de-watering and an excavation plan that fully
    describes the method used to protect workers from cave-in is
    included below

-   Proper permits must be filled out and approved before beginning work
    (i.e. digging, confined space entry permits, etc.)

-   There must be barricading against people and vehicles to eliminate
    the possibility of introducing any hazards

-   A rigging plan for materials in and around the excavation is
    included below.

## CAVE-IN PROTECTION EQUIPMENT

-   Cave-in protection equipment must be provided if 5ft or deeper. For
    excavations greater than 20 feet in depth, the protective systems
    must be designed and approved by a registered professional engineer
    with a specialty in soil mechanics.

-   Where shoring, shielding or systems other than sloping are proposed,
    there must be a submittal of manufacturer's or engineer's data on
    the system to be used, the depths of the excavations where it must
    be applied, and the system configurations to be utilized.

-   Sub-type of soil as defined by the manufacturer's or engineer's
    specifications must be determined; and there must be a submittal of
    soil type determinations and the system configuration selections to
    Plant Engineering Division for approval prior to work being
    performed in the excavation/trench.

**[REFERENCES:]{.underline}**

29 CFR 1926 Subpart P - Excavations

(COMPANY LETTERHEAD)

# Section 8: CONCRETE AND MASONRY PENETRATIONS

**[PERMITS:]{.underline}**

-   All concrete and masonry penetrations must be performed in
    accordance with Plant Engineering "Concrete and Masonry
    Penetrations" procedure(s) ***(Consult with the Plant Engineering
    Division for the current version),*** which requires that a
    completed permit be in place at the jobsite prior to penetrations
    being made.

-   A Lockout/Tagout Program must be submitted and approved if utilities
    must be shutdown to safely perform the work.

**[REFERENCES:]{.underline}**

29 CFR 1926 Subpart Q -- Concrete and Masonry

(COMPANY LETTERHEAD)

# Section 9: ELECTRICAL SAFETY

## ELECTRICAL SAFETY PROGRAM & SAFEGUARD CHECKLIST:

-   Electrical dangers must be observed and improper electrical
    conditions must be notified to all project personnel.

-   Use of the following equipment is prohibited for the safety of all
    involved personnel:

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-   Metal ladders

-   Frayed extension cords

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-   All personnel must be protected from such electrical hazards:

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-   Exposed live electrical parts

-   Ungrounded electrical equipment (double insulated tools is
    acceptable)

-   Unprotected electrical cords

-   Non-GFCI protected equipment

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-   Daily tests and inspections on the following equipment must be made
    to ensure it is safe, free from defects, and functioning properly:

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-   Lighting and illumination equipment

-   Power and Electrical Equipment

-   GFCI's

-   Portable electric tools and cords

-   Extension cords

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-   Safety Representatives must ensure that all project personnel are
    instructed to inspect power tools prior to each use to ensure tools
    are in proper operating condition.

-   Immediately remove all equipment found to be defective for repair or
    replacement.

-   A Control Zone must be utilized to protect personnel who may
    accidentally encounter exposed energized components in a facility
    because of a lack of knowledge or awareness of the hazards.

-   Personnel who may accidentally come in contact with energized
    circuits while working within a Control Zone must be protected by
    the following:

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-   Lockout and Tagout,

-   A barricade, and

-   Personal Protective Equipment appropriate for the task

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-   Equipment failure must be prevented by proper maintenance and
    inspection of all electrical equipment and other equipment/tools
    coming into contact with electric equipment/sources.

**[RERFERENCES:]{.underline}**

29 CFR 1926 Subpart K -- Electrical Safety

29 CFR 1910 Subpart S -- Electrical Safety

NFPA 70E -- Standard for Electrical Safety in the Workplace

## SAMPLE LOCK-OUT/TAG-OUT PROGRAM

## LOCK-OUT/TAG-OUT PROGRAM

POLICY:

The use of the Lock-Out/Tag-Out Program is to prevent an unexpected
operation or release of energy of electrical or electronic equipment.
The unexpected starting of motors may injure persons working on them, or
unexpected energizing of equipment can produce an electrical shock
and/or damage to the equipment. The Lock-Out/Tag-Out Program combines
the use of tags and locks, or other electrical or physical systems to
lock out power to the equipment while it\'s broken, or being worked on.

Locking and tagging key points are proven methods of controlling the
release of energy or hazardous materials, and an important way of
safeguarding workers who operate or repair machines or processes in the
plant. This document defines lock-out/tag-out, list specific procedures
to follow to properly lock-out/tag-out, define responsibility for
lock-out/tag-out, and show the importance of both education and
discipline in these procedures.

INTRODUCTION:

The majority of accidents happen around machinery of some type. Often,
the accident involves electrical shock, burns or exposure to hazardous
materials or moving machinery. These accidents share one thing in
common: the uncontrolled release of energy.

To protect yourself and your co-workers from danger in the workplace,
you must understand that energy, left uncontrolled, can be very
dangerous. Energy, simply defined, is the capacity for doing work.
Kinetic (moving) energy is the force caused by the motion of an object,
such as spinning flywheel. Potential (stored) energy is the unseen force
inside an object when not moving, such as a spring under tension. There
are many sources of energy, which can provide power to machinery.
Section 15, Phase Hazard Analysis identifies specific hazardous energy
sources. These may include:

-   Gravity

-   Electrical

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-   Mechanical

-   Chemical

-   Hydraulic

-   Pneumatic

-   Thermal

-   Nuclear

**A LOCK-OUT** is simply a locking device, such as a padlock, placed on
a power source to prevent the release of hazardous energy that could set
a machine in motion or otherwise endanger an employee working on the
machine. Locks may be used with a lock-out device that holds an energy
control point, such as a switch, lever or valve, in the off position,
making it impossible to operate.

