H&S - Job Planning Form

Health and Safety Job Planning Form

All required fields must be filled in order to submit the form. The form can be saved and completed at a later time using the save button at the end of the page.
Project Name*
Project Number*
Site Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nearest Hospital Name*
Nearest Hospital Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nearest Urgent Care Name*
Nearest Urgent Care Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Location*
OHSM Email
example@example.com
OHSM 2 Email
example@example.com
JPF Prepared By*

First NameLast Name
Preparer Email*
example@example.com
JPF Reviewed By (Project Team Review)*

First NameLast Name
Reviewer Email*
example@example.com
Field Staff*

First NameLast Name
Field Staff Email*
example@example.com
Project Manager*

First NameLast Name
Project Manager Email*
example@example.com
Project Principal*

First NameLast Name
Project Principal Email*
example@example.com
Kickoff Meeting Date*

MonthDayYear
Anticipated Start Date*

MonthDayYear
Anticipated End Date*

MonthDayYear
Other Critical Project Dates
Timeline of critical project activities
Relevant Project Information
Task Description / Rationale and Background Information*
Scope of work, contaminants of concern, relevant site-specific health and safety information
Contaminants of Concern at the Site*
Please indicate specific vapor, soil, and/or groundwater contaminants of concern at the site; include highest concentrations for each contaminant
Work Area Location / Access*
Location(s) of work areas, current site operations, access points, site security
Will a critical procedure be performed as part of the current scope of work? (confined space entry, hot work, excavation, working at heights, critical lifts, and drilling activities)

YesNo
Critical Procedure

Confined Space EntryHot Work / Spark-Producing OperationsExcavation / TrenchingWorking at Heights > 4 feetCritical LiftsDrilling
Will any simultaneous operations (i.e., third-party site operations which are located in the general vicinity of Roux work activities) be performed as part of the project scope?*

YesNo
Please describe any simultaneous operations to be performed at the site
Approximate distance between third-party operations and Roux work activities
Distance in feet (ft)
Minimum-Level of Personal Protective Equipment (Level D is the minimum for all field events)*

Level D (hard hat, steel/composite toe boots, eye protection, hard hat, hand protection, reflective safety vest)Level C (chemical protective coveralls with air-purifying respirator)Level B (chemical protective clothing with self-contained breathing apparatus or supplied air respirator)Level A (fully encapsulated suit with self-contained breathing apparatus)
Will the level of Personal Protective Equipment be modified or upgraded? (e.g., Level D will be modified to include chemical protective coveralls; Level of protection will be upgraded to Level C for specific site activities)*

YesNo
Please describe any modifications or upgrades to Personal Protective Equipment and applicable site activities (if any)
Will a subcontractor(s) be used to complete the anticipated scope of work?*

YesNo
Is the subcontractor(s) a third-party entity (i.e., contracted by another company) or contracted by Roux?

Roux-applicable subcontractor(s)Third-party subcontractor(s)
Subcontractor Company
Subcontractor Contact

First NameLast Name
Subcontractor Phone Number
Please enter a valid phone number.
Subcontractor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subcontractor Comments/Restrictions
Will heavy equipment be used during this project?*

YesNo
Is there a subsurface utility clearance variance associated with this project?

YesNo
Please provide details regarding the subsurface utility clearance variance
Will the project deviate from standard Roux subsurface utility clearance procedures?

YesNo
Please use the link provided to complete a Subsurface Utility Clearance Variance Form

Subsurface Utility Clearance Variance Form
Heavy Equipment Exclusion (HEEZ) Plan
Please select all applicable heavy equipment at the site

BackhoeBoom Lift / CraneBulldozerCompaction RollerDrill RigExcavatorForkliftLull Lift / TelehandlerPayloaderPersonnel LiftSkid SteerVacuum TruckDump TruckOther
Please enter the HEEZ radius for each applicable equipment
Check all safety barrier which apply to the HEEZ:

ConesBarrelsSnow FenceSolid BarsChain-Link FencingJersey BarriersBarricadesCaution TapeOther
Please select all communication methods that apply:

Hand SignalsRadioAir-Horn
Does work require Roux staff to enter the HEEZ when heavy equipment is in operation?

