Before using a copy of this form, verify that it is an acceptable
version by checking with your Experiment Review Coordinator.
Double-click to change the state of a checkbox, or type "X" over the
box, or paste this 

######### EXPERIMENT SAFETY REVIEW FORM

#  REVIEW NUMBER (supplied by ERC): 

**PRINCIPAL INVESTIGATOR: DATE:**

**GROUP:**

**EXT: E-MAIL: LIFE NUMBER:**

**I. DEFINE THE SCOPE OF WORK**

######## Description

*Describe the experiment purpose/scope. Identify all apparatus that will
be used, and associated requirements. List special equipment (X-ray
generators, lasers etc.) that will be used during the project. Identify
measurement and test equipment, apparatus operating conditions, and
required maintenance procedures as appropriate. Include calibration
frequency for formal [calibration
requirements](https://sbms.bnl.gov/standard/05/0500t011.htm). Attach
supporting documents such as engineering calculations, drawings and
specifications.*

*Indicate if modification of facility is required. Include the setup and
decommissioning phases of the experiment. The Work Permit Process/Form
may better address the hazards & controls of the set-up and/or tear down
phases. Indicate if a Work Permit will be used.*

[Enter text here...]{.mark}

######## Materials Used /Waste Generated 

*List materials to be used and wastes generated. Refer to the [**BNL
Chemical Management
System**](http://www.bnl.gov/esh/shsd/cms/main_e.htm) for a complete
listing of the chemicals in your locations. Include samples, chemicals,
controlled substances, gases, cryogens, radioactive materials, and
biological material. You may use generic chemical class descriptions for
commonly used materials (e.g., organic solvents, acids). List disposal
methods. Denote disposal method using the codes below.*

  -------------------------------- ----------- ----------- ---------- ------------
  Materials Used & Wastes          Disposal    Estimated              Estimated
  Generated                        Method Type Quantity               Annual Waste
                                   (Code       (provide               Generation
                                   below)      units)                 

                                               Per Use     Total/Yr   

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

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

[Note]{.underline}: Identify [**Age Sensitive materials or special
handling requirements**](https://sbms.bnl.gov/standard/2n/2n00t011.htm).

Disposal Method Codes:

  --------------- ----------------- --------------------------------------
  Air Emissions   Liquid Effluents  Wastes

  P = Point       S = Sanitary      H = Hazardous
  Source                            

  F = Fugitive    ST = Storm water  I = Industrial (Non-hazardous waste
                                    e.g., oils)

                  O = Other         R = Radioactive

                                    M = Mixed (Radioactive + Hazardous)

                                    RM = Radioactive Medical

                                    MW = Medical

                                    T = Trash
  --------------- ----------------- --------------------------------------

C. Waste Minimization/Pollution Prevention

*Describe how you plan to minimize generation of the wastes described
above, and identify pollution prevention opportunities. Consider
Ordering/using the smallest amount, using recycled material substituting
non-hazardous materials. The [**Pollution Prevention and Waste
Minimization Subject
Area**](https://sbms.bnl.gov/standard/08/0800t011.htm) describes how to
plan, conduct, and closeout work activities to eliminate or minimize the
impact of their activities on the environment.*

[A plan is required here...]{.mark}

**II. IDENTIFY AND ANALYZE HAZARDS ASSOCIATED WITH THE WORK**

In this section indicate the hazards in each class. Include the setup
and decommissioning phases of the experiment.

  ------------------------------------------------------------- ----------------------- ------------- ---------------------- ---------- ------- --------------
  **Physical Hazards** (check all that apply)                                                         **** None                                

  **** Cryogens                                                **** Oxygen deficient                                                  ****   
                                                                atmosphere                                                              Noise   
                                                                                                                                        \> 85   
                                                                                                                                        dBA     

  **** Fall hazards (e.g., ladders, elevated platforms,                                                                                        
  towers)                                                                                                                                       

  **** Material handling equipment (e.g., cranes, hoists,                                                                                      
  forklifts)                                                                                                                                    

  **** Machine shop or nonportable powered tools use                                                                                           

  **** Electrical hazards (exposed conductors, large                                                                                           
  batteries, capacitors, etc)                                                                                                                   

  **** Confined space                                                                                **** Trenching/soil                      
                                                                                                      excavation                                

  **** Extreme temperatures in workplace                                                             **** Remote location                     

  **** Compressed gases (lecture bottles, cylinders, gas                                                                                       
  lines)                                                                                                                                        