**A TAG-OUT** is a written warning telling all others not to operate a
switch or valve that could release hazardous energy or set a machine in
motion. The tag-out is placed prominently on the switch or lever so as
not to be missed.

RESPONSIBILITY:

Locking and tagging key points are proven methods of controlling the
release of energy or hazardous materials, and an important way of
safeguarding workers who operate or repair equipment, or machines, and
processes in the plant. This document lists specific procedures to
follow to properly lock-out/tag-out, and show the importance of both
education and discipline to these procedures.

It is be the responsibility of the ***[(insert name of responsible
individual)]{.underline}*** to enforce the lock-out/tag-out procedure as
well as provide the necessary equipment to comply in all respects with
the procedure. Transferred employees must be instructed by their
supervisor in the purpose and use of lock-out/tag-out procedure.
Supervisors must be responsible for enforcing the specific
lock-out/tag-out procedures listed below.

> 1\. Production and support departments must be responsible for being
> knowledgeable of and adhering to this procedure. No locks must be
> removed from equipment without first consulting the BNL Facilities and
> Operations Directorate Maintenance Department.
>
> 2\. A lock-out/tag-out continued from one shift to the next must be
> the responsibility of the craftsmen involved to remove the appropriate
> lock and replace it with a new one.
>
> 3\. If more than one individual is required to lock-out or tag-out
> equipment, each must place their own lock or tag on the affected
> equipment in such a way as to be certain the equipment is locked out.
> If the affected equipment cannot accept multiple locks or tags, a
> multiple lock-out or tag-out hasp must be used.

EQUIPMENT:

Equipment must consist of the following:

1\. Padlocks. Sufficient quantities of padlocks available each lock to
have an individual key, and one master key controlled by maintenance
supervision.

> 2\. Multiple lock tongues. To be used in case more than one department
> is involved in a job.
>
> 3\. Danger/Warning tags. To be used wherever it is necessary to warn
> maintenance employees, and operators of a repair.

4.  Equipment must be distributed and controlled by ***[(insert name of
    responsible individual)]{.underline}***.

WHEN TO LOCK-OUT-TAG-OUT:

Most equipment is designed with safe switches, disabling the equipment
for minor repair or

calibration during normal operation. In general, these switches provide
adequate protection

for minor repair which is routine, repetitive, and necessary to the
normal use of the

equipment. Lock-out/tag-out procedures must be used for the following
situations:

1\. Major repairs or overhaul.

> 2\. When working alone, out of visual contact of the controlling
> switch.
>
> 3\. Anytime there is danger of injury from an unexpected release of
> energy.
>
> 4\. Any situation that threatens an employee's safety.

LOCK-OUT/TAG-OUT PROCEDURES:

The following are specific procedures to be followed for
lock-out/tag-out:

> 1\. Notify all affected areas and employees of the impending lockout
> situation, the reason for it and estimated start and duration times.
>
> 2\. Equipment shutdown and isolation. Place all switches in the
> \"off\" or \"safe\" position. Disconnect sources of power, ensuring
> all sources of both primary and secondary power to the equipment are
> interrupted.
>
> 3\. Dissipate residual energy. Shutting down equipment does not mean
> there is no energy left in it. Check for trapped pressure or residual
> electricity in the system.
>
> 4\. Lock-out or tag-out all in-line points of control. In most cases,
> this may be more than one place, or more than one lock, if several
> people are working on the equipment.
>
> 5\. Lock-out verification. Take nothing for granted. Verify that the
> locked-out switch or control cannot be overridden. Test the equipment
> to be certain that the locked-out switch is de-energized & not simply
> malfunctioning. Press all start buttons or valves to see if the
> equipment starts. Ensure the system you are working on is the same one
> that has been locked out.
>
> 6\. Perform the work scheduled. Try to foresee all possible hazards.
> Ensure the new/repair work does not bypass the lockout and reactivate
> the system.
>
> 7\. Lock and/or tag removal. All locks and tags are to be left in
> place until work is completely finished. This is especially true when
> more than one employee is working on the equipment. A lock is never to
> be removed except by the person who placed it there.
>
> ***NOTE: Only immediate supervisors are to authorize emergency removal
> of a lock or tag. The individual who applied the tag must be notified
> that the tag is being removed.***
>
> 8\. Equipment start up. Make a final safety check before restarting
> equipment, to be certain it is safe to operate. Make sure of the
> following:
>
> a\. All tools and other items have been removed.
>
> b\. All machine guards are returned to their proper position.
>
> c\. All electric, hydraulic, pneumatic or other systems are properly
> reconnected.
>
> d\. All employees are clear of equipment.

Many of the lock-out/tag-out procedures appear to be common sense, and
they are.

Following them will ensure safe operation calibration, maintenance and
repair of equipment

and/ or processes, without dangerous surprises or injury.

**WORKING ON OR NEAR ENERGIZED CIRCUITS**

-   It is the policy of ***(insert company name)*** that, except under
    extreme circumstances, work must not be done on energized circuits.

-   Work with voltages less than 50 volts (in BNL Range \"A\") is not
    considered working on or near energized conductors. Energized parts
    that operate at less than 50 V to ground are not required to be
    de-energized if there must be no increased exposure to electrical
    burns or to explosion due to electric arcs. **BNL will issue
    energized work permits**.

-   Energized work permits must address, as a minimum, the following
    elements:

1)  A description of the circuit and equipment to be worked on and their
    location;

2)  Justification for why the work must be performed in an energized
    condition;

3)  A description of the safe work practices to be employed;

4)  Results of the shock hazard analysis;

5)  Determination of shock protection boundaries;

6)  Results of the flash hazard analysis;

7)  The Flash Protection Boundary;

8)  The necessary personal protective equipment to safely perform the
    assigned task;

9)  Means employed to restrict access of unqualified persons from the
    work area;

10) Evidence of completion of a job briefing, including a discussion of
    any job-specific hazards (Include in Phase Hazard Analysis --
    Section 15);

11) Energized work approval signature as indicated above

-   For all energized work, regardless of the voltages, the appropriate
    personal protective equipment must be worn.

-   Work performed on or near energized circuits performed by qualified
    persons related to testing, troubleshooting, voltage measuring,
    etc., is permitted without an energized work permit, provided
    appropriate safe work practices and personal protective equipment in
    accordance with NFPA 70-E is used.

EDUCATION AND DISCIPLINE:

The key to worker safety is education. The purpose of this document is
to ensure that everyone understands the importance of lock-out/tag-out
and how to recognize when it is in use. These elements must be covered
during initial contractor/vendor orientation and during the pre-job and
periodic "tool-box" talks. By educating all employees to the importance
of following proper safety procedures, a safer working environment can
be ensured.

As with all safety procedures, a fair uniform enforcement of discipline
must be in place. Employees are responsible for their own safety, the
safety of their fellow employees and the safety of the facility.
Violating lock-out/tag-out procedures is a major safety violation and
will subject the employee to immediate discipline.

REFERENCES:

> [BNL Electrical Safety Subject
> Area](https://sbms.bnl.gov/SBMSearch/LD/ld08/ld08d151.htm?parentID=304)

29 CFR 1910.147 The Control of Hazardous Energy (Lockout/Tagout)

> 29 CFR 1926.417 Lock-out and Tagging of Circuits

NFPA 70E Standard for Electrical Safety in the Workplace

## PERIODIC INSPECTION CHECKLIST

DATE OF INSPECTION \_\_\_/\_\_\_/\_\_\_ TIME OF INSPECTION
\_\_\_\_\_\_\_\_\_\_

NAME OF INSPECTOR \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME OF EMPLOYEE BEING INSPECTED
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DATE OF ORIGINAL TRAINING \_\_\_/\_\_\_/\_\_\_

DEPARTMENT WHERE WORKING
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

MACHINE OR EQUIPMENT
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DEVIATIONS OR INADEQUACIES OBSERVED DURING THE INSPECTION:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

REVIEW CONDUCTED OF EMPLOYEE\'S RESPONSIBILITIES? Yes\_\_\_ No\_\_\_

INITIAL TRAINING TO BE REPEATED? Yes\_\_\_ No\_\_\_

THE SIGNATURES BELOW CERTIFY THAT A PERIODIC INSPECTION HAS

BEEN PERFORMED, AND COMPLETED.

INSPECTOR\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
EMPLOYEE\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## SAFETY MASTERCARD

Name of Equipment:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Operator:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Job Requested by:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Department:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Ready for Service Check-Off:\_\_\_\_\_\_\_\_\_

Job Description:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Reason for
Job:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Operations:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  -------------- -------------- -------------- -------------- --------------
  **Operations   **Location of  **Lock-out or  **Test         **Job Complete
  Lock No**      Lock/Tag       Tag-out**      Isolation**    Signoff**
                 w/Hasp**                                     

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              
  -------------- -------------- -------------- -------------- --------------

**Serviceperson:
\_\_\_\_\_\_**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**(COMPANY LETTERHEAD)**

# Section 10: MOBILE EQUIPMENT PROGRAM

## SAFE OPERATION AND MAINTENACE:

Prior to the use of motor vehicles or mobile equipment, this plan must
be discussed with all employees, including subcontractor employees,
concerning the scope of work to be accomplished, and the methods to
accomplish that work safely.

The supervisor, foreman, or safety representative must verify that all
vehicles and mobile equipment have been inspected and maintained at the
beginning of each shift to assure all parts, equipment and accessories
affecting safe operation are in proper operating condition and free from
defects. Inspection and maintenance must include:

-   Operator License, Certification, or other Qualifications

-   Backup alarms

-   Rollover Protective Structures (ROPS)

-   Lighting

-   Cab Glass

-   Fluid Levels

-   Leak/Spill Containment and Cleanup Equipment, Procedures and
    Training

-   Traffic Safety Requirements

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-   Spotters

-   Cones

-   Flag Personnel

-   Traffic Warning and Information Signs

-   Emergency Signals

-   Work Plan

-   Traffic Diversion Plan

-   Approvals from Local Authorities and Agencies

All defects must be corrected before placing vehicle in service.

Employees must not operate vehicles or mobile equipment with an
obstructed view to the rear without a reverse signal alarm
distinguishable from the surrounding noise level unless an observer
signals that it is safe to do so.

**THE OPERATOR IMMEDIATELY STOPS THE VEHICLE**

**OR MOBILE EQUIPMENT IF HE/SHE**

**LOSES SIGHT OF THE OBSERVER**

All vehicles and equipment must be maintained in a leak free condition.
Fittings and hoses must be frequently inspected for tightness, proper
seal, deterioration, or loss of leak-tight integrity.

All personnel must know the emergency stop signal and must use it in the
event of, or potential for, imminent danger or violation of a
radiological requirement. Where feasible, ground personnel, spotters,
supervisors, and safety representatives must carry air horns as an
established emergency stop signal for all equipment.

Every attempt must be made to establish and maintain equipment
operations a safe distance away from ground personnel or other equipment
that may be adversely impacted by the operation of mobile equipment.
Safe work zones must be established to prohibit personnel from being
within the range of motion of equipment, material being manipulated or
carried by equipment, or material or structures that could potentially
become entangled or disturbed by equipment. In any area, personnel must
not approach equipment from within the range of motion defined above
without the operator's knowledge and consent.

If required to work within the range of motion of equipment or
materials, personnel must attend daily toolbox discussions with
operators to define the day's plan for accomplishing the work, and
individual responsibilities and work locations. Methods for maintaining
communication via visual contact, hand signals, and the use of air horns
must be established for and understood by all affected personnel.
Personnel working within the range of motion of equipment or materials
must maintain communication with equipment operators at all times as
discussed at the daily toolbox meeting. All personnel working near
mobile equipment must wear high visibility clothing.

Machinery, equipment, or parts thereof, which are suspended or held
aloft, must be substantially blocked to prevent falling or shifting
while personnel are working on, around, or between them. Vehicles and
equipment must be maintained and repaired at our company shop, never on
the customer's property.

**[REFERENCES:]{.underline}**

29 CFR 1926 Subpart O -- Motor Vehicles, Mechanized Equipment, and
Marine Operations

## RIGGING PLAN WORKSHEET

**(INSERT NAME OF CONTRACTOR)**

**Building #:** **Job #:** **Project Title:**

**Location:**

**Note: All lifting operations must be conducted in accordance with
applicable ANSI standards and OSHA requirements.**

  ---------------------- ---------- ---------- ---------------- -------------- ------------------- ----------
  **Equipment List**                                                                               

  **Equipment List**     **Type**   **Qty.**   **Dimensions**   **Capacity**   **Configuration**   **Load**

                                                                                                   

  **Slings**                                                                                       

                                                                                                   

                                                                                                   

  **Shackles**                                                                                     

                                                                                                   

                                                                                                   

  **Roller/Skates**                                                                                

                                                                                                   

                                                                                                   

  **Jacks**                                                                                        

                                                                                                   

                                                                                                   

  **Cribbing/Shoring**                                                                             

                                                                                                   

                                                                                                   

  **Hoist**                                                                                        

                                                                                                   

                                                                                                   

  **Lifting Vehicles**                                                                             

                                                                                                   

                                                                                                   

  **PPE/HAZMAT**                                                                                   

                                                                                                   

                                                                                                   

  **Transport Vehicles**                                                                           

                                                                                                   

                                                                                                   

                                                                                                   
  ---------------------- ---------- ---------- ---------------- -------------- ------------------- ----------

**C. RIGGING PLAN**

The following must be considered when developing a rigging plan:

> [Suspect/Counterfeit Item (S/CI)
> inspections](https://sbms.bnl.gov/sbmsearch/subjarea/72/72_SA.cfm?parentID=72)
>
> Weight of Lift
>
> Center of Gravity
>
> Tag lines and locations of attendants
>
> Prelift Meeting- Documented, attendees, content
>
> Designated Signal Person
>
> Designated Person In Charge (PIC)
>
> Communication and Signals- Hand signals, emergency signals, voice
> communications.

**Remarks:**

Descriptive Drawing/sketch of Pre & Post lift locations and
encumbrances/clearances, impact on utilities **(contact Plant
Engineering Division)** and capacities and protective measures where
required are attached

Describe Method of Accomplishment -a written description of the
operations is attached. All lifting operations must be conducted in
accordance with ANSI and OSHA requirements.

Describe process that will be used for assuring that Suspect/Counterfeit
Items are not used during rigging and material handling
activities***.***

**[REFERENCES:]{.underline}**

2 CFR 1926 Subpart H -- Material Handling, Storage, Use and Disposal

SBMS Suspect/Counterfeit Items subject area

## SITE-CLEARING PLAN WORKSHEET

**(INSERT NAME OF CONTRACTOR)**

**Building #:** **Job #:** **Project Title:**

**Location:**

**Note: All tree felling, cutting, handling, and chipping operations
must be conducted in accordance with applicable ANSI standards and OSHA
requirements.**

  ------------------- ---------- ---------- ----------------- -------------- ------------------- ----------
  ***Equipment                                                                                   
  List***                                                                                        

  **Equipment List**  **Type**   **Qty.**   **Operator(s)**   **Capacity**   **Configuration**   **Load**

                                                                                                 

  **Saws**                                                                                       

                                                                                                 

                                                                                                 

  **Loaders**                                                                                    

                                                                                                 

                                                                                                 

  **Skidders**                                                                                   

                                                                                                 

                                                                                                 

  **Chippers**                                                                                   

                                                                                                 

                                                                                                 

  **Trucks**                                                                                     

                                                                                                 

                                                                                                 

  **Transport                                                                                    
  Vehicles**                                                                                     

                                                                                                 

                                                                                                 

  **Slings/Cables**                                                                              

                                                                                                 

                                                                                                 

  **Other**                                                                                      

                                                                                                 

                                                                                                 

                                                                                                 
  ------------------- ---------- ---------- ----------------- -------------- ------------------- ----------

The following must be considered when developing a site-clearing plan:

> Person In Charge (PIC)
>
> Name
>
> phone/pager #'s
>
> qualifications/experience, include any safety training received.
>
> Daily Pre-clearing site evaluation
>
> Existing encumbrances, appurtenances, or other obstacles.
>
> Changes in site conditions or other trade activities.
>
> Coordination with other trades
>
> Site access control, area marked, fenced, or otherwise identified.
>
> Communication and Signals
>
> Hand signals
>
> emergency signal
>
> voice communication.

Training- Initial, ongoing, weekly toolbox talks, daily operations plan.

Equipment inspection and maintenance

> Inspect equipment daily or before each use for:
>
> safety guards and features in good condition and working order; i.e.
> kickback protection
>
> ROPS/FOPS, PPE, alarms, cab glass, etc..

Daily Pre-clearing site evaluation- Existing encumbrances,
appurtenances, or other obstacles. Changes in site conditions or other
trade activities.

Coordination with other trades- Site access control, area marked,
fenced, or otherwise identified.

Communication and Signals- Hand signals (see chart), emergency signal,
voice communication.

Training- Initial, ongoing, weekly toolbox talks, daily operations plan.

