--------------------------------- ----------------------- --------------
  **To be completed by LBNL                                 
  Procurement**                                             

  Requisition Number                Subcontractor           PO Number:
                                                                 

  Requester/Division                Buyer                   
  --------------------------------- ----------------------- --------------

+-----------------------+----------------------------+-----------------+
| **To be completed by  |                            |                 |
| LBNL Requester /      |                            |                 |
| Division**            |                            |                 |
+-----------------------+----------------------------+-----------------+
| [Instr                |                            |                 |
| uctions]{.underline}: |                            |                 |
| The LBNL              |                            |                 |
| Requester/Division    |                            |                 |
| must complete this    |                            |                 |
| section of the form   |                            |                 |
| and return it to      |                            |                 |
| Berkeley Lab          |                            |                 |
| Procurement for new   |                            |                 |
| subcontracts. The     |                            |                 |
| Subcontractor must    |                            |                 |
| then complete Items   |                            |                 |
| 1-19 to identify all  |                            |                 |
| hazards that could be |                            |                 |
| present in the scope  |                            |                 |
| of work and the       |                            |                 |
| hazard control        |                            |                 |
| methods to be         |                            |                 |
| applied. If you have  |                            |                 |
| any questions in      |                            |                 |
| filling-in this       |                            |                 |
| document, please      |                            |                 |
| contact your Division |                            |                 |
| Safety Coordinator or |                            |                 |
| the Program Manager   |                            |                 |
| for Non-Construction  |                            |                 |
| Subcontractor Safety  |                            |                 |
| Assurance (NSSA) at   |                            |                 |
| (510) 486-5440.       |                            |                 |
+-----------------------+----------------------------+-----------------+
| Date Prepared         |                            |                 |
+-----------------------+----------------------------+-----------------+
| Estimated start time  |                            |                 |
| / length of job       |                            |                 |
| /                     |                            |                 |
+-----------------------+----------------------------+-----------------+
| Requester/Division    | Phone /Fax                 | E-Mail Address  |
|                       |                            |                 |
+-----------------------+----------------------------+-----------------+
| Prepared By           | Phone /Fax                 | E-Mail Address  |
|                       |                            |                 |
+-----------------------+----------------------------+-----------------+
| Scope of Work (Doing  |                            |                 |
| what, where, with     |                            |                 |
| what materials):      |                            |                 |
|                       |                            |                 |
|                       |                            |                 |
+-----------------------+----------------------------+-----------------+
| Job Location (Bldg.   |                            |                 |
| No.) / Site           |                            |                 |
+-----------------------+----------------------------+-----------------+

  --------------------------------- -------------------------------------
  Date Completed                    Requestor/Division Approval      

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

**To Be Completed by Subcontractor/Vendor**

> **Completion of this completed form is a prerequisite for beginning
> work**
>
> [Instructions]{.underline}: Complete this form for on-site services
> involving hands-on work and bring it to the LBNL site for review and
> approval by the University Technical representative (Requester) or
> designee. When possible, also send the completed form (by fax or
> e-mail) to the Requestor/Division prior to coming to the LBNL site.
> Identify all hazards that could be present. If a box is checked "Yes,"
> then additional documentation may be required. If you have any
> questions about filling-in this document, please contact the
> Requestor/Division identified above. This completed checklist is
> equivalent to a Safety Management Plan for the scope of work and
> constitutes subcontractor submission of an Injury and Illness
> Prevention Plan (IIPP). Prior to arriving at the LBNL site,
> subcontractor personnel performing the work should review the *LBNL
> Non-Construction Safety Orientation* located at
> http://www.lbl.gov/ehs/ssa/nssa/

  ----------------------------------- ----------------- ------------------
  Subcontractor Point of Contact      Phone             Pager      
                                                        

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

*Instructions: Check either Yes or No to each of the questions in the
summary list below. If you answer Yes to any of the questions, refer to
the same question in accompanying checklist and provide the requested
information.*

Yes No

1\. **Facility Modification** -- Does the scope of your job include any
modifications to our facility? If so, describe on following page.

2\. **Utilities Shut-Off \--** Does the work involve shutting off any
electrical circuits, water, gas, or steam valves, or other utilities? If
so, specify which utilities are to be shut off.

3\. **Electrical Work \--**Will work be performed on any electrical
component or equipment (i.e., work involving installation, demolition,
modification or testing and analysis of electrical equipment or
conductors)? If so, describe on the following page.

4\. **Personal Protective Equipment** -- Does the scope of the work
involve hazards that require the use of any personal protective
equipment. If so, describe on the following page.

5\. **Fall Protection** -- Will you be working at heights above 6 feet
and within 15 feet of an unprotected edge? If so, describe the work
which will require fall protection on the following page.

6\. **Fire Protection/Prevention** -- Will your work include the use of
open flames such as torches, welders, grinders, tar pots or any other
tool or process/procedure that could cause sparks or open flames? Will
work be performed near combustible storage containers? Describe on the
following page.

7\. **Welding/Brazing/Soldering**? Will your work include processes that
join materials? Describe on the following page.