  **** Pressurized vessels or systems                                                                                                          

  **** Vacuum chambers or systems with \>1000 J stored energy                                                                                  

  **** Autoclaves or high temperature ovens                                                                                                    

  **** Open flames                                                                                   **** Welding,                            
                                                                                                      brazing, silver                           
                                                                                                      soldering                                 

  **** Flammable gases/liquids/solids                                                                **** Other spark                         
                                                                                                      producing activity                        

  **** Other (specify):                                                                                                                        

  **Chemical Hazards** (check all that apply)                                                         **** None                                

  **** Carcinogens                                             **** Highly acute                    **** Reproductive                        ****
                                                                toxins                                toxins                                    Corrosives

  **** Flammable liquids                                       **** Flammable solids                **** Strong oxidizers                    **** Oils

  **** Explosives                                              **** Peroxidizables                  **** Pyrophoric                          **** PCBs
                                                                                                      materials                                 

  **** Asbestos                                                ****                                 **** Controlled                          
                                                                Pesticides/herbicides                 substances                                

  **** Highly reactive materials                                                                     **** Perchlorates                        

  **** Storage or use of Beryllium or Beryllium articles.                                                                                      
  Attach [Beryllium Use Review                                                                                                                  
  Form](https://sbms.bnl.gov/standard/12/1201e011.htm) if                                                                                       
  checked.                                                                                                                                      

  **** Toxic metals (e.g., As, Ba, Be, Cd, Cr, Hg, Pb, Se, Ag)                                                                                 

  **** Other (specify):                                                                                                                        

  **Radiation Hazards** (check all that apply)                                                        **** None                                

  **** Sealed radioactive sources                                                                    **** Windowless                          
                                                                                                      radioactive sources                       

  **** Dispersible radioactive materials                                                             **** Neutron-emitting                    
                                                                                                      radioactive sources                       

  **** Non-fissionable radioactive materials                                                         **** Fissionable                         
                                                                                                      radionuclides                             

  **** Ionizing radiation-generating devices (x-ray sources,                                                                                   
  accelerators)                                                                                                                                 

  **** Class II, IIIa, or IIIb (visible \<15mW) lasers                                               **** Class IIIb                          
                                                                                                      (nonvisible \>15mW) or                    
                                                                                                      IV lasers                                 

  **** Dynamic magnetic fields \>1G at 60 Hz or dynamic                                                                                        
  electric fields \> 1kV/m at 60 Hz                                                                                                             

  **** Static magnetic fields \< 5 G. No Exposure Form is                                                                                      
  required                                                                                                                                      

  **** Static magnetic fields \> 5 G and \< 600 G                                                    **** Static magnetic                     
                                                                                                      fields exposure.                          
                                                                                                      Attach Static Magnetic                    
                                                                                                      Fields Exposure Form                      
                                                                                                      when required.                            

  **** Static magnetic fields ≥ 600 G                                                                                                          

  **** Radio frequency (RF) or Microwave sources exceeding 10                                                                                  
  mW radiated output                                                                                                                            

  **** Infrared sources \> 10 W                                                                      **** Ultraviolet                         
                                                                                                      sources \> 1 W                            

  **** Extremely low frequency (ELF) radio sources                                                                                             

  **** Other (specify):                                                                                                                        

  **Biological Hazards** (check all that apply)                                                       **** None                                

  **** Regulated etiological agent                                                     ****                                ****              
                                                                                        Recombinant                          Animals            
                                                                                        DNA                                                     

  **** Human blood/components, human tissue/body fluids                                                                     ****              
                                                                                                                             Human              
                                                                                                                             subjects           

  **** Other (specify):                                                                                                                        

  **Offsite Work** (check appropriate box)                                                            **** None                                

  **** Reviewed or controlled by ES&H programs at the offsite                                        **** Requires                            
  location                                                                                            additional controls                       
                                                                                                      (include in the next                      
                                                                                                      section)                                  

  **[Security Issues                                                                                  **** None                                
  Checklist](https://sbms.bnl.gov/standard/3k/3k22e011.htm)**                                                                                   
  (check all that apply)                                                                                                                        

  **** Access controls                                                                               **** Cyber security                      

  **** Classified materials or information                                                           ****                                     
                                                                                                      Counter-intelligence                      
                                                                                                      work                                      

  **** Import or export controls                                                                     **** Personnel                           
                                                                                                      security                                  

  **** Nuclear material control and accountability                                                   **** Valuable                            
                                                                                                      materials                                 

  **** Other (specify):                                                                                                                        
  ------------------------------------------------------------- ----------------------- ------------- ---------------------- ---------- ------- --------------

*See [Identification of Significant Environmental Aspects and Impacts
Subject Area](https://sbms.bnl.gov/standard/0m/0m00t011.htm)* or your
ECR if you need assistance completing the following table.

  -------------------------------------------------------- -----------------------
  Significant Environmental Aspects (check all that apply)  None

   Any amount of hazardous waste generation               

   Any amount of radioactive waste generation             

   Any amount of mixed waste generation (radioactive      
  hazardous waste)                                         

   Any amount of transuranic waste generation             

   Any amount of industrial waste generation (e.g., oils, 
  vacuum pump oil)                                         

   Any amount of Regulated Medical Waste                  

   Any atmospheric discharges that require engineering    
  controls to reduce hazardous air pollutants or           
  radioactive emissions, or are identified as a Title V    
  emission unit, or require monitoring under NESHAP        

   Any liquid discharges that require engineering         
  controls to limit the quantity or concentration of the   
  pollutant, or include radionuclides detectable at the    
  point of discharge from the facility, or contain any of  
  the chemicals listed on BNL's SPDES permit               

   Storage or use of any chemicals or radioactive         
  materials that require engineering controls -- see       
  [**Storage and Transfer of Hazardous and Nonhazardous    
  Materials Subject                                        
  Area**](https://sbms.bnl.gov/standard/0k/0k00t011.htm)   

   On-site or off-site transportation of chemicals or     
  dispersible radioactive materials                        

   Any use of once-through cooling water with a flow of 4 
  gpm -- 24 hrs/day (10 gpm -- 8 hrs/day, daily use of     
  \>15 gpm for \>60 days) and discharging to the sanitary  
  sewer                                                    

   Soil contamination or activation                       

   Any underground pipes/ductwork that contains chemical  
  or radioactive material/contamination                    

   Other environmental aspects related to your work       
  (specify):                                               

   Process Assessment Form required (determined by ECR or 
  other qualified person)                                  
  -------------------------------------------------------- -----------------------

**III. DEVELOP AND IMPLEMENT HAZARD CONTROLS**

*For each hazard identified in the previous section, describe how that
hazard is controlled. Identify the **Engineering Controls (e.g.,
interlocks, shielding), Administrative Controls (e.g., procedures, RWPs)
or Personal Protective Equipment (e.g., respirators, gloves; see the
[Personal Protective Equipment Subject
Area](https://sbms.bnl.gov/standard/2r/2r00t011.htm)**) that will be
employed to reduce hazards to acceptable levels.*

*The Experiment Review Coordinator, along with the **Principal
Investigator** (PI) and Building Manager, as appropriate, will evaluate
this experiment for impacts that will require an update to the Facility
Use Agreement (FUA), and or Fire/Rescue Run Cards.*

*The **PI** develops and implements hazard controls in consultation
with, and using feedback from, the personnel who will be performing the
work.*

####  {#section .unnumbered}

#### A. Physical Hazards/Controls  {#a.-physical-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

#### *[Note]{.underline}: Include maintenance, inspection and testing, and formal calibration, including frequency as appropriate.* {#note-include-maintenance-inspection-and-testing-and-formal-calibration-including-frequency-as-appropriate. .unnumbered}

#### B. Chemical Hazards/Controls {#b.-chemical-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: Refer to the [Working with Chemicals Subject
Area](https://sbms.bnl.gov/standard/17/1700t011.htm) for requirements
regarding particularly hazardous chemicals such as carcinogens,
reproductive toxins, and highly acute toxins, including postings,
decontamination plan, and address above.*

#### C. Environmental Hazards/Controls {#c.-environmental-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
|                         |                                            |
+-------------------------+--------------------------------------------+
|                         |                                            |
+-------------------------+--------------------------------------------+
|                         |                                            |
+-------------------------+--------------------------------------------+
|                         |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: Identify the requirements from applicable waste
management subject area
([**hazardous**](https://sbms.bnl.gov/standard/0e/0e00t011.htm),
[**radioactive**](https://sbms.bnl.gov/standard/0h/0h00t011.htm),
[**mixed**](https://sbms.bnl.gov/standard/0f/0f00t011.htm), [**regulated
medical**](https://sbms.bnl.gov/standard/0p/0p00t011.htm)). List all
applicable environmental permits (Suffolk County Art. XII, Title V
Emission Source, etc.) and the relevant controls required by those
permits.*

#### D. Radiation Hazards/Controls {#d.-radiation-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: List sources/materials. Attach or refer to
Radiation Work Permits.*

#### E. Biological Hazards/Controls {#e.-biological-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: List additional approvals/permits/reviews required
(e.g., BNL Biosafety Committee approval).*

