BELFOR USA Pre Task - Planning Worksheet

Pre Task Plan / Job Site Analysis

• Job number / document #

• Client / Site

• Conducted on

  Date
• Location
  Address

• Occupancy Type

  Select Assembly Business Educational Factory/Industrial Institutional Mercantile Residential

  • Assembly
  • Business
  • Educational
  • Factory/Industrial
  • Institutional
  • Mercantile
  • Residential

• Approximate age of structure / Year Built

• Do EPA --RRP Regulations apply?

  Select Yes No

  • Yes
  • No

• BELFOR Personnel / Crew Members

• Sub -Contractors On Site

• Add location
  Address

• Select date

  Date

• Type of work to be completed // Scope

• Job Number ( If available / created yet)

A.. SAFETY : please describe control measures for any item checked yes or at risk.

• 1. Is barricading and or signage required protecting facilities, personnel or equipment ? <br>- electrical dangers posted - eye protection <br>- hard hat area - no smoking <br>- authorized personnel - other <br><br>

  Safe

  At Risk

  N/A

• 2. Will work involve live systems or energized equipment?

  Safe

  At Risk

  N/A

• 3. Is lockout / tag-out of energized equipment required?

  Safe

  At Risk

  N/A

• 4. Will work involve falls greater than 6 feet or greater?

  Safe

  At Risk

  N/A

• 5. Are ladders, mechanical / electrical work platforms (MEWP) , scaffolds or work platforms needed to perform task?

  Safe

  At Risk

  N/A

• 6. Will the task involve the use of chemicals or be adjacent to process piping / equipment containing chemicals?

  Safe

  At Risk

  N/A

• 6a. Have material data safety sheets been provided to crew? <br>- hazcom <br>- container labeling <br>- proper chemical use <br>-

  Safe

  At Risk

  N/A

• 6b. Has a chemical approval request been completed for the use of the chemicals ?

  Safe

  At Risk

  N/A

• 6c. Does the work require disposal of chemicals?

  Safe

  At Risk

  N/A

• 6d. Will the work generate odors?

  Safe

  At Risk

  N/A

• 6e. Are chemicals stored properly ( double containment) ?

  Safe

  At Risk

  N/A

• 6f. Have personnel been trained in use and proper disposal of ppe?

  Safe

  At Risk

  N/A

• 7. Does this require the demolition of electrical / mechanical or chemical systems or equipment?

  Safe

  At Risk

  N/A

• 8. Does this work involve removing floor tile and or ceiling tiles?

  Safe

  At Risk

  N/A

• 9. Will weather conditions affect the completion of this task?

  Safe

  At Risk

  N/A

• 10. Does this work require awkward positions or static postures?

  Safe

  At Risk

  N/A

• 11. Can this work be assembled at waist height as opposed to overhead or below grade?

  Safe

  At Risk

  N/A

• 12. Is adequate material handling equipment available to move/ lift materials? (( forklift, pallet jack, chain fall, cable hoist)) ?

  Safe

  At Risk

  N/A

• 13. Will work involve employee exposure to hazardous noise levels ( exceeding 85 DBA)?

  Safe

  At Risk

  N/A

• 14. Housekeeping <br>- aisle ways, walkways - removal procedures <br>- nails - debris containers <br>- removal procedures - overall neat appearance <br>- materials tools, equipment

  Safe

  At Risk

  N/A

• 15. Fire Prevention <br>A. Extinguishers on site <br>B. storage of containers/ labeling <br>C. Compressed gas cylinders <br>D. Contaminated rag storage<br>E. welding/ cutting <br>F. Ventilation

  Safe

  At Risk

  N/A

• 16. Site Security <br>- fencing / lockable gates , doors <br>- locks/ lock box <br>- lighting

  Safe

  At Risk

  N/A

B. Potential Impacts

1. Will the work involve or have the potential to impact ::

• A. Fire detection and or smoke detectors?

  Safe

  At Risk

  N/A

• B. electrical systems ?

  Safe

  At Risk

  N/A

• C. Plumbing systems ?

  Safe

  At Risk

  N/A

• D. Roofing systems ?

  Safe

  At Risk

  N/A

• E. Flooring systems?

  Safe

  At Risk

  N/A

• G. Ceiling systems?

  Safe

  At Risk

  N/A

• H. Doors and door frames?

  Safe

  At Risk

  N/A

• I. Production tools?

  Safe

  At Risk

  N/A

• J. Other security / Life safety systems ?

  Yes

  No

  N/A

C. Permits required?

• Hot work permit

  Yes

  No

  N/A

• At height work permit

  Yes

  No

  N/A

• Confined space permit

  Yes

  No

  N/A

• Critical lift plan

  Yes

  No

  N/A

• Mechanical Electrical Work Platforms ( MEWP) permits

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

D. Personal Protective Equipment Requirements. PPE

• Fall Protection

  Yes

  No

  N/A

• Eye

  Yes

  No

  N/A

• Respirators

  Yes

  No

  N/A

• Head

  Yes

  No

  N/A

• Foot / Toe

  Yes

  No

  N/A

• Face Shield

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Others / Misc.

  Yes

  No

  N/A

Type of Gloves required

• Kevlar

  Yes

  No

  N/A

• Rubber

  Yes

  No

  N/A

• Leather

  Yes

  No

  N/A

• Cotton

  Yes

  No

  N/A

• Nitrile

  Yes

  No

  N/A

• Butyl / Chemical gloves

  Yes

  No

  N/A

• Mechanics / General purpose

  Yes

  No

  N/A

• Others

  Yes

  No

  N/A

E. General

• 1. Has work area been walked by crew to identify safety and or impact concerns ?

  Safe

  At Risk

  N/A

• 2. Is the area safe to work in?

  Safe

  At Risk

  N/A

• 3. Has the work been coordinated with other trades in the area?

  Safe

  At Risk

  N/A

• 4. All tools and equipment in safe / good condition <br>* including extension cords, slings , hand tools etc...

  Safe

  At Risk

  N/A

• 5. All necessary training for this task has been completed?

  Safe

  At Risk

  N/A

• 6. All new employees familiarized with work area?

  Safe

  At Risk

  N/A

• 7. Sufficient personnel have been assigned to the task / tasks safely?

  Safe

  At Risk

  N/A

• 8. Emergency exits and equipment have been identified? <br>( phones, fire extinguishers, eyewash, etc..)

  Safe

  At Risk

  N/A

• 9. Contingency plans have been developed for unexpected events ? <br>( medical emergencies, and or equipment failure)

  Safe

  At Risk

  N/A

• 10. Certified first aid / CPR personnel on site along with First Aid Kits ? <br>- contents of kit <br>- kit available? <br>- trained employees

  Yes

  No

  N/A

• IF WORK CONDITIONS OR ACTIVITIES CHANGE , WORK MUST STOP!
  
  UNTIL TASK PLAN IS REVISED AND REVIEWED BY CREW
  
  PLEASE POST A COPY IN WORK AREA

• Foreman

• Project manager

• Safety Officer

• Estimator

• BELFOR office assignment ( location)

• System Owner (( If Required)) ( loss contact representative)

Created by: David Weaver BELFOR USA Regional Safety Manager

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