Contractor Safety Plan Template

				
Company Logo Here	Additional Company Logo	
Project Name				
Address or				
GPS Location				
Job #				
Contract/CWA # #Number				
Est. Start Date				

VERSION CONTROL

Contractor	Date Submitted By Contractor to PG&E:		
PG&E	Date of PG&E LOB Acceptance:		
Contractor	Date of Kick-off (In-Construction):		
Contractor	Date of Project Completion (Post-Construction):		

 	TABLE OF CONTENTS	

1.0	General Information	
2.0	Emergency Action Plan	
3.0	Risk Assessment and Hazard Identification	
3.1	Cranes	
4.0	Certifications and Licenses	
5.0	Managing Subcontractors	
6.0	Accident/Incident Reporting Protocol	
7.0	Site Orientation Page – Contractors	
8.0	Site Orientation Page – PG&E	
9.0	Change Log	

1.0 General Information	

Scope of Work Summary:	
	Name(s)	Email	Contact #	
PG&E Contacts	Project Manager				
	Work Supervisor(s)				
					
	Other				
					
	PG&E Site Safety Rep(s)/
Inspector(s)				
					
	Risk Assessment Author				
	Environmental Specialist				
Contractor Contacts	CSP Author				
	Site Safety Rep(s)				

					

					

2.0 Emergency Action Plan	
Purpose: The following information shall be utilized to ensure effective and swift response to all emergencies.

Clinic (First Aid)	Clinic 2 (Drug Testing)	
Name:*		Name: *		
Address: *		Address: *		
Phone #:*		Phone #:*		
Hours of Service: *		Hours of Service: *		
	
Hospital	Ambulance	
Name: *		Name: *		
Address:		Address:		
Phone #: *		Phone #:*		
Hours of Service:		Hours of Service:		
	
Police/Sheriff	Fire Department	
Name: *		Name: *		
Address:		Address:		
Phone #: *		Phone #:*		
Hours of Service:		Hours of Service:		

First Aid Kit Location(s) *		
AED Location(s) *		
Fire Extinguisher Location(s) *		
SDS Location(s) *		
CPR Certified (who?) *		

(*) Denotes Required Field

Map View of Evacuation Plan – Print and Post

Show a map of the location with both primary and secondary meeting locations identified. Also, show map with directions to the emergency center identified on page 4.

Map of A and B Meeting Location

Meeting Location A – please indicate on map (Primary)	Meeting Location B – please indicate on map (Secondary)	

Map View of Evacuation to Nearest Medical Facility – Print and Post
Show map with directions to the emergency center identified on page 6.

Directions to Medical Facility	Map to Medical Facility	

Risk Assessment and Hazard Identification/JHA	
Check the  box if this hazard is present and then describe the hazard under “Hazard Description”. The Contractor shall complete the “Contractor’s Mitigation Plan”.
Environmental Hazards or write in Task under other and complete

	Category	Hazard Description	Contractor’s Mitigation Plan	

	Animal Risks			

	Poison Oak/Plants			

	Insects			

	Dust			

	Silica			

	Lead			

	Asbestos			

	Hazardous Soil			

	Chemicals/Compounds			

	Spills			

	SPCC Additional Provisions			

	Other			

	Other			

	Other			

Physical Hazards or write in Task under other and complete

	Category	Hazard Description	Contractor’s Mitigation Plan	

Access Issues			

	Neighboring Facilities/Homeowner
Issues			

	No Phone Access (Poor Cell Reception)			

Night Operations			

Weather			

Noise Exposure			

Vehicles/Equipment			

Excavation			

Confined Space			

	Suspended Loads/Rigging			

	Elevated Work (Working at Heights or Near Excavation)			

	Hot Work (Cutting, Welding)			

	Working in Close
Proximity to High Voltage			

Control Room Work			

	Compromised Structures			

Other			

Other			

Other			

	Work will require clearance		Electric Fault Duties (Provided by PG&E)		
			kV	Amps		
			kV	Amps		

	Job requires vehicle grounding					
			kV	Amps		
		
Contract Company will ensure that sufficiently rated Protective Grounds for the job SOW will be used.	