#### F. Offsite Work Hazards/Controls {#f.-offsite-work-hazardscontrols .unnumbered}

+-------------------------+--------------------------------------------+
| ### Hazard              | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: List the location of all off-site work and identify
any off-site organization whose ESH requirements will be followed (e.g.,
other DOE Labs). Indicate additional controls (not specified above) that
are needed.*

G. Security Issues/Controls

+-------------------------+--------------------------------------------+
| ### Issue               | **Controls (Administrative, Engineered,    |
|                         | Protective Equipment)**                    |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+
| ###                     |                                            |
+-------------------------+--------------------------------------------+

*[Note]{.underline}: See the [Security
Checklist](https://sbms.bnl.gov/standard/3k/3k22e011.htm), and, if
necessary, consult the security office at 4691 or 4496 for more
information or guidance.*

**IV. PERFORM WORK WITHIN CONTROLS**

All work shall be performed within the controls identified within this
document. It is the PI's responsibility to ensure that this document is
kept up to date. The PI should consult with the ERC as appropriate to
determine if changes to this document are significant enough to require
a new review/document.

If a hazard assessment may be required for this experiment, the PI
should contact the ES&H Coordinator and/or the ERC for assistance. The
PI should document any hazard assessments performed for this experiment
in Section VI.

###### A. Training

List all project personnel, indicating they are authorized and competent
to perform the work described. List the training required for each
individual. Identify any certifications or experiment-specific training
required. Indicate if any project personnel are minors (under 18 yrs. of
age). Contact your Training Coordinator and ES&H Coordinator as
appropriate for assistance.

*It is the responsibility of the PI to maintain a complete up-to-date
list of personnel and their full training requirements, and to ensure
that training and qualifications are maintained. A [sample ESR signature
form](http://www.phy.bnl.gov/~safety/documents/ReviewFormsLink.html)* is
available.

  --------------------- -------------- --------------------------------------
  **Name**              **Life/Guest   **Required Training (Course or JTA
                        \#**           code)**

                                       

                                       

                                       

                                       

                                       

                                       

                                       

                                       

                                       

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

*[Note]{.underline}: The [BNL Training and Qualifications Web
Site](http://training.bnl.gov/) contains course offerings and
descriptions, required training checklist, as well as employee training
records.*

######## B. OSHA/DOE Required Medical Surveillance {#b.-oshadoe-required-medical-surveillance .unnumbered}

*Indicate if potential exposure is in excess of trigger levels listed.
Exposure evaluation and/or medical surveillance may be required.
Additional [training](http://training.bnl.gov/) may be required for any
indicated agent. See the [SBMS](https://sbms.bnl.gov/ch00d011.htm)* for
additional information and controls on the hazards listed.

