+--------------+------+------------+---------+-------+--------------+
| Project      |      |            |         | Acc   |              |
| Title:       |      |            |         | ount: |              |
+--------------+------+------------+---------+-------+--------------+
| Principal    |      |            |         |       |              |
| I            |      |            |         |       |              |
| nvestigator: |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+
| Site:        |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+
| Site Owner   |      |            |         |       |              |
| or Managing  |      |            |         |       |              |
| Agency:      |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+
| Will work be |      |            |         |       |              |
| performed    |      |            |         |       |              |
| under        |      |            |         |       |              |
| another      |      |            |         |       |              |
| agency's     |      |            |         |       |              |
| ES&H plan?   |      |            |         |       |              |
| (If so, make |      |            |         |       |              |
| the plan     |      |            |         |       |              |
| available to |      |            |         |       |              |
| all LBNL     |      |            |         |       |              |
| p            |      |            |         |       |              |
| articipants) |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+
| C            |      |            |         |       |              |
| ollaborating |      |            |         |       |              |
| Or           |      |            |         |       |              |
| ganizations: |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+
| Summary      |      |            |         |       |              |
| Description  |      |            |         |       |              |
| of Site      |      |            |         |       |              |
| Work:        |      |            |         |       |              |
|              |      |            |         |       |              |
| Operations   |      |            |         |       |              |
| Schedule:    |      |            |         |       |              |
| *(Indicate   |      |            |         |       |              |
| dates of     |      |            |         |       |              |
| trips, daily |      |            |         |       |              |
| schedule if  |      |            |         |       |              |
| known.       |      |            |         |       |              |
| Changes and  |      |            |         |       |              |
| additional   |      |            |         |       |              |
| dates after  |      |            |         |       |              |
| OSSEPP       |      |            |         |       |              |
| approval can |      |            |         |       |              |
| be indicated |      |            |         |       |              |
| on revision  |      |            |         |       |              |
| form.)*      |      |            |         |       |              |
+--------------+------+------------+---------+-------+--------------+

###  {#section .unnumbered}

### *Contact Information for Site Personnel (LBNL and Other)* (identify which participant is the Site Safety Officer) {#contact-information-for-site-personnel-lbnl-and-other-identify-which-participant-is-the-site-safety-officer .unnumbered}

  --------------------- -------------------- ---------------- -------------
  Name                  Title or Job         Organization     Cell and/or
                        Description                           telephone
                                                              number

                                                              

                                                              

                                                              

                                                              

                                                              

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

## Emergency Response Information: Some of the requested information may only be available after arrival on site or at onsite safety meeting. If this is the case, indicate how you will obtain this information. 

  --------------- -- ------------------------------- ------ -----------------
  First Aid                                                 
  Responder                                                 
  (*Site                                                    
  personnel with                                            
  First Aid                                                 
  Training*)                                                

  Nearest                                                   
  hospital or                                               
  clinic:                                                   

  Nearest phone                                             
  if cell phones                                            
  don't work:                                               

  Suggested                                                 
  emergency                                                 
  evacuation                                                
  route and                                                 
  meeting area:                                             

  Primary                                            Ext.   
  Emergency                                                 
  Contact at                                                
  LBNL:                                                     

  Alternate                                          Ext.   
  Emergency                                                 
  Contact at                                                
  LBNL:                                                     
  --------------- -- ------------------------------- ------ -----------------

