Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
SECTION I
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GENERAL LOCATION:
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DATE & TIME OF SURVEY:
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Ambient Temperature Outside (F):
SPECIFIC LOCATIONS
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1. Location & elevation:
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Dry Bulb Temperature (F):
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WBGT (F):
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2. Location & elevation:
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Dry Bulb Temperature (F):
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WBGT (F):
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3. Location & elevation:
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Dry Bulb Temperature (F):
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WBGT (F):
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4. Location & elevation:
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Dry Bulb Temperature (F):
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WBGT (F):
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5. Location & elevation:
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Dry Bulb Temperature (F):
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WBGT (F):
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REMARKS:
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Monitored by / EID:
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Instrument Serial #:
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Instrument Calibration Due Date:
SECTION II - Dress Requirements
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Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
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Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Required:
- Street Clothes
- Lab Coat
- Single Dress Out
- Double Dress Out
- Rain Suit
- Bubble Suit
- Respirator(cartridge)
- Arc Flash Audit
- Supplied Air
- SCBA
- Ice Vest
- Hood
-
Work Description:
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WORK DESCRIPTION PROVIDED BY:
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DATE:
SECTION III - Special Requirements
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Medical Screen (High Heat Stress Survey Checklist is required for employees reporting a medical condition that may affect work in areas with WBGT temperature equal to or greater than 90 degrees F)
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Outside observer required?
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Mechanical cooling required?
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Personal protective equipment required (specify)?
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Radiant Heat shielding recommend?
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WORK TIME RECOMMENDATIONS:
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SPECIAL INSTRUCTIONS / REMARKS:
SIGNATURES
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SIGNATURE OF EVALUATOR:
For Entries into areas above 150 F WBGT requires Management Review & Approval
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Print Reviewing/Approval Manager(s) NAME(s):
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Approving Manager Signature:
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NOTE: Approval at TVAN Locations require approval by Plant Manager. Approval at FPG locations require approval by Operations or Maintenance Manager.
SECTION IV - Work Shift Log (required if WBGT is equal to or greater than 90F)
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PERSON (A):
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IN (1)
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OUT (1)
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IN (2)
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OUT (2)
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IN (3)
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OUT (3)
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IN (4)
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OUT (4)
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Person (A) Total Time:
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Person (B):
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IN (1)
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Out (1)
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IN (2)
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Out (2)
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IN (3)
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Out (3)
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IN (4)
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Out (4)
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Person (B) Total Time:
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Person (C):
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IN (1)
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Out (1)
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IN (2)
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Out (2)
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IN (3)
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Out (3)
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IN (4)
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Out (4)
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Person (C) Total Time:
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Person (D):
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IN (1)
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Out (1)
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IN (2)
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Out (2)
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IN (3)
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Out (3)
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IN (4)
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Out (4)
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Person (D) Total Time:
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Person (E):
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IN (1)
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Out (1)
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IN (2)
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Out (2)
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IN (3)
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Out (3)
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IN (4)
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Out (4)
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Person (E) Total Time:
