APS WORK/PROJECT CHECKLIST

***(To be used for non-ANL non-User hands-on work at the APS.)***

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  **Part 1. Work/Project Description** (To be completed by the requestor)

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Job Title: [     ]{.underline} Date: [     ]{.underline}

Location of Work: [     ]{.underline}

Requestor: [     ]{.underline} Phone No: [     ]{.underline}
Organization: [     ]{.underline}

APS Coordinator: [     ]{.underline} Phone No: [     ]{.underline} Pager
No: [     ]{.underline}

Proposed Start Date: [     ]{.underline} Required Completion Date:
[     ]{.underline}

Job Description : [     ]{.underline}

General Comments/Potential Safety Issues: ­­­­­ [     ]{.underline}

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  **Part 2. Risk Classification & Contractor Access Requirements** (To be
  completed by APS Coordinator or ESH Coordinator)

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Risk Classification: Construction High Moderate Low Determiner
[     ]{.underline}

Documentation: Full Safety Plan Job Safety Analysis No Documentation
Required (Date) [     ]{.underline}

Contractor Training: Contractor Safety Orientation Mini-Contractor
Safety Orientation Bldg. Orient. Other

Other Requirements: [     ]{.underline}

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

(Permits, Escorts, etc.)

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  **Part 3. Design and ESH Review** (APS Coordinator to obtain approvals
  as necessary)

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######## 

######## Reviewed Designated/Alternate Signature & Date Check If 

######## Y N/A Comments Attached

APS Conventional Facilities [*R. Janik /J. Sidarous*]{.underline}

Industrial Hygiene [*R. Hinterman/J. Davis*]{.underline}

Health Physics [*J. Vacca/S. Butala*]{.underline}

Fire Protection [*T. Tess/G. Schroeder*]{.underline}

Environmental Review [*T. Barkalow /J. Lang*]{.underline} NEPA Ref No:
[     ]{.underline} Occupant [     ]{.underline}

Work for CATS [*E. Chang/P. Rossi*]{.underline}

FMS Building Maintenance [*G. Kailus /J. Golema*]{.underline}

Building Manager [*R. Whitman /E. Russell /B. Tasker*]{.underline}

Laser Safety [*E. Chang/B. Murdoch*]{.underline}

Shielding Design [*Julie Cross/Patricia Fernandez*]{.underline}

Other [     ]{.underline} [     ]{.underline}

(specify)

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  **Part 4. Project Management** (To be completed before authorization to
  proceed is signed by APS Coordinator)

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ANL Requisition No: [     ]{.underline} or N/A Name of Contractor:
[     ]{.underline} Contract No: [     ]{.underline}

Contractor Manager/Supervisor: [     ]{.underline} Phone/Pager:
[     ]{.underline}

Contractor Safety Coordinator: [     ]{.underline} 10 Hr OSHA or
Equivalent training

Safety Plan/JSA Title & approval date: [     ]{.underline} or Blanket
JSA No: [     ]{.underline}

Authorization to Proceed: [     ]{.underline}

(APS Coordinator)