### Site- and Work-Specific Hazards and Controls {#site--and-work-specific-hazards-and-controls .unnumbered}

+---------+-----------------------------+-----------------------------+
| Hazard  | Description of Hazard (if   | Control Measures (list what |
| Type    | hazard not present,         | you will do to reduce risk  |
|         | indicate N/A not            | to hazard, such as safety   |
|         | applicable)                 | training, personal          |
|         |                             | protective equipment, other |
|         |                             | precautions)                |
+---------+-----------------------------+-----------------------------+
| C       | *(e.g. weather extremes see | *(e.g. appropriate          |
| limate: | also HEAT and COLD          | clothing, sunscreen)*       |
|         | discussion in               |                             |
|         | **Attachments** section at  |                             |
|         | end of document)*           |                             |
+---------+-----------------------------+-----------------------------+
| P       | *(e.g. remote location,     |                             |
| hysical | cliffs, flowing water,      |                             |
|         | working in tunnels/mines)*  |                             |
+---------+-----------------------------+-----------------------------+
| Che     | *(e.g. site-wide            |                             |
| mical\* | contamination, possible     |                             |
| (in     | contact with contaminated   |                             |
| cluding | media)*                     |                             |
| radiol  |                             |                             |
| ogical) |                             |                             |
+---------+-----------------------------+-----------------------------+
| Bio     | *(e.g. possible contact     |                             |
| logical | with contaminated media or  |                             |
|         | insects, snakes -- see      |                             |
|         | BIOLOGICAL discussion in    |                             |
|         | **Attachments** section at  |                             |
|         | end of document)*           |                             |
+---------+-----------------------------+-----------------------------+
| O       | *(describe site access,     |                             |
| ff-road | vehicular and foot travel)* |                             |
| travel  |                             |                             |
+---------+-----------------------------+-----------------------------+
| Potable | *(is it available?)*        |                             |
| water   |                             |                             |
+---------+-----------------------------+-----------------------------+
| Er      | *(e.g.moving/carrying       | Test the weight by lifting  |
| gonomic | equipment over 20 lbs,      | or sliding one corner.      |
|         | repetitive activities,      |                             |
|         | reaching to high or low     | Can you use a mechanical    |
|         | work-heights, Prolonged     | lift, hand truck, or other  |
|         | forward-bending; other      | equipment to help reduce    |
|         | static/awkward postures*)   | the load?                   |
|         |                             |                             |
|         |                             | Can you lift the load       |
|         |                             | safely, or is it a 2- or    |
|         |                             | more person lift? If        |
|         |                             | there's any doubt, ask for  |
|         |                             | help.                       |
+---------+-----------------------------+-----------------------------+
| Ele     | *(e.g. high voltage         |                             |
| ctrical | sources, work near water)*  |                             |
+---------+-----------------------------+-----------------------------+
| Other   | *(including confined space, |                             |
|         | trenching and excavation,   |                             |
|         | rigging, high pressure,     |                             |
|         | laser, fire, use of boat or |                             |
|         | aircraft)*                  |                             |
+---------+-----------------------------+-----------------------------+

## \*Hazardous Waste Site Attachment

If the site is known or suspected to contain hazardous waste and
LBNL-ESD is the primary site manager, attach completed site-specific
safety plan, as required by 29 CFR 1910.120.

Other Measures to Reduce Identified Risks

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

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

**Required Safety Training and Personal Protective Equipment**

  -----------------------------------------------------------------------
  General Safety Training: (*This includes First Aid, CPR and Fire
  Extinguisher. For remote locations, at least one of the site personnel
  must have first aid and CPR. If LBNL site personnel are not required to
  have first aid and CPR, provide explanation.)*

  Required Safety Training for special task or special zone personnel:

  Daily Onsite Safety Meetings *(describe who will lead the meetings, and
  what will be covered).*

  *If safety training is required by host organization attach document*
  (e.g. memo from host).
  -----------------------------------------------------------------------

## 

## Personal Protective Equipment (PPE)

+-----------------------------------------------------------------------+
| PPE required for all persons on-site:                                 |
|                                                                       |
| *(employee expenditures for personal items required for work, such as |
| mosquito repellent and sunscreen are reimbursable)*                   |
+-----------------------------------------------------------------------+
| PPE required for personnel working on special tasks or in special     |
| zones:                                                                |
+-----------------------------------------------------------------------+

### Environmental Protection {#environmental-protection .unnumbered}

  -----------------------------------------------------------------------
  **Does this work present any of the following Potential Threats to the
  Environment**: Fluid injection or withdrawal, tracer release, biotic
  sample collection, presence of threatened or endangered species,
  protected wetland, surface water, archeological resources, other:
  (indicate N/A if not applicable)

  **If yes, describe measures that will be taken to mitigate potential
  environmental damage**:
  -----------------------------------------------------------------------

### If any of the following Site and Work Clearances and Permits are required, indicate who prepared the document, and date of approval: (indicate N/A if not applicable) {#if-any-of-the-following-site-and-work-clearances-and-permits-are-required-indicate-who-prepared-the-document-and-date-of-approval-indicate-na-if-not-applicable .unnumbered}

> Owner Permission, Utilities Screening, Dig or Drill Permit, Blastic
> Permit, USEPA, Water Quality Board, Air Quality Board, US Fish &
> Wildlife, Cal Fish & Game, or other:

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

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

### Signatures {#signatures .unnumbered}

The information provided in this plan is, to the best of my knowledge,
accurate and complete as of the date of signing. Significant changes in
situation, personnel, equipment, materials and work plans shall be
appended as soon as they are known.