+----------------------+---------------------+-------------------------+
| **Regulated Hazard** | **Hazard Specific   | **Medical Surveillance  |
|                      | Training Trigger**  | Exposure Trigger**      |
+======================+=====================+=========================+
| **** None           |                     |                         |
+----------------------+---------------------+-------------------------+
| **** Inorganic      | Any day above the   | 30 days/year above the  |
| Arsenic              | OSHA action level   | action level (without   |
|                      | (without regard to  | regard to respirator    |
|                      | respirator use)     | use)                    |
+----------------------+---------------------+-------------------------+
| **** Biohazards     | None                | See Subject Area for    |
| (CDC/NIH/WHO listed  |                     | guidance                |
| Agent)               |                     |                         |
+----------------------+---------------------+-------------------------+
| **** Cadmium        | Any day above the   | 30 or more days/year at |
|                      | OSHA action level   | or above the action     |
|                      |                     | level                   |
+----------------------+---------------------+-------------------------+
| **** Lasers         | Use Class IIIb or   | Use Class IIIb or Class |
|                      | Class IV Lasers     | IV Lasers               |
+----------------------+---------------------+-------------------------+
| **** Lead           | Any day above the   | 30 or more days/year at |
|                      | OSHA action level   | or above the action     |
|                      |                     | level                   |
+----------------------+---------------------+-------------------------+
| **** Methylene      | Any day above the   | -   30 days/year at or  |
| Chloride             | OSHA action level   |     above the action    |
|                      |                     |     level               |
|                      |                     |                         |
|                      |                     | -   10 days/year above  |
|                      |                     |     the 8-hour TWA PEL  |
|                      |                     |     or the STEL         |
|                      |                     |                         |
|                      |                     | -   Any time above the  |
|                      |                     |     8-hour TWA PEL or   |
|                      |                     |     STEL for any period |
|                      |                     |     of time where an    |
|                      |                     |     employee at risk    |
|                      |                     |     from cardiac        |
|                      |                     |     disease or other    |
|                      |                     |     serious MC-related  |
|                      |                     |     health condition    |
|                      |                     |     and employee        |
|                      |                     |     requests inclusion  |
|                      |                     |     in the program      |
+----------------------+---------------------+-------------------------+
| **** Noise          | Any day above the   | Any time equal or       |
|                      | ACGIH TLV           | greater then 85 dBA TWA |
|                      |                     | 8-hour dose             |
+----------------------+---------------------+-------------------------+
| **** OSHA Regulated | Any day above the   | -   Routinely above the |
| Chemicals            | OSHA PEL            |     action level (or in |
|                      |                     |     the absence of an   |
| > *Acrylonitrile*    |                     |     action level, the   |
| > *Benzene*          |                     |     PEL)                |
| >                    |                     |                         |
| > *Benzidine 1,3     |                     | -   Event such as a     |
| > Butadiene*         |                     |     spill, leak or      |
| >                    |                     |     explosion results   |
| > *4-Dimethyl        |                     |     in the likelihood   |
| > aminoazobenzene*   |                     |     of a hazardous      |
| >                    |                     |     exposure            |
| > *Ethylene oxide*   |                     |                         |
| > *Ethyleneimine*    |                     |                         |
| >                    |                     |                         |
| > *Formaldehyde*     |                     |                         |
| > *Vinyl Chloride*   |                     |                         |
+----------------------+---------------------+-------------------------+
| **** Static         | Worker who          | -   Any time at ≥ 0.5   |
| Magnetic Fields      | routinely works in  |     mT (5 G) for        |
|                      | magnetic field      |     Medical Electronic  |
|                      |                     |     Device wearer       |
|                      |                     |                         |
|                      |                     | -   Any day at ≥ 60 mT  |
|                      |                     |     (600 G) to whole    |
|                      |                     |     body \[8 hour       |
|                      |                     |     average\]           |
|                      |                     |                         |
|                      |                     | -   Any day at ≥ 600 mT |
|                      |                     |     (6000 G) to limbs   |
|                      |                     |     \[8 hour average\]  |
|                      |                     |                         |
|                      |                     | -   Any Time at ≥ 2 T   |
|                      |                     |     (20,000 G) to whole |
|                      |                     |     body \[ceiling\]    |
|                      |                     |                         |
|                      |                     | -   Any time at ≥ 5 T   |
|                      |                     |     (50,000 G) to limbs |
|                      |                     |     \[ceiling\]         |
+----------------------+---------------------+-------------------------+

##### 

##### C. Emergency Procedures

*Identify any emergency actions, procedures, or equipment that must be
in place to insure personnel safety and environmental protection.
Include the location of emergency shutoffs, and spill control
materials.*

[Enter text here...]{.mark}

######## D. Transportation {#d.-transportation .unnumbered}

*Identify materials, hazards and controls for any on-site and off-site
transportation of hazardous and/or radioactive materials. See relevant
SBMS Subject Areas.*

[Enter text here...]{.mark}

###### 

###### E. Notifications

*The PI or designee should notify building occupants of any activities
that might impact them or their work, and document this here. List
external personnel/organizations that require notification related to
experimental activities and/or to be notified of changes (e.g., a BNL
Committee for review/approval, Occupational Medicine Clinic,
Fire/Rescue).*

[Enter text here...]{.mark}

######## F. Termination/Decontamination  {#f.-terminationdecontamination .unnumbered}

*Describe any decommissioning plan, including decontamination of the
area at termination of the experiment. Identify any hazards and
controls, special precautions or procedures. Include chemical and waste
reconciliation. Indicate if a walk-down or an ERE will be scheduled to
ensure the area is suitable for future projects. Indicate if Work Permit
Form/Procedure will be used.*

[A plan is **required** here...]{.mark}

**G. Community Involvement Issues**

*Identify issues that may require community involvement (see the
[Community Involvement in Laboratory Decision-making Subject
Area](https://sbms.bnl.gov/standard/19/1900t011.htm)) and describe the
plan that addresses these issues. Attach the Community Involvement
Checklist.*

[Enter text here...]{.mark}

**V. PROVIDE FEEDBACK ON ADEQUACY OF CONTROLS AND CONTINUE TO IMPROVE
SAFETY MANAGEMENT**

*Provide comments on the review process, including this form and
communication. Identify any lessons learned or worker feedback
contributing to modifications/improvements to the controls or process.*

[Enter text here...]{.mark}

## VI. ATTACHMENTS

Use this section to include any supporting documents, hazard
assessments, figures, tables, etc. that were not entered into the
previous sections of the form.