YesNo
Does work require Roux staff to enter the HEEZ when heavy equipment is not in operation?

YesNo
If Roux staff must enter the HEEZ, please describe work activities:
The above HEEZ approach has been reviewed and complies with Corporate H&S expectations? (please insert name of reviewer)

First NameLast Name
Has the above HEEZ approach been reviewed with subcontractor prior to mobilization?

YesNo
Please indicate the individual with whom the HEEZ approach was reviewed
Please ensure the HEEZ approach and JPF is reviewed in detail with the subcontractor prior to mobilization to the site.
Is the project site within 100 feet of a subway or rail line?*

YesNo
Is there any potential for "fouling the tracks"? (i.e., placement of an individual or an item of equipment in such proximity to a track that the individual or equipment could be struck by a moving train or on-track equipment)

YesNo
Has the owner/operator of the subway or rail line been contacted regarding necessary work permits, site-specific training, and third-party health & safety requirements?

YesNo
Please select the railroad owner/operator
Please describe "third-party rail spur," "other," and "not applicable" responses
Will a Flagman, EIC (Engineer in Charge), or RWIC (Roadway Worker in Charge) be used during work with potential for fouling the tracks?

YesNo
Will the subway or rail line adjacent to the work area be isolated during all operations which are fouling the tracks? (Rail lines are isolated from the adjacent line(s) when no movement on the adjacent lines can foul or access the isolated portion of rail line.)

YesNo
Please describe the method of rail line isolation to be implemented
Please describe "No" responses and applicable health & safety protocols
Has an MTA permit or No Impact Letter been obtained from MTA?*

YesNoN/A
Will any of the work activities occur indoors?*

YesNo
Please indicate the work activities to be performed indoors
Will there be any coring, cutting, or jackhammering into concrete or any material containing quartz (e.g., concrete, cement, brick)?*

YesNo
Silica Exposure Control Plan
Subcontractor Company
Brief Description of Silica Dust-Generating Operations
Please indicate the equipment/task

(i) Stationary masonry saws(ii) Handheld power saws (any blade diameter)(iii) Handheld power saws for cutting fiber-cement board (with blade diameter of 8 inches or less)(iv) Walk-behind saws(v) Drivable saws(vi) Rig-mounted core saws or drills(vii) Handheld and stand-mounted drills (including impact and rotary hammer drills)(viii) Dowel drilling rigs for concrete(ix) Vehicle-mounted drilling rigs for rock and concrete(x) Jackhammers and handheld powered chipping tools(xi) Handheld grinders for mortar removal (i.e., tuckpointing)(xii) Handheld grinders for uses other than mortar removal(xiii) Walk-behind milling machines and floor grinders(xiv) Small drivable milling machines (less than half-lane)(xv) Large drivable milling machines (half-lane and larger)(xvi) Crushing machines(xvii) Heavy equipment and utility vehicles used to abrade or fracture silica-containing materials (e.g., hoe-ramming, rock ripping) or used during demolition activities involving silica-containing materials(xviii) Heavy equipment and utility vehicles for tasks such as grading and excavating but not including: Demolishing, abrading, or fracturing silica-containing materials
Respirable crystalline silica - Mandatory engineering control methods
If the pre-populated mitigating action(s) are not employed, the minimum level of respiratory protection will be half-mask respirator with P100 cartridges. Before fit testing and respirator use for occupational purposes, medical evaluations must be provided to determine the wearer’s ability to use a respirator. Before an employee uses any respirator, the employee must be fit tested with the same make, model, style, and size of respirator that will be used.If the pre-populated mitigating action(s) are not employed, the minimum level of respiratory protection will be half-mask respirator with P100 cartridges
Respirable crystalline silica - Mandatory work practices
• Check any dust shrouds and/or hoses to make sure they are not damaged prior to starting work.
• Ensure hoses do not become bent or kinked, and keep hoses out of the path of travel. 
• All vacuums and dust collection systems should be operated at the frequency and flowrate recommended by the manufacturer.
• If airborne dust is visible, work should be stopped to reassess engineering controls and work practices. 
• Additional dust suppression may be warranted to control airborne levels of dust.
Respirable crystalline silica - Respiratory protection
If the above referenced engineering controls are not employed, the minimum level of respiratory protection during potential silica-generating work activities will be a half-mask elastomeric respirator with NIOSH P100 cartridges. Before fit testing and respirator use for occupational purposes, medical evaluations must be provided to determine the wearer’s ability to use a respirator. Before an employee uses any respirator, the employee must be fit tested with the same make, model, style, and size of respirator that will be used.
Respirable crystalline silica - Exclusion Zone
Non-essential workers will remain 15 feet from all silica-generating work activities.
Will outdoor temperatures exceed 80 degrees F during field activities?*

YesNo
Site-Specific Heat Illness Prevention Plan
Outdoor Work where the temperature is anticipated to be greater than 80 degrees F
The anticipated outdoor temperature range (i.e., minimum to maximum) for field activities
Ex: 89-97 degrees F
Is there potential for temperatures in excess of 95 degrees F?

YesNo
High-Heat Procedures
Please indicate the level of work intensity for Roux employees

Light work: operating equipment, inspection work, walking on flat, level ground, using light hand tools (wrench, pliers, etc.), travel by conveyance, groundwater and/or soil sampling for short periodsModerate work: drilling, hand augering, groundwater and/or soil sampling for extended periods, carrying equipment/supplies weighing 20–40 pounds, using digging tools (shovel, fin-hoe, air knife) for short periodsHeavy Work: climbing, carrying equipment/supplies weighing 40 pounds or more, installing utilities, using digging tools (shovel, fin-hoe, air knife) for extended periods
Roux employees will be engaged in:
Please indicate the level of work intensity for Roux subcontractors

Light work: operating equipment, inspection work, walking on flat, level ground, using light hand tools (wrench, pliers, etc.), travel by conveyance, groundwater and/or soil sampling for short periodsModerate work: drilling, hand augering, groundwater and/or soil sampling for extended periods, carrying equipment/supplies weighing 20–40 pounds, using digging tools (shovel, fin-hoe, air knife) for short periodsHeavy Work: climbing, carrying equipment/supplies weighing 40 pounds or more, installing utilities, using digging tools (shovel, fin-hoe, air knife) for extended periods
Roux subcontractors will be engaged in:
Shade to be provided for outdoor workers:

pop-up Tentscanopiesumbrellasstructures mechanically ventilated or open to air movement (e.g., garage)full and thick tree canopies that block direct sunlightbuildings and structuresenclosed areas which provide cooling comparable to shade in open-airvehicles with air conditioningOther
Type(s) of drinking water and hydration to be provided for workers:

water fountainswater dispenserswater bottlesOther
Is drinking water continuously plumbed or otherwise continuously supplied?

YesNo
Supply of Drinking Water
The anticipated location(s) of drinking water will be:
Heat stress administrative controls to be implemented for outdoor work:

Work schedule rotationModified tasksMandatory rest breaks in a cool areaModify work clothingUsing the buddy system to allow workers to monitor each other for heat illness.Other
Heat-protective equipment to be provided for indoor work if feasible engineering controls do not decrease the temperature enough and administrative controls do not minimize the risk of heat illness:

Cooling vestsWater or air-cooled garmentsWetted over-garmentsHeat-reflective clothingSupplied-air personal cooling systemsNeck fansOther
Are there any indoor workplaces where the indoor temperature is anticipated to be greater than 82 degrees F?

YesNo
Indoor Work where the indoor temperature is anticipated to be greater than 82 degrees F
Cooling areas will be stationed at the following location(s):
Must be as close to the work area(s) as practicable
Engineering control that will be implemented to lower the indoor temperature, heat index, or both to the lowest possible level

Cooling fans or air conditioningIncreased natural ventilation, such as open windows and doors when the outdoor temperature or heat index is lower than the indoor temperature and heat indexLocal exhaust ventilation at points of high heat production or moisture (such as exhaust hoods in laundry rooms)Reflective shields to block radiant heatInsulating/isolating heat sources from workers, or isolating workers from heat sourceElimination of steam leaksCooled seats or benchesEvaporative coolersDehumidifiersOther
Heat stress administrative controls that will be implemented for indoor work:

Work schedule rotationModified tasksMandatory rest breaks in a cool areaModify work clothingUsing the buddy system to allow workers to monitor each other for heat illness.Other
Heat-protective equipment that will be provided for indoor work if feasible engineering controls do not decrease the temperature enough and administrative controls do not minimize the risk of heat illness:

Cooling vestsWater or air-cooled garmentsWetted over-garmentsHeat-reflective clothingSupplied-air personal cooling systemsNeck fansOther
Indoor Work Zone Procedures

The following procedures apply to indoor workplaces when the indoor temperature is greater than 82°F.

Procedures for Temperature Assessment for Indoor Work

When it is reasonably suspected that indoor temperatures or heat indexes exceed 87 degrees F or 82 degrees F when employees are wearing heat-restrictive clothing or working near radiant heat sources, temperature or heat index measurements are taken. Additionally, temperatures are taken at times when the highest heat exposure is expected and when they are reasonably expected to be 10o F higher than the previous measurements.

Measurements shall be recorded in the Site-specific Logbook.

Procedures for Access to Cool-Down Areas for Indoor Work

Cool-down areas(s) will be located at {typeA224}. Cool-down area location(s) will be as close as practicable to the work area(s). The temperature in the indoor cool-down areas will be maintained at less than 82 degrees Fahrenheit by To ensure that cool-down area(s) will be less than 82 degrees F, indoor temperatures within the cooling area(s) will be monitored with a wet bulb globe temperature monitor and engineering controls will be implemented to lower the indoor temperature as needed.

If an employee takes a preventative cool-down rest break, SS/SHSO will do the following:
- Monitor employees, including asking them if they are experiencing any symptoms of heat illness.
- Encourage employees to stay in the cool-down area. Employees should not return to work until any signs of heat illness are abated or for a minimum of 5 minutes, whichever is longer.
  - The travel time to and from the shade or cool-down area is not included in the minimum 5-minute break period.
- If employees are experiencing heat illness, supervisors follow the necessary heat illness first aid or emergency response procedures applicable to the symptoms. Remember: If an employee is exhibiting symptoms of heat illness, they should not be left alone.
Higher temperatures, humidity, and increased direct sunlight will prompt more frequent breaks. Supervisors will encourage these breaks and account for them when planning work.

Control Measures for Indoor Work

Control measures will be implemented when either of the following occurs:
- Indoor temperature or heat index is 87 degrees Fahrenheit or higher.
- Indoor temperature is 82 degrees Fahrenheit or higher and workers are either:
  - Wearing clothing that restricts heat removal or
  - Working in an area with high radiant heat.
The following engineering controls will be implemented to lower the indoor temperature, heat index, or both to the lowest possible level. These controls help make the work environment cooler or create a barrier between the worker and the heat: {typeA221}

The following administrative controls will be implemented once all feasible engineering controls have been implemented. These controls are modified work practices that can reduce heat exposure by adjusting work procedures, practices, or schedules: {heatStress}

The following personal heat-protective equipment will be provided if feasible engineering controls do not decrease the temperature enough and administrative controls do not minimize the risk of heat illness. This personal heat-protective equipment consists of special cooling devices that the worker wears on their body that can protect them in hot environments: {heatprotectiveEquipment223}
Will private subsubsurface utility location (i.e., Ground Penetrating Radar, Electromagnetic Induction, Radio Frequency Line Tracing) be performed as part of the scope of work?*

YesNo
Will any of the work activities require confined space entry? (i.e., work in areas with limited or restricted means for entry/exit and are not designed for continuous occupancy)*

YesNo
Will Roux personnel or subcontractors be performing the confined space entry?*

RouxSubcontractor
Confined Space Entry Required Guidelines
-Before confined space entry commences, concentrations of hazardous gases inside the space will be measured throughout the vertical profile using a multi-gas meter (oxygen [O2], carbon monoxide [CO], hydrogen sulfide [H2S], volatile organic compounds [VOCs], lower explosive limit [LEL]). Personnel conducting air monitoring will assume a position that precludes breathing in the atmosphere of the confined space. -If hazardous gases are not present or are present within the acceptable limits (see site-specifc HASP), the space may be declassified as a permit-required confined space. -If hazardous gases are measured outside the acceptable limits (see site-specifc HASP), ventilate the space via forced air (blower, with ductile vent if needed) for at least 30 minutes, re-monitor the breathing zone with a 5-gas meter and extended tubing, provide worker respiratory protection as applicable, and approve the Confined Space Entry (CSE) permit. -All personnel involved with the CSE task (Entrant, Attendant, and Supervisor) must understand their roles and responsibilities. Roux must obtain all training (including non-entry confined space rescue training) and fit-testing records for all CSE personnel prior to initiating entry. -A dedicated CSE Attendant, who will under no circumstances enter the confined space, will be stationed outside of the confined space at all times during the CSE. -The CSE Entrant will don the neccesary PPE inlcuding potential respiratory protection, vapor-barrier coveralls, and/or fall protection equipment prior to entry. -The CSE Supervisor will be responsible for determining if acceptable entry conditions are present within a permit space where entry is planned, authorizing entry and overseeing entry operations, and terminating entry. -Communication between the CSE Attendant and the CSE Entrant will be maintained at all times through verbal communication, two-way radio, and/or hand signals. -Roux will confirm with local emergency response authorities prior to work that non-entry confined space rescue is possible in the event of an emergency.
Project Team Incident Notification Flowchart
(Only numeric values for mobile number, no spaces or symbols)

SHSO/Field Staff: Full Name*  Mobile:    Phone Number*
Project Manager: Full Name*  Mobile:    Phone Number*
Project Principal: Full Name*  Mobile:    Phone Number*
OHSM:   Full Name*   Mobile:   Phone Number*
OM:   Full Name*   Mobile:   Phone Number*
CHSD: Brian Hobbs, (631) 807-0193
Additional Project Personnel Contact List/Information

Project Role:Title    Name: Full Name  Mobile:    Phone Number
Project Role:Title    Name: Full Name  Mobile:    Phone Number
Project Role:Title    Name: Full Name  Mobile:    Phone Number
Project Role:Title    Name: Full Name  Mobile:    Phone Number
Job Related H&S Documentation*

Site-Specific HASPJSAsContractor HASPAdditional PermitsClient-specific requirements
Please List Additional Permits
Please specify client-specific requirements
Public utility mark-out required? (required prior to all subsurface work)*

YesNo
Please indicate the public utility mark-out ticket number
Please indicate the date of mark-out/call-in

MonthDayYear
Date
Hazard Assessment & Mitigating Actions
Ergonomics (please select the applicable hazards)*

1a. Bending and lifting equipment / bottleware1b. Repetitive bending and twisting motions1c. Static postures while performing oversight1d. Overexertion1e. Gripping, pinching, and/or pulling motions1f. Kneeling1g. Not Applicable1h. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards)
Not Applicable
Caught/Crushed (please select the applicable hazards)*

2a. Caught/crushed between heavy equipment and object2b. Caught/crushed between vehicle and object2c. Caught in machinery or equipment (pinch points, drill rig, mechanical fencing, contractor tools, etc.)2d. Engulfment by shifting materials (fill, gravel, sand, excavations)2e. Crushed by elevated heavy equipment2f. Not Applicable2g. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards)
Not Applicable
Exposure (please select the applicable hazards)*

3a. Airborne vapor or chemical hazards3b. Airborne construction dust hazards (excavation, drilling, hammer drilling, etc.)3c. Atmospheric hazards (oxygen, carbon monoxide, hydrogen sulfide, flammable gases)3d. PCB, hexavalent chromium, and/or pesticide contaminated particulates3e. Biological Hazards (insects, allergenic plants)3f. Cold Stress3g. Heat Stress3h. Rain/snow3i. Wetland conditions3j. Handling contaminated soil/groundwater or preservatives3k. Injection Amendments3l. Noise > 85 dBA3m. Suspect Asbestos-Containing Materials (ACM) or Lead-Based Paint (LBP)3n. Confirmed Asbestos-Containing Materials (ACM) or Lead-Based Paint (LBP)3o. Not Applicable3p. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards)
Not Applicable
Contact (please select the applicable hazards)*

4a. Contact with heavy equipment4b. Contact with third-party traffic4c. Struck by falling, swinging, or rolling objects (shoring equipment, building materials, stored objects, use of rigging)4d. Struck by projectile objects (debris from pneumatic, electric, or powder-actuated tools)4e. Not Applicable4f. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards)
Not Applicable
Slips/Trips/Falls (please select the applicable hazards)*

5a. Obstructions in the path of travel5b. Working at heights greater than 4 feet5c. Ladder use5d. Scaffolding5e. Excavations with potential for a depth greater than 4 feet5f. Working over or near water/drowning5g. Not Applicable5h. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards below)
Not Applicable
Energy/Utilities (please select the applicable hazards)*

6a. Onsite energized equipment6b. Subsurface energized lines and utilities6c. Overhead energized and equipment lines6d. Lock Out-Tag Out required for work6e. Spark-producing operations or "Hot Work"6f. Not Applicable6g. Other
Mitigating/Corrective Actions (please begin each mitigating action on a new line and edit as applicable)*
Additional Mitigating/Corrective Actions (please provide additional mitigating action(s) and mitigating action(s) for "Other" hazards below)
Not Applicable
Job Safety Analysis

Please make sure the appropriate JSAs are included in the HASP and are available onsite.
Please select the applicable JSAs*

Asphalt PavingATV/UTV DrivingBackfilling/Excavation/CompactionConcrete Form and PourCuttingDirect Push DrillingDrivingDrone Use - Site ReconDrum HandlingElevation SurveyingExcavation and TrenchingFence Installation and RepairGroundwater Gauging and SamplingHand AugeringHollow Stem Auger - Drilling and Well InstallationISCR InjectionLifting Storm Drain/Grate with a CrowbarMobilization and DemobilizationMonitoring Well Pad Concrete RepairMonitoring/Recovery Well DevelopmentScaffolding Setup and UseSite Walk and InspectionSoil SamplingSoil Vapor SamplingSonic Drilling and Well InstallationSpotting Heavy MachinerySpotting Third Party TrafficSub-Slab Vapor Pin Installation & SamplingTree/Brush/Overgrowth Lawn MaintenanceTruckingVac Track Guzzler OperationsPreclearing Air KnifeWetland DelineationsOther
Please indicate site-specific JSAs used:
Safety Data Sheets (SDS) for Chemicals Brought Onsite
Please list all SDS for chemicals which will be brought on-site*
Please upload a copy of SDS for EPA hazardous materials (5 MB limit)

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Site-Specific Health & Safety Plan (HASP)

The site-specific HASP should be updated whenever the project scope work changes or new hazards are present at the site.
Please provide a link for the Site-Specific HASP*
Please ensure all appendices and attachments are the latest version(s).
Site Plan including Emergency Muster Points
Please attach site plan file (Do not copy/paste images; 5 MB limit)*

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Project Orientation Checklist
The Roux Project Manager will ensure that all the following items have been addressed for this task and that all Subcontractors understand and agree to all expectations. Please check all that apply.*

Project ScopeUse of Sanitary FacilitiesAny Special Hazards (site or project specific)Smoking AreasMinimum PPE RequirementsSite Access / Traffic RegulationsJSA ReviewHousekeepingHASP Review (including review of SDSs)ID Badges / Site Security IssuesMedical Emergency ProceduresWaste Disposal ExpectationsMedical Non-Emergency ProceduresDrug and Alcohol PolicyIncident Management ProceduresOSHA/other Trainings RequiredManagement of Short Service WorkersNecessary Third-Party Issued Permits (operating, construction, other)Other
Are greater than 50% of Roux’s field workforce at the job site SSEs (e.g., the only Roux field worker at the site is an SSE)

YesNo
Has a Short Service Employee (SSE) Exemption Form been completed by the project manager and approved by the Operations Manager (OM)?

YesNoNot applicable
Please use the save function below to provide the JPF for project manager approval prior to submission.
Please use the link provided to complete an SSE Exemption Form (if applicable)

SSE Exemption Form
Should be Empty:

Health and Safety Job Planning Form

Relevant Project Information

Site-Specific Heat Illness Prevention Plan

Hazard Assessment & Mitigating Actions

Job Safety Analysis

Safety Data Sheets (SDS) for Chemicals Brought Onsite

Site-Specific Health & Safety Plan (HASP)

Site Plan including Emergency Muster Points

Project Orientation Checklist

Please use the save function below to provide the JPF for project manager approval prior to submission.