Equipment inspection and maintenance- Inspect equipment daily or before
each use for safety guards and features in good condition and working
order; i.e. kickback protection, ROPS/FOPS, PPE, alarms, cab glass,
etc..

**Remarks:**

Descriptive Drawing- Sketch of site to be cleared showing beginning and
ending locations or areas of concentration, direction of work to
progress, locations of clearing operations (generic if no unusual
circumstances expected, or specific for areas requiring operational
changes to accommodate existing or future obstacles or site conditions),
safe working distances or radii, material handling/trucking
routes(generic and specific), material staging and processing areas,
telephone, sanitation supplies, lunch/break areas.

Describe Method of Accomplishment- A written description of the
operations, the personnel performing them and their sequence, i.e.
Felling, limbing, bucking, skidding, chipping, loading, cabling, etc. is
attached. All clearing operations must be conducted in accordance with
ANSI and OSHA requirements.

**(COMPANY LETTERHEAD)**

# Section 11: FALL PROTECTION

**General:**

-   Each employee (regardless of their craft) on a working/walking
    surface 6 feet or more above a lower level must be protected from
    falling by a guardrail system, a safety net system, or personal fall
    arrest system. Where a guardrail system is employed, and a
    controlled access zone has been established for leading edge work,
    the control line may be used in lieu of a guardrail system along the
    edge that parallels the edge.

-   Guardrails must be constructed at all floors or roof openings if
    these openings cannot be covered well and rails must be constructed
    at all elevator shafts or stairwells.

**Observe any possibilities of elevated falls.**

**Ladders:**

-   There must be careful observation of and advising to all personnel
    on proper use of ladders, slope of ladders, height above elevation
    levels, conditions of ladders.

-   Ladders must be properly inspected to make sure that the following
    conditions are not encountered:

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-   Broken rungs or missing steps

-   Improperly secured and erection of ladder

-   Improper ladders used (i.e. using metal ladders for electrical work)

-   Poorly constructed man-made ladders

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-   Use of ladders with broken/missing rungs or steps, broken/split side
    rails, or other faulty or defective equipment is prohibited. If
    ladders are defective in any way they must be discarded and removed
    from the site.

-   Ladders must be tied off to prevent displacement.

-   Ladders must extend 36" above the landing area.

-   Man-made (not commercially purchased) ladders must be constructed,
    as specified by OSHA:

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-   Width of single cleat ladders must be between 15 and 20 inches.

-   Cleats must be uniformly spaced, 12 inches, top to top. Filler
    blocks must be used between the cleats.

-   Two-inch by four-inch lumber, minimum, must be used for side rails
    up to 16 feet long.

**Scaffolds:**

-   Personnel must be properly advised on the use of scaffolds,
    guardrails, and toe-boards guarding tubular welded frame scaffolds.

-   Scaffolds must be properly erected and guarded; and they must be
    fully planked, equipped with guardrails, and set on sound rigid
    footing.

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-   All scaffolds used on this job must be designed by **(Insert Name of
    Qualified Person)** and constructed and loaded in accordance with
    that design.

-   Each employee who works on the scaffold must be trained by **(Insert
    Name of Qualified Person)** in the subject matter to recognize the
    hazards associated with the type of scaffold in use and to
    understand the procedures to control or minimize those hazards.

-   ***(Insert Name of Company)*** must have each employee who is
    involved in erecting, disassembling, moving, operating, repairing,
    maintaining, or inspecting a scaffold trained by ***(Insert Name of
    Competent Person)*** to recognize any hazards associated with that
    work.

-   For this project, the type of scaffold to be use is ***(Insert type
    of scaffold)*** and conforms to the requirements of ***(Insert
    appropriate 29 CFR 1926 Subpart L Section)***

**References:**

> [BNL SBMS Fall Protection Subject
> Area](https://sbms.bnl.gov/sbmsearch/subjarea/180/180_SA.cfm?parentID=180)
>
> 29 CFR 1926 Subpart L Scaffolds
>
> 29 CFR 1926 Subpart M Fall Protection
>
> 29 CFR 1926 Subpart X Stairways and Ladders

## SCAFFOLD TRAINING SESSION ACKNOWLEDGEMENT SHEET

LOCATION:

GIVEN BY:

JOBSITE:

DATE OF TRAINING SESSION:

-   I understand the nature of electrical hazards, fall hazards, and
    falling object hazards in the work area.

-   I understand the correct procedures for dealing electrical hazards
    and for erecting, maintaining, and disassembling the fall protection
    systems and falling object protection systems being used.

-   I understand the proper use the scaffold and the proper handling of
    material on the scaffold.

-   I am aware of the maximum intended load and the load carrying
    capabilities of the scaffold.

  ------------------------------------------------ ----------------------
  **NAME**                                         **DATE**

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    

                                                    
  ------------------------------------------------ ----------------------

**(COMPANY LETTERHEAD)**

# Section 12: WELDING/CUTTING - OPEN FLAME OPERATIONS

**[CUTTING/WELDING PERMIT:]{.underline}**

-   Proper cutting/welding permits must be obtained from the Fire/Rescue
    Group (Building 599)

-   Requirements of the section [Cutting and
    Welding](https://sbms.bnl.gov/sbmsearch/subjarea/178/178_pro2.cfm)
    in the Fire Safety Subject Area must be observed

-   Notification must be made to the Fire/Rescue Group and a permit
    obtained 48 hours prior to work commencing.

-   A dedicated fire watch and fire extinguisher for the cutting/welding
    operation must be available

**[REFERENCES:]{.underline}**

29 CFR 1926 Subpart J -- Welding and Cutting

Fire Safety Subject Area

# Section 13: CONFINED SPACES

Confined Space Entry:

-   Entry into confined spaces must be in accordance with Brookhaven
    National Laboratory SBMS [Subject Area -- Confined
    Spaces](https://sbms.bnl.gov/sbmsearch/subjarea/122/122_SA.cfm)

-   BNL Plant Engineering Division, if required, must provide all
    permits.

-   BNL Fire/Rescue Group, or an alternate rescue company, must provide
    emergency response and must be available whenever there is an entry
    into a permitted confined space.

**[REFERENCES:]{.underline}**

BNL SBMS Confined Space Subject Area

**(COMPANY LETTERHEAD)**

# Section 14: RESPIRATORY PROTECTION AND EXPOSURE MONITORING

## RESPIRATORY PROTECTION

-   Respirators, applicable and suitable for the purpose intended, must
    be provided by ***(Insert Name of Company)*** when such equipment is
    necessary to protect the health of the employee.

-   ***(Insert Name of Company)*** is responsible for establishing and
    maintaining a respiratory protection program in accordance with OSHA
    regulations.

### EXPOSURE MONITORING

All work on the project must be done within the occupational exposure
limits for Industrial Hygiene hazards set in OSHA 29CFR1926, 29CFR1910,
and American Conference of Governmental Industrial Hygienists (ACGIH)
*Threshold Limit Values®* (TLV) (including, but not limited to,
chemical, lead, silica, asbestos, beryllium, noise, non-ionizing
radiation, and heat stress hazards on the project). Compliance with the
OSHA Permissible Exposure Limits and ACGIH *Threshold Limit Values®*
must be determined by representative personnel exposure monitoring and
dosimetry conducted by the ***(insert name of company)*** or their
representative. The details of the project's exposure monitoring
equipment, methods, and monitoring strategy are included in this Health
and Safety Plan.

If data is available to support the supposition that real-time
monitoring is not necessary, i.e., data exists on a previous job, or in
peer-reviewed literature, to show that neither the ACGIH or OSHA
exposure limits are exceeded, then such data must be included with this
Health and Safety Plan, and reviewed and approved by either the BNL
Industrial Hygiene Group or ***(Insert name of company)*** safety and
health and professional responsible for Industrial Hygiene monitoring.

***(Insert name of company)*** will provide qualified monitoring and
hazard assessment personnel to conduct all Industrial Hygiene
monitoring. In addition, personnel who conduct exposure monitoring on
workers who handle, disturb, or remove friable asbestos containing
material will maintain NYSDOL Industrial Code Rule 56 & USEPA required
training and certification for Project Monitor. Copies of all monitoring
personnel certifications are included as part of this Health and Safety
Plan

***(Insert name of company)*** will conduct monitoring with calibrated
equipment using National Institute of Occupational Safety and Health
(NIOSH) or OSHA approved methods, and have analysis conducted by an
American Industrial Hygiene Association (AIHA) Proficiency Analytical
Testing certified laboratory or by National Institute of Standards and
Testing (NIST) traceable calibrated direct reading instrumentation. All
instrumentation used for surveys must be calibrated in compliance with
the manufacturer's specification prior to use in the field.

Copies of all equipment calibration, field sampling sheets, laboratory
analysis reports, and hazard assessment evaluation reports must be
submitted to the BNL within 5 days after the receipt of results from
analytical laboratories or within 5 days after analysis by direct
reading instruments, meters, or monitors. The monitoring equipment to be
used on this project is listed on the attached table.

Conditions which require exposure monitoring include, but are not
limited to:

-   Asbestos

-   Beryllium

-   Chemicals, Working With

-   Confined spaces

-   Lead

-   Natural Hazards in the Environment (Heat stress)

-   Nanomaterials

-   Noise and Hearing Conservation

-   RF/Microwave

-   Static Magnetic Fields

#### EXPOSURE MONITORING EQUIPMENT

  ----------------- ---------- ---------- --------------- ----------------------
  **Name of         **Model    **Serial   **Calibration   **Name of Technician
  Equipment**       Number**   Number**   Date**          Authorized to Operate
                                                          the Equipment**

                                                          

                                                          

                                                          

                                                          

                                                          

                                                          

                                                          

                                                          

                                                          
  ----------------- ---------- ---------- --------------- ----------------------

**[MONITORING STRATEGY]{.underline}**

  ------------- -------------- ------------- -------------- ---------------
  **Work        **Substance    **Initial     **Subsequent   **Monitoring
  Activity**    Being          Monitoring    Monitoring     Equipment**
                Monitored**    Frequency**   Frequency**    

                                                            

                                                            

                                                            

                                                            

                                                            

                                                            

                                                            

                                                            

                                                            
  ------------- -------------- ------------- -------------- ---------------

***Section 15 PHASE HAZARD ANALYSIS***

The Phase Hazard Analysis (PHA) is intended to identify each phase of
the project, the specific hazards associated with each of those phases,
and to **[detail]{.underline}** the mitigation and prevention measures
to be taken to prevent injuries, property damage, and environmental
insults. For example, if the project requires working from elevations, a
detailed description of the fall protection measures (including the type
of equipment used) which will be taken. If respiratory protection is
required, the type of respirator must be listed. It is not sufficient to
say, "Comply with OSHA regulations".

Where special or heavy equipment will be used, the contractor must
specify the type of equipment to be used, e.g., front-end loader, man
lift, concrete finishing equipment, etc. The contractor must research
available information for each specialized piece of equipment, including
operating manuals, manufacturer's web sites, etc., and address those
hazards identified by the manufacturer of the equipment. If available
prior to the start of the project the contractor must supply to the BNL
Construction Safety Engineer that portion of the equipment-operating
manual or other reference material, which discusses the safety
precautions of that piece of equipment.

Attached is an example of typical list of project phases. It is intended
that the contractor develop his own list for the specific project.

**(COMPANY Letterhead)**

# Section 15: PHASE-HAZARD ANALYSIS

# (Insert Job Title Here)

For each phase of the work (as appropriate) indicate the hazards that
must be encountered and the prevention and mitigation controls which
must be in place.

  ------------------------ ---------------------- ------------- -------------------------- --------------
  **Task**                 **Activity**           **Hazards**   **Mitigation/Reduction**   **Comments**

  ***General Site          Working around heavy                                            
  Safety***                equipment                                                       

                           Site Clearing                                                   

                           Dust control                                                    

                           Mobilization/Staging                                            

                           Fueling Equipment                                               

  ***Site Preparations***  Excavation                                                      

                           Backfilling                                                     

                           Compacting                                                      

                           Grading                                                         

                           Asphalt placement                                               

                           Road Bed Stone                                                  
                           Placement                                                       

  ***Concrete/Masonry***   Foundation Demolition                                           

                           Masonry/Exterior Work                                           

                           Reinforcing steel                                               

                           Concrete Placement                                              

                           Wood cutting                                                    

  ***Electrical***                                                                         
  ------------------------ ---------------------- ------------- -------------------------- --------------

  ----------------- -------------- ------------- -------------------------- --------------
  **Task**          **Activity**   **Hazards**   **Mitigation/Reduction**   **Comments**

  ***Structural     Hoisting and                                            
  Steel***          Rigging                                                 

                    Metal/Roof                                              
                    Decking                                                 

                    Structural                                              
                    Glazing                                                 

                                                                            

                                                                            

                                                                            

  ***Utilities***                                                           

  ***Interior                                                               
  Finish Work***                                                            

  ***HVAC***                                                                

  ***Roofing***                                                             

  ***Flooring***                                                            
  ----------------- -------------- ------------- -------------------------- --------------

(COMPANY LETTERHEAD)

# Section 16: SOURCES OF RADIATION

LASERS

Only lasers, which are Class 2, 3A, or 3R, will be permitted on the
construction site.

-   Only qualified and trained employees will be assigned to install,
    adjust, and operate laser equipment. Proof of qualification of the
    laser equipment operator will be available and in possession of the
    operator at all times. (*Name of Contractor)* will have the training
    documentation on file or it will be readily available.

-   Areas in which lasers are used will be posted with standard laser
    warning placards.

-   Only those devices labeled as Class 2 or 3a, or 3r (**no greater
    than 5 milliwatts**) will be used

-   Never intentionally stare into the laser beam.

-   Never intentionally aim the beam at oneself or another person,
    particularly in the facial area.

-   The beam will be turned off when not in use.

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-   Mirror-like surfaces will be avoided when directing the laser beam.
    A reflected beam can act like a direct beam on the eye.

-   Areas in which lasers are used will be posted with standard laser
    warning placards. These can be obtained form the BNL Laser Safety
    Officer.

-   Beam shutters or caps will be utilized, or the laser turned off,
    when laser transmission is not actually required. When the laser is
    left unattended for a substantial period of time, such as during
    lunch hour, overnight, or at change of shifts, the laser will be
    turned off.

-   When it is raining or snowing, or when there is dust or fog in the
    air, the operation of laser systems will be prohibited where
    practicable; in any event, employees will be kept out of range of
    the area of source and target during such weather conditions.

-   Laser unit in operation should be set up above the heads of the
    employees, when possible.

## IONIZING RADIATION SOURCES

BNL must be notified in advance of all sources of ionizing radiation
(e.g., Troxler Density Gauges, radiography sources, etc.) brought to the
site. Contractors who use these sources in the performance of work at
BNL must demonstrate that they are properly licensed by the State of New
York to own and use these sources. These sources must be used and
controlled consistently with the BNL Radiological Control Manual.

(<https://sbms.bnl.gov/SBMSearch/ProgDesc/RadCon/RadCon_PD.cfm>) and
site-wide radiological control procedures.

Work with radiation sources will be performed by competent persons
trained in the use of radiological devices and in the hazards associated
with them.

● All work with these sources of ionizing radiation must be authorized
through a BNL Work permit and/or Radiological Work Permit (RWP).

● The Facility Support Representative will determine if a RWP is
required.

-   The BNL Construction Safety Engineer will be made aware of the
    intent to use radiation sources.

-   Appropriate BNL radiological postings will be maintained while the
    radiation source is in use.

-   Only authorized and trained personnel will be allowed access to the
    radiologically controlled area.

-   Appropriate BNL dosimetry will be worn at all time while in the area
    and maintained in accordance with the RWP

## REFERENCES

-   OSHA Construction Standards -- 29 CFR 1926.53 and 1926.54

-   BNL Radiological Control Manual

(COMPANY LETTERHEAD)

***Section 17: OCCUPATIONAL MEDICINE***

To ensure the continued health of our employees ***(Insert name of
contractor)*** maintains a comprehensive occupational medicine program.
This program is under the direction and control of ***(Insert name of
certified occupational medicine physician)***.

**[CONTRACTOR RESPONSIBILITIES:]{.underline}**

***(Insert name of contractor)*** provides comprehensive occupational
medicine services to each of its employees, or workers under his
control, who

-   work at BNL for 30 or more days in a 12 month period; or

-   work for any length of time at BNL and are required by statute to be
    enrolled in a medical or exposure monitoring program.

***(Insert name of contractor)*** affirms that these services are fully
compliant with all provisions of Section 8 ("Occupational Medicine") of
Appendix A of the Federal Regulation 10CFR851 including the following
provisions:

Services are provided by an occupational medicine provider ("OMP") that

-   plans and implements the occupational medicine services

-   is under the direction of a physician licensed in the state of New
    York.

-   is staffed by health care professionals with valid New York State
    licenses in their respective professions.