	Work requires use of Protective Grounds		

Cranes if applicable	

Weight of Load (Weight Provided by PG&E only):		
Make of Crane:	If yes to any below, a Critical lift plan is required:	
Model of Crane:	a. Is load over 100k lbs or 70% of crane capacity?		
Radius of Lift:	Yes	No		
Load Chart Capacity:	b. Are two cranes being used?	Yes	No	
	c. Does lift include personnel?	Yes	No	

Insert Picture/Sketch of Lift Plan

I certify that all contract employees covered under this CSP on PG&E property are trained and qualified to perform the task(s) they have been assigned. (This must be signed at the kickoff by the Contractor)

Contractor Site Representative Signature

4.0	Certifications and Licenses	

Description		Contract Employee Name(s)
(If all, type ALL in the space below)	Expiration Date	
Class A Commercial License	
			
Crane Operator Certification	
			
Crane Equipment Certification	
			
HAZWOPER	
			
Forklift Operator Certification	
			
Asbestos Class III Maintenance Worker	
			
Respiratory Protection	
			
Excavation Competent Person	
			
Other	

5.0	Managing Subcontractors	

Subcontractor Name	
Subcontractor Scope	
ISN ID #	Subcontractor Contact Name	Subcontractor Contact Phone	

					

					

					

					

					

Event Reporting Protocol	

PG&E Requirements

Contractors shall notify the PG&E Representative of any incidents that may occur while on PG&E property per the PG&E LOB Contractor Safety Oversight Procedure or immediately ( as soon as safely possible). Incident types include:
Injury/illness to Contractor’s employee or to the public (Serious Injury/Fatality – SIF–Incidents or incidents with SIF-Potential will be treated with highest priority)
Motor Vehicle Incident
Property/Equipment Damage
Work Procedure Error (and whether or not an outage was caused)
Dig-In (whether at-fault or not-at-fault)
Near Hits/Good Catches

An initial written report is due within 24 hours of the incident for SIF and SIF-Potential Incidents and ensures any written incident reports meet PG&E’s Causal Evaluation Standard.

 Contractor’s Requirements

7.0      Site Orientation Page - Contractors	 All site personnel are required to be introduced and instructed on the content and hazard mitigation measures/JHA included in or in conjunction with this CSP prior to beginning work on the project. This section of the CSP shall be used to document employees who have completed a review of this CSP including their name, signature, classification, company name and date.

Name	Signature	Classification	Company Name	Date	

					

					

					

					

					

7.0      Site Orientation Page – Contractors (Page 2 of 3)	 All site personnel are required to be introduced and instructed on the content and hazard mitigation measures/JHA included in this CSP prior to beginning work on the project. This section of the CSP shall be used to document employees who have completed a review of this CSP including their name, signature, classification, company name and date.

Name	Signature	Classification	Company Name	Date	

					

					

					

					

					

7.0      Site Orientation Page – Contractors (Page 3 of 3)	 All site personnel are required to be introduced and instructed on the content and hazard mitigation measures/JHA included in this CSP prior to beginning work on the project. This section of the CSP shall be used to document employees who have completed a review of this CSP including their name, signature, classification, company name and date.

Name	Signature	Classification	Company Name	Date	

					

					

					

					

					

8.0	Site Orientation Page – PG&E	
PG&E Employees and representatives of PG&E shall use this page to indicate that an orientation to this CSP has been completed.
Name	Signature	Position	Company Name	Date	

					

					

					

					

					

9.0	Change Log for changing conditions	
Indicate changes made on the CSP in the table below. For each date a change is made, an additional section 9.0 will need to be completed and shall be added as an additional page to the overall CSP. Multiple changes may be required for each date, which is why multiple lines have been provided.

Date	Reason for Change	Change Description	Section(s) Changed	PG&E Representative who Accepted Change	

					

Once the crew has reviewed the changes above, please have them sign below indicating they understand the change.

Name	Signature	Classification	Company Name	Date Reviewed Change	

					

					

9.0	(Page 2 of 3) Change Log – Continued (Additional Page as Needed)	
Indicate changes made on the CSP in the table below. For each date a change is made, an additional section 9.0 will need to be completed and shall be added as an additional page to the overall CSP. Multiple changes may be required for each date, which is why multiple lines have been provided.

Date	Reason for Change	Change Description	Section(s)
Changed	PG&E Representative who
Accepted Change	

					

Once the crew has reviewed the changes above, please have them sign below indicating they understand the change.

Name	Signature	Classification	Company Name	Date Reviewed Change	

					

					

9.0	(Page 3 of 3) Change Log – Continued (Additional Page if Needed)	
Indicate changes made on the CSP in the table below. For each date a change is made, an additional section 9.0 will need to be completed and shall be added as an additional page to the overall CSP. Multiple changes may be required for each date, which is why multiple lines have been provided.

Date	Reason for Change	Change Description	Section(s)
Changed	PG&E Representative who
Accepted Change	

					

Once the crew has reviewed the changes above, please have them sign below indicating they understand the change.

Name	Signature	Classification	Company Name	Date Reviewed Change