Daily Safety Task Planner - duplicate

• Document No.

• Daily Safety Task Planner

• Project Name

• Conducted on

  Date

• Prepared by: Tom Morris

• Location
  Address

SECTION #1 PROJECT INFORMATION

Date

• Select date

  Date

Project Name

• Project

  Select Renal Pancreas Liver Transplant Discharge Pharmacy SIM Center

  • Renal Pancreas Liver Transplant
  • Discharge Pharmacy
  • SIM Center

Project Number

• Job Number

  16-0655-Q

  16-0749-Q

  16-0644-Q

Address

• Add location
  Address

Supervisor Information

• Company Name

  Hagerman

• Supervisor Name

  Roger Meyer

• Phone Number

  (812) 447-0016

Describe Planned Work Activities For The Day

SECTION #2 SAFETY HAZARDS

Are fall hazards or overhead hazards present?

• Choose all that apply

  Select Slips, Trips, Falls Elevated work above 6' Elevated work below 6' with hazard present Holes in walls or floors Use of cranes or Lulls Rigging Overhead Work Trench/Excavation

  • Slips, Trips, Falls
  • Elevated work above 6'
  • Elevated work below 6' with hazard present
  • Holes in walls or floors
  • Use of cranes or Lulls
  • Rigging
  • Overhead Work
  • Trench/Excavation

• Other than listed above.

  Yes

  No

• Explain.

Have energy sources been identified? NOTE: If energy source is present it must be addressed by the proper permit or procedure.

• Choose all that apply.

  Select Mechanical Electrical Chemical Thermal Hydraulic Pneumatic

  • Mechanical
  • Electrical
  • Chemical
  • Thermal
  • Hydraulic
  • Pneumatic

• Other than listed above.

  Yes

  No

• Explain.

Are hazardous materials present?

• Choose all that apply.

  Select Lead/Asbestos Mercury/Heavy Metals Allergens/Biologicals Chronic issue related materials Radiation

  • Lead/Asbestos
  • Mercury/Heavy Metals
  • Allergens/Biologicals
  • Chronic issue related materials
  • Radiation

• Other than listed above?

  Yes

  No

• Explain

Are hazardous conditions present?

• Choose all that apply

  Select Compressed Gas Ergo Hazards Noise Temperature Extremes Hot/Cold

  • Compressed Gas
  • Ergo Hazards
  • Noise
  • Temperature Extremes Hot/Cold

• Other than listed above?

  Yes

  No

• Explain

Are barricades needed to protect work space?

• Choose all that apply

  Select Yellow Caution Tape Red Danger Tape Fencing Barriers

  • Yellow Caution Tape
  • Red Danger Tape
  • Fencing
  • Barriers

• Other than listed above?

  Yes

  No

• Explain

Emergency Equipment Communicated & Verified (Specify Location)

• Rally Point:

• Severe Weather:

• Safety Shower:

• Eyewash Station

• Radio

• Other: Specify:

Other procedures or precautions

• Is there any other safety precautions or emergency procedures needed?

  Yes

  No

• Explain

SECTION #3 SAFETY PRECAUTIONS/EMERGENCY PROCEDURES

Are chemicals present?

• Choose all that apply

  Select Gases/Vapors Dust/Fumes Odors Asphyxiates e.g Nitrogen, Argon Toxic Oxidizer

  • Gases/Vapors
  • Dust/Fumes
  • Odors
  • Asphyxiates e.g Nitrogen, Argon
  • Toxic
  • Oxidizer

• Other than listed above?

  Yes

  No

• Explain

Are line breaking or tank cleaning procedures part of the work?

• Choose all that apply

  Select Drained/Isolated/Purged Cleaned/Decontaminated Sludge/Residue Flammable/Combustible Corrosive (acid/caustic) Reactives Steam/ Condensate

  • Drained/Isolated/Purged
  • Cleaned/Decontaminated
  • Sludge/Residue
  • Flammable/Combustible
  • Corrosive (acid/caustic)
  • Reactives
  • Steam/ Condensate

• Additional information list here.

Are there any additional permits, tags, or safety plans required for the project.

• Choose all the apply

  Select SDS Reviewed by site safety Fall Protection Safety Plan Lockout/Tagout Confined Space EntryPermit Trenching/ Excavation Plan Demolition Plan Lifting/Rigging Plan Barricade Signage Utility Line Locate and Marking Hot Work Permit Sprinkler Shutdown Permit Roof Entry Permit Energized Electrical Permit Scaffold Tag Red, Scaffold Tag Yellow Scaffold Tag Green

  • SDS Reviewed by site safety
  • Fall Protection Safety Plan
  • Lockout/Tagout
  • Confined Space EntryPermit
  • Trenching/ Excavation Plan
  • Demolition Plan
  • Lifting/Rigging Plan
  • Barricade Signage
  • Utility Line Locate and Marking
  • Hot Work Permit
  • Sprinkler Shutdown Permit
  • Roof Entry Permit
  • Energized Electrical Permit
  • Scaffold Tag Red,
  • Scaffold Tag Yellow
  • Scaffold Tag Green

Elimination or Mitigation of noted Hazards

• Please list how you plan to eliminate or mitigate noted hazards

PPE Required

• Choose all that apply.

  Select Safety Glasses Goggles Face Shield Hard Hat Safety Toed Boots Hand Protection Hearing Protection Respirator Protective Clothing Fall Protection

  • Safety Glasses
  • Goggles
  • Face Shield
  • Hard Hat
  • Safety Toed Boots
  • Hand Protection
  • Hearing Protection
  • Respirator
  • Protective Clothing
  • Fall Protection

• If hand protection, hearing protection, respirators, protective clothing, or fall protection were chosen in the list above. Please state the type you will be using e,g (Hand Protection: Chemical Gloves)

• If other PPE Is needed. Please list here.

SECTION #4 VERIFICATION and ACCEPTANCE (Indicates that all the information covered on this daily safety plan has been reviewed, understood, and hazards eliminated or controlled.

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