TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 1 of 12
Site Specific Safety Plan Procedure Form
Updated 10.17.14
Procedure Intent:
This procedure will:
1. Help identify and document EHS (Environmental, Health, and Safety) issues and/or concerns in the project
specifications/bidding process so that Subcontractors will be prepared to provide Contractor with a specific Site
Specific Safety Plan. The advantages are:
a. Open communications between Contractor site representatives and Subcontractors regarding the potential safety
hazards well in advance of job/task execution
b. Subcontractor will be informed of Contractor’s EHS expectations
c. Any associated costs for EHS compliance issues will be captured ahead.
Intended Output:
The Subcontractor will provide Contractor with a written Site Specific Safety Plan using the attached Site Specific Safety
Plan Form that will document how the Subcontractor will address any anticipated and/or recognized hazards associated
with their project/contract work. This is an important step in the communication process to promote open communication
between the Service provider/Subcontractor and Contractor.
Contractor Life Saving Commitments Program:
Contractor has developed the Life Saving Commitments program which focuses on eliminating serious injury and death on
the job site. This program identifies eight of the most prevalent high-hazard activities, or “commitments”, encountered on
Contractor projects. Sections pertaining to any of the eight commitments in the Site Specific Safety Plan are labeled with the
corresponding Life Saving Commitment symbol and highlighted in orange.
#1: Stored #2: Fall #3: Cranes & #4: Confined #5: #6: Mobile #7: Caught-in #8: Drugs &
Energy Protection Rigging Spaces Excavations Equipment / Struck-by Alcohol
A Site Specific Safety Plan shall be completed and submitted for all field work performed.
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 2 of 12
Site Specific Safety Plan Form
The Contractor project manager/requestor/etc. should assist the Subcontractor in completing this form.
Use the Contractor Subcontractor Safety Program Document as a reference and resource and consult with the Contractor
EHS Department.
All required signatures must be obtained by t h e S u b c o n t r a c t o r and/or C o n t r a c t o r project
manager/requestor/etc. prior to submittal. The completed form must be submitted to and approved by the Contractor EHS
PRIOR to ANY work taking place.
NAME OF PROJECT/WORK: DATE:
PROJECT/WORK LOCATION: PROJECT #:
CONTRACTOR PROJECT PHONE:
MANAGER:
CONTRACTOR PHONE:
SUPERINTENDENT:
CONTRACTOR FOREMAN: PHONE:
NAME OF SUBCONTRACTOR TO
CONTRACTOR:
PREPARED BY: PHONE:
EMAIL:
SUBCONTRACTOR SAFETY REP: PHONE:
EMAIL:
NAME OF SUBCONTRACTOR TO
SUBCONTRACTOR:
PREPARED BY: PHONE:
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 3 of 12
BRIEF SCOPE/ DESCRIPTION OF PROJECT/WORK:
Emergency Evacuation Plan and Location (to be determined by Contractor Site Supervision):
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 4 of 12
LIFE SAVING COMMITMENTS
#1: STORED ENERGY
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
LOCKOUT / TAGOUT (LOTO): N/A ☐
If yes, Contractor Superintendent will inspect
LOTO source and ensure LOTO procedures
Will LOTO be required? ☐ ☐ are followed.
Are LOTO procedures available? ☐ ☐
Has a responsible person been assigned for
☐ ☐
overseeing LOTO requirements?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
PIPE AND VESSEL PRESSURE TESTING: N/A ☐
Will any pipe/vessel pressure testing be
required?
☐ ☐
**NOTE: Hydrostatic testing is Contractor's
preferred testing medium.
Will pipe/vessel testing be performed within
☐ ☐
design specifications?
Has Pressure Testing Safety Plan been
developed and approved in accordance with
the Stored Energy Procedure?
**NOTE: All Pressure Testing Safety Plans will be ☐ ☐
submitted to Project Management Team for
approval. EHS will review as needed. Hydrostatic
is the preferred testing method.
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
COMPRESSED GAS: N/A ☐
Type of cylinders and quantity:
Will cylinders be brought on site? ☐ ☐
Are there plans for safe use and storage
☐ ☐
on site?
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 5 of 12
LIFE SAVING COMMITMENTS
#2: FALL PROTECTION
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
LADDERS / SCAFFOLDING: N/A ☐
Metal ladders will be approved by Contractor
Will ladders be required? (All Ladders - min Superintendents.
☐ ☐
300 lb rating.)
Will scaffolding be required? (Scaffold Tags Provide Competent Person(s) name, contact
and inspections are required per Contractor ☐ ☐ information and training verification.
policy.)
Will fall protection be required? List
☐ ☐
equipment to be used.
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
FALL PROTECTION, LEADING EDGE
WORK, ELEVATED SURFACES (no safety N/A ☐
monitors):
Has a Fall Protection Rescue Plan been
☐ ☐
developed? Attach and describe plan.