> [OMP Information]{.underline}
>
> OMP Name:
>
> Address:
>
> Phone #: Fax #:

The OMP determines the content of the worker health evaluations in
accordance with current sound and acceptable medical practices and all
pertinent statutory and regulatory requirements

At a minimum, these services include:

-   Medical surveillance and medical certification examinations in
    compliance with all OSHA, DOE or other statutory or contractual
    requirements for such examinations applicable to the work to be
    performed and the type and level of workplace exposures. Frequency
    of such examinations to be determined by statute, contractual
    requirement or best medical practice as determined by the OMP.

-   Prior to the employee's 30^th^ day of work at BNL an occupational
    medical examination must be conducted for workers involved in
    physically demanding tasks, the task involves potential exposure to
    workplace hazards, or exposure to adverse environmental conditions.

-   Evaluation at the time of potentially work-related illness,
    potentially harmful exposure or injury at BNL to determine
    work-relatedness, any need for medical restrictions or work removal,
    and referral for definitive care, if indicated.

-   Return-to-work evaluations where a worker has been absent for 5 or
    more workdays due to illness or injury.

-   Restricted duty as medically indicated.

-   Creation and retention of a medical record that complies fully with
    all requirements specified in paragraph 8(f) of Appendix A 10CFR 851
    for each employee for whom the OMP has provided occupational
    medicine services.

-   Verbal and written communication to each employee as to the purpose,
    nature and results of all medical evaluations and tests performed
    and documentation of this communication in the medical record.

-   Timely submittal of the results of health evaluations to BNL where
    such information will facilitate the mitigation of worksite hazards.
    Such communications will not include the release of confidential,
    personally-identifiable medical information, other than in
    exceptional instances where there is a compelling, overriding public
    health or public safety need.

The following occupational medicine services are also provided by the
OMP, except where the OMP determines that they are not applicable or not
feasible. Such a determination is documented in writing for each service
that will not be provided, with sufficient explanation:

-   Participation in worker protection teams, as well as worker safety
    and health team meetings and committees as defined, respectively, in
    paragraphs 8 (e)(2) and 8(d)(3) of 10CFR 851.

-   Case Management of Ill or Injured workers to facilitate
    rehabilitation and safe return to work.

-   A health promotion program to include disease and risk factor
    screening for the major causes of morbidity and mortality within the
    employee population, if determined to be cost effective. If deemed
    not cost effective, the OMP's decision and its basis must be
    documented in the outline of comprehensive occupational medicine
    services.

-   ***(Insert name of contractor)*** health and disability insurance
    claims data (de-identified) is used by the OMP in determining the
    major causes of morbidity and mortality within ***(Insert name of
    contractor)*** workforce, if such information is available to
    ***(Insert name of contractor)***.

-   Cost effectiveness to be judged by available evidence, published
    medical studies, demonstration projects at other institutions or
    internal analyses.

-   Review and approval of the medical and behavioral aspects of
    ***(Insert name of contractor)*** -sponsored or ***(Insert name of
    contractor)*** --supported (if they exist).

-   Employee Assistance Programs (EAPs)

-   Alcohol and substance abuse rehabilitation programs; and

-   Wellness programs

-   If the work requires immunization, a hazardous waste program, or
    involves exposure to blood-borne pathogens, the OMP must review the
    medical aspects to assure their conformance to applicable
    guidelines.

***(Insert name of contractor)*** provides to the OMP

-   Access to information (de-identified) from health, disability and
    other insurance plans appropriate for determining the major causes
    of morbidity and mortality among the contractor's employees.

-   Information on the physical demands and working conditions that is
    associated with each contractor employee's job.

-   Employee job-task and hazard analysis information, including actual
    or potential work-site exposures of each employee. BNL will provide
    potential radiological hazard exposure information if applicable.

-   Notification when an employee has been absent because of an injury
    or illness for more than 5 consecutive workdays.

-   Referral of employees about whom the supervisor has concerns
    regarding ability to safely perform job duties.

-   The opportunity to participate in worker protection teams, as well
    as worker safety and health team meetings and committees (where
    applicable).

**[BNL RESPONSIBILITIES:]{.underline}**

BNL will provide the ***(Insert name of contractor)*** OMP with

-   Access to pre-existing work-site hazard information, e.g., chemical,
    radiological, biological, asbestos.

-   Access to the workplace for evaluation of job conditions and issues
    relating to workers\' health.

-   Information or materials requested by the ***(Insert name of
    contractor)*** or OMP to assist the OMP in developing occupational
    medicine services. This information and materials may include
    relevant portions of BNL's Worker Safety and Health Program, BNL
    policies, procedures and forms, as well as consultation with
    relevant BNL health, safety and occupational medicine personnel.

-   Chapter 8 of Appendix A of 10 CFR 851 and its implementation guide
    DOE G 440.1-8

For work performed at BNL, the ***(Insert name of contractor)*** is
covered under BNL's site emergency plan, and may be asked by BNL to
provide BNL with information relevant to the plan, or to assist in
developing a portion of the plan.

**[REFERENCES]{.underline}**

Code of Federal Regulation -- 10CFR 851 - [Worker Safety and
Health]{.underline}

**[PHYSICIAN'S ACKNOWLEDGEMENT]{.underline}**

I affirm that the services which I provide are

(Name of Physician)

fully compliant with the provisions of Section 8 (Occupational Medicine)
of Appendix A

of the Federal Regulation 10CFR851including the following:

-   Plan and implementation of the occupational medicine services.

-   I am a physician licensed in the State of New York.

-   My office is staffed with health care professionals with valid New
    York State licenses in \_\_\_\_\_\_\_\_\_\_\_,
    \_\_\_\_\_\_\_\_\_\_\_\_\_, and \_\_\_\_\_\_\_\_\_\_\_\_\_\_.

-   I will provide medical surveillance and medical certification in
    compliance with OSHA, DOE or other statutory or contractual
    requirements.

> (Signature of Physician) (Date)