8\. **Refrigeration Repair or Maintenance** -- Will your work include
work on chillers? If so, describe on the following page.

9\. **Power & Hand Tool** -- Will your work require the use of dangerous
power and hand tools, e.g.; circular saws, axes, chisels, etc.? If so,
list the tools and describe their use on the following page.

10\. **Hazard Communication/Toxic** **Substances** -- Will the scope of
your work require the use of hazardous substances? If so, list all that
apply below and include requested information on the following page.

11\. **Excavation of Ground Surfaces and Penetration of Existing
Concrete Structures** -- Will the scope of your work require you to
perform any mounting to walls or penetration (including chipping) into
the ground, walls, floors, sub floors, and/or any excavation, trenching,
including the use of stakes or poles? Describe including the depth of
the penetration on the following page.

12\. **Confined Space Entry** -- Will the scope of your work require you
to be working in a confined space (including manholes) where
combustible, toxic, or other hazardous materials are present. If so,
describe on the following page.

13\. **Lead Paint Removal** -- Will the work involve sanding, grinding,
scraping, brazing, welding, or otherwise disturbing painted surfaces in
such a way that particles may become airborne? If so, describe the scope
of work you will be performing that disturbs the lead.

14\. **Painting Walls** -- Does the scope of your work include sanding
walls and/or ceilings or washing of exterior walls (There is a potential
for disturbing lead or asbestos)? If so, describe.

15\. **Asbestos** -- Will you work with asbestos? Is so, describe the
scope of your work that will involve removing the asbestos, how much
asbestos your will be removing.

16\. **Lasers** -- Will you be working on Class 3B or Class 4 lasers or
microwave sources greater than 5 mW/cm2, including warranty work. If so,
describe your scope of work.

17 **Radiation Safety** -- Will radiography be performed or radioactive
materials or ionizing radiation sources be used? If so, describe the
hazards below and how you will protect the worker.

18\. **Hazardous and Radiological Waste** -- Does the scope of work
include the generation of hazardous or radiological waste? If so,
describe the wastes and how you will minimize the generation of the
waste.

19\. **Other** -- Identify any other hazard associated with this job and
the controls you are planning on using to protect the worker.

Yes No

1\. **Facility Modification** -- Does the scope of your job include any
modifications to our facility? If so, describe below.

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

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

2\. **Utilities Shut-Off**

Does the work involve shutting off any electrical circuits, water, gas,
or steam valves, or other utilities? If so, specify which utilities are
to be shut off.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

And, provide written policy and procedure to be followed to perform
lock-out and tag-out operations. See LBL EHS manual, Chapter 18 for
minimum requirements (http://www.lbl.gov/ehs/pub3000/CH18.html).

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

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

3\. **Electrical Work**

Will work be performed on any electrical component or equipment (i.e.,
work involving installation, demolition, modification or testing and
analysis of electrical equipment or conductors)? If so, describe below

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

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

Describe the hazards involved and how you will protect the worker.

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

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

Will your work be performed near any open or exposed electrical
energized equipment or energized circuits (greater than 50 volts)? If
so, describe below.

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

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

Describe the hazards involved and how you will protect the worker

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

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

4\. **Personal Protective Equipment** -- Does the scope of the work
involve hazards that require the use of any of the protective equipment
listed below?

+------------+-------------+-------------+---------------------------+
| Check all  | PPE         | Hazard(s)   | Worker Protection         |
| that Apply | Required    | Description | Method(s)                 |
+------------+-------------+-------------+---------------------------+
|            | Safety      |             |                           |
|            | Glasses     |             |                           |
+------------+-------------+-------------+---------------------------+
|            | Ear plugs   |             |                           |
|            | or ear      |             |                           |
|            | muffs       |             |                           |
+------------+-------------+-------------+---------------------------+
|            | Steel toes  |             |                           |
|            | shoes       |             |                           |
+------------+-------------+-------------+---------------------------+
|            | Gloves      |             |                           |
+------------+-------------+-------------+---------------------------+
|            | Respirators |             | [Additional Documentation |
|            |             |             | required:]{.underline}    |
|            |             |             |                           |
|            |             |             | -   Respiratory           |
|            |             |             |     Protection Plan       |
|            |             |             |                           |
|            |             |             | -   Medical Release       |
|            |             |             |                           |
|            |             |             | -   Quantitative Test     |
|            |             |             |                           |
|            |             |             | -   Fit Test Records      |
|            |             |             |                           |
|            |             |             | -   Training Records      |
+------------+-------------+-------------+---------------------------+
|            | Electrical  |             |                           |
|            | personal    |             |                           |
|            | protective  |             |                           |
|            | equipment   |             |                           |
+------------+-------------+-------------+---------------------------+
|            | Other       |             |                           |
|            | personal    |             |                           |
|            | protective  |             |                           |
|            | equipment   |             |                           |
+------------+-------------+-------------+---------------------------+

5\. **Fall Protection** -- Will you be working at heights above 6 feet
and within 15 feet of an unprotected edge? If so, describe the work
which will require fall protection.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

6\. **Fire Protection/Prevention** -- Will your work include the use of
open flames such as torches, welders, grinders, tar pots or any other
tool or process/procedure that could cause sparks or open flames? Will
work be performed near combustible storage containers? Describe below.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

7\. **Welding/Brazing/Soldering**? Will your work include processes that
join materials? Describe below.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

8\. **Refrigeration Repair or Maintenance** -- Will your work include
work on chillers? If so, describe below.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

9\. **Power & Hand Tool** -- Will your work require the use of dangerous
power and hand tools, e.g.; circular saws, axes, chisels, etc.? If so,
list the tools and describe their use below.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

10\. **Hazard Communication/Toxic** **Substances** -- Will the scope of
your work require the use of hazardous substances? If so, check all that
apply below and include requested information.

+--------+----------+------------+---------------+-------------------+
| Check  | Type of  | List       | Hazard(s)     | Worker Protection |
| all    | H        | materials  | Description   | Method(s)         |
| that   | azardous | or         |               |                   |
| Apply  | S        | products,  |               |                   |
|        | ubstance | attach     |               |                   |
|        |          | material   |               |                   |
|        |          | safety     |               |                   |
|        |          | data       |               |                   |
|        |          | sheets.    |               |                   |
+--------+----------+------------+---------------+-------------------+
|        | C        |            |               | -   Attach your   |
|        | hemicals |            |               |     Hazard        |
|        | or       |            |               |     Communication |
|        | chemical |            |               |     Program.      |
|        | related  |            |               |                   |
|        | products |            |               |                   |
+--------+----------+------------+---------------+-------------------+
|        | Gases    |            |               | -   Attach your   |
|        |          |            |               |     Hazard        |
|        |          |            |               |     Communication |
|        |          |            |               |     Program.      |
+--------+----------+------------+---------------+-------------------+
|        | Bi       |            |               | -   Attach your   |
|        | ological |            |               |     Biosafety     |
|        | m        |            |               |     Program.      |
|        | aterials |            |               |                   |
+--------+----------+------------+---------------+-------------------+
|        | F        |            |               | -   Attach your   |
|        | lammable |            |               |     Hazard        |
|        | ma       |            |               |     Communication |
|        | terials, |            |               |     Program.      |
|        | i        |            |               |                   |
|        | ncluding |            |               |                   |
|        | f        |            |               |                   |
|        | lammable |            |               |                   |
|        | a        |            |               |                   |
|        | dhesives |            |               |                   |
|        | and      |            |               |                   |
|        | glues    |            |               |                   |
+--------+----------+------------+---------------+-------------------+
|        | Rad      |            |               | -   Attach your   |
|        | ioactive |            |               |     Radiation     |
|        | m        |            |               |     Protection    |
|        | aterials |            |               |     Program.      |
|        | or       |            |               |                   |
|        | r        |            |               |                   |
|        | adiation |            |               |                   |
|        | ge       |            |               |                   |
|        | nerating |            |               |                   |
|        | devices  |            |               |                   |
|        | \>       |            |               |                   |
|        | Class1   |            |               |                   |
+--------+----------+------------+---------------+-------------------+

11\. **Excavation of Ground Surfaces and Penetration of Existing
Concrete Structures** -- Will the scope of your work require you to
perform any mounting to walls or penetration (including chipping) into
the ground, walls, floors, sub floors, and/or any excavation, trenching,
including the use of stakes or poles? Describe including the depth of
the penetration.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

12\. **Confined Space Entry** -- Will the scope of your work require you
to be working in a confined space (including manholes) where
combustible, toxic, or other hazardous materials are present.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

Attach your Confined Space Program.

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

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

13\. **Lead Paint Removal** -- Will the work involve sanding, grinding,
scraping, brazing, welding, or otherwise disturbing painted surfaces in
such a way that particles may become airborne? If so, describe the scope
of work you will be performing that disturbs the lead.

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

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

Describe how you plan to control the spread of airborne lead and protect
the worker.

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

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

14\. **Painting Walls** -- Does the scope of your work include sanding
walls and/or ceilings or washing of exterior walls (There is a potential
for disturbing lead or asbestos)? If so, describe.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

15\. **Asbestos** -- Will you work with asbestos? Is so, describe the
scope of your work that will involve removing the asbestos, how much
asbestos your will be removing.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

Attach your asbestos program.

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

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

16\. **Lasers** -- Will you be working on Class 3B or Class 4 lasers or
microwave sources greater than 5 mW/cm2, including warranty work. If so,
describe your scope of work.

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

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

Describe the hazards involved and how you will protect the worker.

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

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

Attach your laser safety program.

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

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

17 **Radiation Safety** -- Will radiography be performed or radioactive
materials or ionizing radiation sources be used? If so, describe the
hazards below and how you will protect the worker.

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

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

Have you completed General Employee Radiation Training (EHS 405) at
LBNL?

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

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

18\. **Hazardous and Radiological Waste** -- Does the scope of work
include the generation of hazardous or radiological waste? If so,
describe the wastes and how you will minimize the generation of the
waste.

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

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

19\. **Other** -- Identify any other hazard associated with this job and
the controls you are planning on using to protect the worker.

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

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**Notes**