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

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

Principal Investigator Date

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

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

ESD Safety Coordinator Date

### Reading Acknowledgement {#reading-acknowledgement .unnumbered}

## I have read the Off-Site Safety and Environmental Protection Plan, and any amendments for

  -----------------------------------------------------------------------
  *(Insert Project Title)*

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

and have been made aware by the Principal Investigator (PI), Site-Safety
Officer (SSO) or my immediate supervisor of the safety and environmental
hazards contained within. I understand that if I have any questions or
concerns I may seek resolution from the PI, Site Safety Officer, my
supervisor, or other coworker, to my satisfaction. I WILL NOTIFY MY
SUPERVISOR THAT I AM PARTICIPATING IN THIS FIELD WORK.

Employee No. Print Name Signature Date

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

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

                                                                  

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

### Attachments {#attachments .unnumbered}

  -----------------------------------------------------------------------
  **Itemize all attachments here. Attachments may include** LBNL
  Personnel Training Records, Site Maps, Personal Emergency Contact
  Information, copies of passport and visa for foreign travel.

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

#### BIOLOGICAL HAZARDS, INDICATIONS, PRECAUTIONS AND RESPONSE

[Ticks]{.underline}: Exposure to ticks which may harbor the bacteria
responsible for Lyme disease can be found in the western states,
particularly Northern California, northeast states, and north-central
states. Precautionary measures to prevent exposure include:

-   Wear light-colored clothing so that ticks can be spotted more
    easily.

-   Tuck pant legs into socks or boots and shirt into pants.

-   Spray insect repellent containing DEET on clothes and on exposed
    skin other than the face.

-   Wear a hat and a long-sleeved shirt for added protection.

-   Walk in the center of trails to avoid overhanging grass and brush.

-   Inspect the backs of co-workers during the day.

After being outdoors, remove clothing and wash and dry it at a high
temperature; inspect body carefully and remove attached ticks with
tweezers, grasping the tick as close to the skin surface as possible and
pulling straight back with a slow steady force; avoid crushing the
tick\'s body.

[Early Lyme Disease]{.underline}: The early stage of Lyme disease is
usually marked by one or more of the following symptoms and signs:

-   Fatigue

-   Chills and fever

-   Headache

-   Muscle and joint pain

-   Swollen lymph nodes

-   A characteristic skin rash, called erythema migrans.

[Erythema migrans]{.underline}: Is a red circular patch that appears
usually 3 days to 1 month after the bite of an infected tick at the site
of the bite. The patch then expands, often to a large size. Sometimes
many patches appear, varying in shape, depending on their location. The
center of the rash may clear as it enlarges, resulting in a bulls-eye
appearance. Not all rashes that occur at the site of a tick bite are due
to Lyme disease, however. For example, an allergic reaction to tick
saliva often occurs at the site of a tick bite. Allergic reactions to
tick saliva usually occur within hours to a few days after the tick
bite, usually do not expand, and disappear within a few days. Any signs
or symptoms of Lyme Disease occurring after a tick bite should be
evaluated by a physician.

[Snakes]{.underline}: Two families of venomous snakes are native to the
United States. The vast majority are pit vipers, of the family
Crotalidae, which include rattlesnakes, copperheads and cottonmouths
(water moccasins). About 99 percent of the venomous bites in this
country are from pit vipers. Some snakes carry a neurotoxic venom that
can affect the brain or spinal cord. Copperheads, on the other hand,
have a milder

and less dangerous venom that sometimes may not require antivenin
treatment. The other family of domestic poisonous snakes is Elapidae,
which includes two species of coral snakes found chiefly in the Southern
states. Though coral snakebites are rare in the United States\--only
about 25 a year by some estimates\--the snake\'s neurotoxic venom can be
dangerous. A 1987 study in the Journal of the American Medical
Association examined 39 victims of coral snakebites. There were no
deaths, but several victims experienced respiratory paralysis, one of
the hazards of neurotoxic venom. Some bites, such as those inflicted
when snakes are accidentally stepped on or encountered in wilderness
settings, are nearly impossible to prevent. But the following
precautions can lower the risk of being bitten:

-   Leave snakes alone.

-   Stay out of tall grass unless you wear thick leather boots, and
    remain on paths as much as possible.

-   Keep hands and feet out of areas you can\'t see.

-   Be cautious and alert when climbing rocks.

According to the American Red Cross, these steps should be taken if
bitten by a poisonous snake:

-   Wash the bite with soap and water.

-   Immobilize the bitten area and keep it lower than the heart.

-   Get medical help.

-   If a victim is unable to reach medical care within 30 minutes, a
    bandage, wrapped two to four inches above the bite, may help slow
    venom. The bandage should not cut off blood flow from a vein or
    artery. A good rule of thumb is to make the band loose enough that a
    finger can slip under it.

-   A suction device may be placed over the bite to help draw venom out
    of the wound without making cuts. Suction instruments often are
    included in commercial snakebite kits.

**HEAT HAZARDS, INDICATIONS AND RESPONSE**

## Exposure to high temperatures without adequate fluid intake or breaks can result in heat exhaustion or heat stroke.

[Heat exhaustion]{.underline}: Is caused by the loss of large amounts of
fluid by sweating, sometimes with excessive loss of salt. A worker
suffering from heat exhaustion still sweats but experiences extreme
weakness or fatigue, giddiness, nausea, or headache. In more serious
cases, the victim may vomit or lose consciousness. The skin is clammy
and moist, the complexion is pale or flushed, and the body temperature
is normal or only slightly elevated.

In most cases, treatment involves having the victim rest in a cool place
and drink plenty of liquids. Victims with mild cases of heat exhaustion
usually recover spontaneously with this treatment. Those with severe
cases may require extended care for several days. There are no known
permanent effects.

[Heat stroke]{.underline}: Is the most serious of health problems
associated with working in hot environments. It occurs when the body\'s
temperature regulatory system fails and sweating becomes inadequate. The
body\'s only effective means of removing excess heat is compromised with
little warning to the victim that a crisis stage has been reached.

A heat stroke victim\'s skin is hot, usually dry, red or spotted. Body
temperature is usually 105F or higher, and the victim is mentally
confused, delirious, perhaps in convulsions, or unconscious. Unless the
victim receives quick and appropriate treatment, death can occur.

Any person with signs or symptoms of heat stroke requires immediate
hospitalization. However, first aid should be immediately administered.
This includes removing the victim to a cool area, thoroughly soaking the
clothing with water, and vigorously fanning the body to increase
cooling.

Further treatment at a medical facility should be directed to the
continuation of the cooling process and the monitoring of complications
that often accompany the heat stroke. Early recognition and treatment of
heat stroke are the only means of preventing permanent brain damage or
death.

**COLD HAZARDS, INDICATIONS AND RESPONSE**

## Common harmful effects of cold include frostbite and general hypothermia.

[Frostbite:]{.underline} Occurs when skin tissue actually freezes and
cell damage results. Fingers, toes, cheeks, nose, and ears are primarily
affected. The symptoms of frostbite include uncomfortable sensations of
coldness; there may be a tingling, stinging, or aching feeling followed
by numbness. Initially the frostbitten area appears white and is cold to
the touch. This is followed by heat, redness, and swelling. Occasionally
a victim may not be aware of the frostbite.

Tissue damage can be mild and reversible or severe, resulting in
scarring and tissue death. Amputation or loss of function can be an
unfortunate result. First aid includes treating affected areas with warm
water at 102° to 110°F. Be careful to avoid rubbing frostbitten areas
because this can lead to greater tissue injury. If there is a chance for
refreezing, do not rewarm the affected areas.

[General hypothermia]{.underline}: Is the progressive loss of body heat
with prolonged exposure to cold. Body heat loss is accelerated more
rapidly when a person is wet because of sweat or working in a damp
environment. Most cases of hypothermia develop in air temperatures
between 30° & 50°F, but significant hypothermia can occur with air
temperatures as high as 65°F (particularly when clothing is wet), or in
the water at 72 degrees F.

The first symptoms of hypothermia are uncontrollable shivering and
feeling of cold. As the body\'s temperature continues to drop, an
individual can become confused, careless, and disoriented. At this point
a person may make little or no effort to avoid further exposure to the
cold. For those working around machinery or animals, accidental injury
is an additional risk. When the core body temperature falls below 86°F,
the body's adaptive mechanisms for reducing heat loss become ineffective
and death can occur.

Individuals experiencing mild hypothermia should be immediately moved to
a warm, dry shelter. Further heat loss is minimized by removing wet
clothing and applying warm blankets for insulation. Warm, nonalcoholic,
caffeine-free drinks may be offered. More severe cases of hypothermia
require intensive medical care.