Site Specific Safety Plan (SSSP) Request
Requestor (P&S Employee):
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First Name
Last Name
Date SSSP Needed:
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-
Month
-
Day
Year
Please provide the date the SSSP needs to be completed and ready to submit to the customer.
Job Information
If applicable, provide the contact info for our staff on the project.
Job #:
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Job Name:
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Please provide the official job name that the customer, engineer, and/or owner will use.
Customer/General Contractor:
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Job Site Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
P&S Scope of Work:
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Provide a brief written scope of work.
Estimated Project Start Date:
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Month
-
Day
Year
Provide the estimated start date for the project.
P&S Personnel
If applicable, provide the contact info for our staff on the project.
Foreman/Leadman Name:
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First Name
Last Name
Foreman/Leadman Phone Number:
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Please enter a valid phone number.
Superintendent Name:
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First Name
Last Name
Superintendent Phone Number:
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Please enter a valid phone number.
Project Manager Name:
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First Name
Last Name
Project Manager Phone Number:
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Please enter a valid phone number.
General Contractor Personnel
If applicable, provide the contact info for the GC's staff on the project.
GC Project Manager Name:
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First Name
Last Name
GC Project Manager Phone Number:
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Please enter a valid phone number.
GC Safety Manager Name:
First Name
Last Name
GC Safety Manager Phone Number:
Please enter a valid phone number.
GC Main Office Phone Number:
Please enter a valid phone number.
Owner Personnel
If applicable, provide the contact info for the Owner's staff on the project.
Owner Project Manager Name:
First Name
Last Name
Owner Project Manager Phone Number:
Please enter a valid phone number.
Owner Safety Manager Name:
First Name
Last Name
Owner Safety Manager Phone Number:
Please enter a valid phone number.
Owner Main Office Phone Number:
Please enter a valid phone number.
Subcontractors:
If applicable, list all subcontractors we will use on this project and provide a brief SOW for each.
List of subcontractors:
Potential Project Hazards (Based on our Scope of Work):
Select all of the hazards that our employees could potentially encounter on this project.
Select the hazards and/or exposures that may be present:
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Confined Space Entry
Excavating
Exposure to asbestos
Exposure to electrical arc flash
Exposure to hazardous substances
Exposure to Silica Dust
Hoisting and/or rigging
Needing Respiratory Protection
Working at night
Working around (or near) cranes and/or digger derricks
Working from heights above 6'
Working from ladders
Working in (or near) excavations deeper than 5'
Working in Aerial Equipment (Bucket Trucks, Lifts, etc.)
Working near (or in) road way traffic (Work Zone Safety)
Working on energized electrical circuits
Working on scaffolding
Utilizing forklifts
Utilizing Powder Actuated Tools
Note: By default, all Site Specific Site Plans will address the following topics and hazards:
Pfeiffer & Son Statemetn of Safety Policy
Safety & Health Responsibility
Accident/Incident/Near-miss Reporting and Investigation
Assured Grounding
Bloodborne Pathogens
Disciplinar Action
Drug Free Workplace
Emergency and Fire Prevention
Hazard Communication
Hearing Conservation
Heat Stress
Housekeeping
Medical Services and First Aid
Mobile Phone Usage
Personal Protective Equipment (PPE)
Safety Meeting Schedule
Short Service Employees
Stop Work Authority
Tool Safety
Other Hazards/Exposures:
List any other hazards that our employees may encounter, that are not listed above.
Additional Training Needed:
List any additional training that may be required prior to starting work.
Other items the Owner/GC requires we address:
List any other items the Owner or GC requires us to address.
Submit
Should be Empty: