1. GENERAL INFORMATION
GREATER SOUTHWEST CONSTRUCTORS, INC.

PO BOX 834

WEATHERFORD, TX 76086	2. CONTRACT NUMBER

3. DATE

1C. TELEPHONE

4. SITE LOCATION

5A. SITE PHONE (S)

5B. SITE FAX

6. SITE SUPERINTENDENT

7A. MAXIMUM

WORKERS/SHIFT

7B. SHIFTS/DAY

7C. SHIFT TIMES

8A. MAJOR EQUIPMENT SUBCONTRACTOR WILL USE

8B. MAJOR EQUIPMENT LOWER-TIER SUBCONTRACTOR (S) WILL USE

II. DESIGNATED SAFETY PERSONNEL
9A. SUBCONTRACTOR ON-SITE SAFETY REPRESENTATIVE

9B. SAFETY REPRESENTATIVES TRAINING & EXPERIENCE

10A. PERSON(S) RESPONSIBLE FOR DAILY HOUSEKEEPING

10B PROVISIONS FOR DRINKING WATER & SANITATION FACILITIES

11A. PERSON(S) RESPONSIBLE FOR DAILY SAFTEY INSPECTIONS

11B. SAFETY INSPECTOR’S QUALIFICATIONS & EXPERIENCE

OSHA TRAINING
12A. PERSON(S) CERTIFIED IN FIRST-AID/CPR

12B. CERTIFICATION TYPE/ISSUED BY/EXPIRATION DATE

13A. PERSON(S) CONDUCTING WEEKLY SAFETY MEETINGS

13B. WEEKLY SAFTY MEETINGS (SCHEDULED DAY/TIME)

14 COMPETENT PERSONS

A. HAZARD ANALYSIS: D. MATERIAL HANDLING:

B. CONFINED SPACES: N/A E. SCAFFOLDS: N/A

C. EXCAVATIONS: N/A F. ELECTRICAL POWER DISTRIBUTION:

III. EMERGENCY SERVICES FOR THIS SUBCONTRACT
14A. # FIRST-AID KITS ON-SITE

SERVICED BY:

WHEN?	14B. NEAREST MEDICAL FACILITY / HOSPITAL

ADDRESS:

PHONE #:
14C. AMBULANCE

PHONE #:	14E. FIRE DEPARTMENT

PHONE #:	14D. POLICE

PHONE #:
IV. FIRE FIGHTING EQUIPMENT TO BE ON SITE
15A. EXTINGUSHERS,TYPE

15B. ANSI CLASS/RATING

15C. QUANTITY

15D. SPECIFIC LOCATION

15E. ADDITIONAL FIRE PROTECTION DATA/COMMENTS

IV. HAZURDOUS/FLAMABLE/COMBUSTABLE MATERIALS ON SITE

THIS SECTION IS BRIEF SUMMARY ONLY; PER 29CFR 1926.39(e) SUBCONTRACTOR SHALL HAVE COMPLETE LIST POSTE/AVALIABLE D
16. FOR THIS SITE MSDS TO BE AVALIABLE AT:

FORSEEABLE FLAMABLE/COMBUSTABLE LIQUIDS OR GASES
17A. MATERIAL/DESCRIPTION

17B. STORAGE LOCATION

17C.STORAGE CONTAINER

OTHER FORSEEABLE HAZERDOUS/TOXIC MATERIALS
18A. MATERIAL/DESCRIPTION

18B. STORAGE LOCATION

18C. STORAGE CONTAINER

19A. SUBCONTRACTIOR’S NAME (PRINT)

19B. SUBCONTRACTORS SIGNATURE

19C. DATE:

I. GENERAL WORK SITE INFORMATION

WORK RELEASE #:________________________________________ REGION: __________________________

WORK RELEASE TITLE: __________________________________________________________________________

SITE NAME: ___________________________________________ SITE LOCATION: _____________________

SCOPE OF WORK (ATTACH ADDITIONAL SHEETS IF NECESSARY):___________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

II.SITE ACTIVITITES/TASKS: ACTIVITITES/TASKS TO BE PERFORMED AT THIS SITE UNDER THIS WORK RELEASE ARE IDENTIFIED BELOW. (CHECK EACH ACTIVITY/TASK TO BE PERFORMED BY TSSC PERSONNEL AT THIS SITE. SPECIFY ALL OTHER ACTIVITIES/TASKS IF NOT LISTED).

Activities/Tasks

Site Preparation

Demolition

Vehicle Operations

Heavy Equipment

HazMat Operations

Material Handling/Lifting

Manual

Mechanized

Excavation

Mechanized

Manual

Earth Work

Paving (Asphalt)

Fences/Gates

Landscaping

Fire Detection/Alarm

Fire Suppression

Concrete Work

Non-Reinforced

Reinforced

Pre-Stressed

Form Work

Electrical Work

Live Work

Equipment/Racks

Conduit/Raceways/Ducts

Sheet Metal/Duct Work

Pannels/Disconects

Wire/Cable

Electronics/Control

Emergency Generator

UPS

Lightning Protection

Grounding Rods

Grounding Rods

Hot Work

Arc-welding

Exothermic Welding

Torch Work

Plumbing/Pipe Fitting

Carpentry

Wallboard Installation

Painting

Masonry/Brick Laying

Structural Steel

HVAC Work

Tank Removal/Installation

Underground

Above Ground

Level of Effort

Drafting

Engineering

Site Support

Other ________________________________________ Other _______________________________

Other ________________________________________ Other _______________________________

Other ________________________________________ Other _______________________________

III. Types of Hazards: Hazards or potential hazards associated with site activities/tasks and/ or site conditions present for this work site are identified below.

Physical Hazards

Weather Conditions

Extreme cold

Extreme Hot

High Winds

Other: ___________

Debris Stockpile/Removal

Materials Handling/Storage

Lifting

Moving/Rolling

Hazardous Materials

Asbestos

Lead

PSBs

Other: ___________

Compressed Gases

Fire/Explosion

Falling Objects

Rolling Objects

Cutting/Piercing Objects

Lifting Equipment Operation

Cranes

Man-lifts

Rigging

Physiochemical Hazards

Flammable

Explosive

Corrosive

Reactive

Oxidizing

O2 Rich

O2 Deficiant

Vehicle Operation/Traffic

Heavy Equipment Operations

Limited Working Space

Vertical Clearance

Horizontal Clearance

Hand Tools

Power Tools

Electrical

Pneumatic

Fuel

Powder Actuate Tools

Airborne Particles

Dust/chips/particulate

Vapors/Fumes

Liquids (splash)

Light Radiation

Noise

> 85 dBA

> 90 dBA

Confined Space Entry

Hazardous Atmosphere

Other Hazards

Other: _______________

Chemically Toxic Hazards

Inhalation

Ingestion

Contact

Absorption

Air Contaminant

(29 CFR 1910.1000)

> PEL

> TWA

> STEL

> Ceiling

Electrical Shock

Hot Work

Utilities

Underground

Overhead

Excavating/Trenching

Surface Obstruction

Unstable Soil

Water Infiltration

Near Buildings

Working at Elevation

Ladders

Scaffolding

On Structure

Suspend

Climbing

Rappelling

Working Over Water

Site Condition/Accessibility

Rough Terrain

Remote

Not Accessible by Car

Other: ________________

Biological Hazards

Poisonous Plants

Snakes/Reptiles

Insects/Spiders/Ticks

Other Animals __________

Sewage Waste

Disease Causing Agents:

___________________

___________________

___________________

Radiation Hazards

Ionizing Comments:

______________________________________________________________

Non-Ionizing UV

IR RF

_______________________________________________________________________________

Prepared by: Date:

Work Release Hazard Form
Work Release #
Facility/Location
Work Release Title
Scope of Work
Subcontractor: YES NO
Assessor
Date
Eye/Face Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Chipping, drilling, grinding, riveting, etc.
Powder actuated fastening
Venting/ pressure release
Regulated pressures over 125 psig
Handling or cutting metal banding or wire
Flying particles, dust, etc.
Woodworking, sanding, etc.
Exposed, energized electrical circuits
Battery charging/handling electrolyte
Chemical handling/cleaning/degreasing
Removal of coatings/rust using power tools
Welding, cutting, or brazing
Exposure to potentially infectious materials
Construction work areas
Other:
Head Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Construction work areas
Falling or potential for falling or dropped objects
Impact from flying or moving objects
Within 10’ of a suspended load on crane
Low clearances or other bump hazards
Possible contact with an energized conductor
Other:
Hand Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Objects with rough abrasive/sharp edges
Potential for cuts, abrasion, or puncture
Handling materials that are skin detriment
Harmful temperature extremes
Welding, cutting, or brazing
Possible contact with an energized conductor
Blood or other potentially infectious materials
Other:
Foot Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERING CONTROL
HI	LOW	NONE
Potential exposure to falling objects
Handling heavy objects that could be dropped
Exposure to rolling objects
Movement of tools, stock, or equipment
Exposure to objects that could pierce soles
Handling/transfer/ clean up of hazardous materials
Exposure to energized materials
Other:
Skin Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Dust, dirt, and particles
Oils, resins, greases, or non-hazardous liquids
Abrasive blasting
Spray painting
Asbestos exposure or Lead exposure
Chemical handling/transfer/clean-up operations
Battery charging/handling electrolyte
Operations where clothing burning could occur
Possible electrical arcing/sparking
Prolonged skin exposure to sunlight
Harmful temperature extremes
Other:
Hearing Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERING CONTROL
HI	LOW	NONE
8 hour TWA of 85 dbA or greater
Exposure to diesel engine generators
Use of saws, grinders, generators, etc.
Use of impact tools
Exposure to heavy equipment operations
Exposure to aircraft operations
Exposure to vibratory noise
Any operation where noise level is uncomfortable
Other:
Fall Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERING CONTROL
HI	LOW	NONE
Operations at relative heights greater than 6 feet where adequate safety barriers are not provided
Transport in/working from an aerial lift device
Climbing structures/ladders w/out safety devices
Climbing ladders with ladder climbing devices
Lateral positioning
Entry into a confined space
Other:
Respiratory Protection
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Non-toxic dust, mists, or fumes
Dusts, mists, gases, or vapor exceeding PELs
Paint spray applications
Pesticide applications
Asbestos work situations
Heating specific metals or toxic coatings
Oxygen-deficient environment
Exposure to potential human carcinogens
Work in conditions that are considered IDLH
Particles/vapors that cannot be chemically filtered
Other:
Other
HAZARD/TASK	RISK	EQUIPMENT TYPE OR ENGINEERIN CONTROL
HI	LOW	NONE
Extreme weather conditions
Remote location
Working over/near water
Excavations/trenching
Confined space entry
Biological hazards
Flammable/explosive atmospheres
Radiation hazards
Ergonomic hazards
Other:
Other:
Certification

I certify that this hazard assessment has been conducted with all due

considerations for all potential hazards to the best of my knowledge for

this work site. All hazards or potential have been considered and we

feel this is a safe assessment of same said hazards. This hazard

assessment shall be reviewed periodically and revised as necessary to

address additional environmental, safety, and health hazards (and

potential hazards) present at the work site. Comments, questions, or

concerns should be addressed to Greater Southwest Constructor., Inc., Dept. of

Quality control and safety, P O Box 834, Weatherford, Texas 76086.

Signature Date

Dir. Safety (GSW) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Project Mgr (GSW) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ES&H Engineer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Owner/Representative _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

GSW Greater Southwest Constructors, INC.

SUMMARY DATA FOR SAFETY PROGRAM

1

1

Justin Summarell

2003-11-06

Wanda Clark

JOE R. JONES CONSTRUCTION, INC.