Will fall protection be required? (No Systems to be used:
safety monitors.) 100% protection > 6 ☐ ☐
feet
Are competent/qualified persons Provide Competent Person(s) name and
identified to perform system and contact information.
☐ ☐
equipment inspections, identify hazards,
and anchor points as needed?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
ROOF WORK (no safety monitors): N/A ☐
Attach Fall Protection Plan and Emergency
Rescue Plan (primary and alternate) (to be
Will roof access be required? ☐ ☐ submitted prior to work).
Is there a plan to get materials on/off roof
☐ ☐
in place?
Has a method for securing materials to
☐ ☐
prevent "blow offs" been identified?
Are chemicals or flammable / Approved by:
☐ ☐
combustible materials going on roof?
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 6 of 12
LIFE SAVING COMMITMENTS
#3: CRANES & RIGGING
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
CRANES AND RIGGING: N/A ☐
Attach crane lift plan, operator, rigger and
Will crane operations be required? rd
signaler verification of training. Provide 3 party
**NOTE: If yes, all crane plans will be
☐ ☐ annual inspections.
reviewed by Regional Safety Manager 1 week
prior to the lift.
Have all overhead lines been identified
and the locations appropriately ☐ ☐
communicated?
Will any special lifting devices be needed? ☐ ☐
Will any Critical Lifts take place? Attach and describe critical lift plan and activity.
**Note: Contractor defines a Critical Lift as
meeting any of the following criteria: 1)
exceeds 75% of the capacity of the crane or ☐ ☐
derrick; 2) requires more than one crane or
derrick; or 3) involves lifts over people or critical
work processes.
Attach verification of training (to be submitted
Has all rigging equipment been inspected? ☐ ☐ prior to work).
Is all equipment appropriate for the task(s)? ☐ ☐
Inspection logs completed for equipment/lift
Have all required safety inspections been devices.
☐ ☐
completed?
Will traffic control be provided (pedestrian & Attach flaggers’ names / training (2 minimum).
☐ ☐
vehicular)?
LIFE SAVING COMMITMENTS
#4: CONFINED SPACES
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
CONFINED SPACES: N/A ☐
Will any confined space work be performed?
**NOTE: Atmospheric testing must be conducted ☐ ☐
daily prior to entry into a Confined Space.
Will any Confined Space Entry permits be
☐ ☐
required?
Have affected personnel been trained for
☐ ☐
confined space entry?
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 7 of 12
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
Will external rescue team services to be
used? Please specify the name of the ☐ ☐
provider.
Attach Confined Space Plan (submitted prior to
Have all entry procedures been provided and work).
☐ ☐
documented?
LIFE SAVING COMMITMENTS
#5: EXCAVATIONS
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
EXCAVATIONS (all soil type is C): N/A ☐
Will equipment to be brought on site? Please
☐ ☐
specify type.
Provide Competent Person name, contact info
Will any work activities involve excavations and training verification.
☐ ☐
greater than four feet?
Will a trench box/shoring be needed? ☐ ☐
Does fencing/barricade need to be installed? ☐ ☐
LIFE SAVING COMMITMENTS
#6: MOBILE EQUIPMENT
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
MOBILE EQUIPMENT / POWERED
INDUSTRIAL FORK TRUCKS / LIFTS / N/A ☐
BOOMS:
If yes, keep daily/shift inspection logs on the
Will any mobile powered equipment be equipment.
☐ ☐
required? Type to be brought on site?
Will you be using any special
☐ ☐
attachments? ex. jibs, manlifts, etc.
Attach verification of training (to be submitted
Are operators trained / certified for prior to work).
☐ ☐
operations of equipment?
Spill kit/containment pad required containing
Is there a plan for fuel transfer/storage or 80% equipment capacity.
☐ ☐
battery changes?
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 8 of 12
LIFE SAVING COMMITMENTS
#7: CAUGHT-IN/STRUCK-BY
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
CAUGHT-IN / STRUCK-BY HAZARDS: N/A ☐
Are employees familiar with pinching and
☐ ☐
crushing points?
Are special precautions taken when
working around belts, pulleys, chains, ☐ ☐
etc.?
Are employees aware of the hazards
associated with overhead loads and ☐ ☐
swing radius?
Are all vehicles equipped with
appropriate back-up alarms, horns and ☐ ☐
lights?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
POWDER ACTUATED TOOLS: N/A ☐
Are operators/employees trained / Attach verification (submitted prior to work).
☐ ☐
licensed in use?
LIFE SAVING COMMITMENTS
#8: NO DRUGS OR ALCOHOL
In accordance with the Subcontractor Safety Responsibilities document, subcontractors must agree to adhere to the
Contractor Drug and Alcohol policy. Drugs and alcohol are strictly forbidden from all Contractor jobsites.
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 9 of 12
Additional Focus Areas:
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
PERSONAL PROTECTIVE EQUIPMENT
What type of PPE will be used for this
☐ ☐
project?
Will any special PPE be required, i.e. Attach Respiratory Protection Plan:
☐ ☐
respirators? What type?
Have eye wash and shower stations been
☐ ☐
set up on the jobsite?
Has personnel received training for special
PPE requirements? NOTE: Hi Vis (yellow ☐ ☐
shirt) clothing is required.
Is there verification of medical respiratory Subcontractor to maintain copy on site.
☐ ☐
protection clearance submitted / attached?
Will respirators be worn on a voluntary use? Attach Appendix D for each employee.
☐ ☐
(Half mask, paper, etc.)
Is a de-con area required for suiting
☐ ☐
up/down?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
SIGNS, SIGNALS AND BARRICADES:
N/A ☐
Will yellow or red barricade tape be used?
(Barricades will be built in accordance with ☐ ☐
Contractor policy)
Will perimeter barricades be used? ☐ ☐
Will any caution/danger signs be needed? ☐ ☐
Will flammable gas/liquid labels be needed?
☐ ☐
Will material labels be needed? GHS
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
WORK PERMITS: N/A ☐
Will any pipe or vessel testing
permits be required? ☐ ☐
Will any excavation permits be Attach Plan.
required? ☐ ☐
Will any utility interruption permits be
☐ ☐
required?
Will Hot Work (welding/cutting/grinding/
☐ ☐
soldering/electrical) permits be required?
Will any lead/asbestos permits be required? ☐ ☐
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 10 of 12
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
Will any Fire System Sprinkler/Alarm Out-of-
☐ ☐
Service Permits be required?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
CHEMICAL, BIOLOGICAL, MATERIAL
N/A ☐
PHYSICAL HAZARDS:
Are all employees trained in hazard
☐ ☐
communication / GHS?
Are all MSDS/SDS provided to Contractor
☐ ☐
and a copy easy to obtain at job site?
Are employees trained to handle/use specific
☐ ☐
materials?
Does storage and use meet all Contractor,
☐ ☐
NFPA, Fed and State Regulations?
Do employees working with OSHA regulated
chemicals have proper training for job? ☐ ☐
(silica, asbestos, RCS's, etc.)
Does demo/abatement plans meet Attach Plan:
☐ ☐
applicable standards?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
HOT WORK: N/A ☐
Are hot work activities to be performed?
(Any flame or spark producing task.) Briefly ☐ ☐
describe.
Will any special PPE be required? ☐ ☐
Will fire blankets/protective
☐ ☐
shields/screens be required?
Are fire watch personnel current with
☐ ☐
actual training?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
PAINTING, ADHESIVES, EXPOXIES: N/A ☐
Are there any additional exhausts or fans
☐ ☐
needed during application/curing time?
Are there special PPE/precautions for
☐ ☐
this job?
Will sealant be applied to this job?
☐ ☐
Please specify quantity and job type.
Will this require off-hours application? ☐ ☐
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 11 of 12
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
FLAMMABLE GASES / LIQUIDS: N/A ☐
Will any flammable gases and/or liquids
☐ ☐
be used?
Have provisions for their storage been
☐ ☐
made?
Will appropriate containers be utilized?
☐ ☐
Safety cans are required.
Are secondary containment and spill kits
☐ ☐
required?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
EMERGENCY PREPAREDNESS: N/A ☐
Have designated smoking areas been
☐ ☐
identified and clearly marked?
Have fire alarms been identified? ☐ ☐
Have the appropriate number of fire
extinguishers been identified? ☐ ☐
Inspections will be performed monthly.
Have emergency phone numbers been
☐ ☐
identified?
Have adequate security measures been
☐ ☐
identified?
Have emergency exits been identified
☐ ☐
and marked?
Has an emergency evacuation plan been
☐ ☐
developed?
REQUIRED Specific & detailed information / description
SUBJECT
YES NO required for all questions.
WASTE MANAGEMENT: N/A ☐
Is there a plan for waste disposal in place? ☐ ☐
Are all characterization, containerization,
segregation, storage and disposal ☐ ☐
requirements understood?
Is there a plan for water/wastewater
discharges in place? Describe or attach ☐ ☐
plan.
Approved by:
Is an Erosion Control Plan in place? ☐ ☐
Spill kits will be on site.
Is there a spill plan in place? ☐ ☐
Is a special permit(s) needed? Please Attach copies.
☐ ☐
specify.
TITLE: Site Specific Safety Plan
Project Number: Date:
Project Title:
Subcontractor Name: Page 12 of 12
SUBCONTRACTOR SITE SPECIFIC SAFETY PLAN APPROVALS
* indicates approval required
Print Name Signature Date
* Contractor ESH:
* Contractor PM or
Superintendent:
Subcontractor:
Safety Representative:
nd
2 Tier Subcontractor:
Safety Representative:
rd
3 Tier Subcontractor:
Safety Representative:
