Infectious Disease Control Plan - COVID-19 - Flipbook - Page 33
Approval
Level
Yes
No
Desc. On
Task
Plan?
Attachment
Provided?
TRENCHING & EXCAVATION (REF. IIPP CHAPTER 15)
Will you be working within or creating a trench or excavation. If so, identify competent
person:
M
Determine if shoring is required (5 ft. deep or more)
Utilize ladders every 25’
Is it a confined space?
ID barricading methods
Utilities identified
Monitor conditions daily
Approval
Level
Yes
No
Desc. On
Task
Plan?
Attachment
Provided?
Desc. On
Task
Plan?
Attachment
Provided?
Will your task require special Personal Protective Equipment (PPE)? If yes, specify
below.
Safety glasses / Goggles
Steel toed safety shoes
Face shield
Hearing Protection
Nitrile gloves
Sturdy work boots
Latex gloves
Hard hat
Neoprene gloves
Welding helmet
Work gloves
Fall protection PPE
Electrical PPE (voltage rated gloves, tools, mats, suits)
Other
L
Approval
Level
Yes
No
PERSONAL PROTECTIVE EQUIPMENT
H
CRANE LIFT (REF. IIPP CH. 14)
Will your task involve rigging or other material handling equipment (i.e., crane lift,
forklift, etc.)? If yes, provide equipment certifications and submit crane lift plan as
required.
Crane operator certs
Rigger certs
Last annual crane inspection doc
Company proof of insurance for the crane
Pick plan
Approval
Level
Yes
No
Desc. On
Task
Plan?
Attachment
Provided?
Desc. On
Task
Plan?
Attachment
Provided?
Will you be using open flame or other sources of fire ignition (brazing, welding, torch
cutting, CAD weld, grinding)? Or could your activity produce sparks? If you
answered “yes” to any of these, you must have a completed and signed “Hot Work”
permit before working.
M
Approval
Level
Yes
No
L
L
M
CONFINED SPACE WORK (REF. IIPP CHAPTER 10)
Will you be entering a Confined Space (trench or manhole)? If yes, you must meet the
requirements of TEAMWRKX Confined Space Management Program and attach
applicable documents including confined space permit, if applicable.
H
Approval
Level
HOT WORK
Yes
No
Desc. On
Task
Plan?
Attachment
Provided?
FALL PROTECTION/INTERSTITIAL SPACE/ELEVATED WORK
Will your activities result in hazards to those above, below, or around the work area?
Will the occupants of the areas directly underneath your work area be notified prior to
the start of any interstitial area work and will the area below be cleared of individuals
and remain isolated during the performance of your work? Will the area be taped off?
Will you be conducting work at elevated locations (i.e. scaffold, elevated platform) or
will you be working within 6 ft. of roof edges? If no, follow appropriate ladder work
practices. If yes, provide fall protection training verification records as required.
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