Breakdown of security-related tasks

This is an effort of the team with the participation of management, supervisors and employees

FORMTEXT
Company name: Foreman/Project Manager:

Date : Time: Place: Associated occupational risk assessment ID:

General description of the intervention:

EMERGENCY PROTOCOLS
Emergency phone number: Emergency radio station:

Gathering place: Emergency response location:

Location of fire extinguishers: Location of eye rinse solutions: Location of the first aid kit:
OPERATIONS INVOLVING A RISK OF DEATH Check all the answers that apply. No operation with a risk of death applies

Entering a confined space Cranes and rigging Electrical installation Handling equipment Dangerous Energy Control/Breaker

Motorized heavy equipment Digging/Excavation Motorized vehicle Work at height

MANDATORY INSPECTIONS Check all the answers that apply. No mandatory inspection Other:

Teleported Crane Electrical equipment Excavation Fall protection Forklift Heavy

equipment

Scale Motorized vehicle Respirator Rigging Scaffolding Welding equipment

COMPULSORY PERMITS Check all the answers that apply. No compulsory permits Other:

Explosion Head breaker Work permit Dangerous Grutting Radiation work Grid drop/floor plate/bodyguard Sharp-
stitching

Hot work Powered Locking and Entering a confined Overhead power lines Excavation and digging Working
electrical equipment labelling space on roofs
MANDATORY PREVENTION PLANS Check all the answers that apply. OTHERS OBLIGATORY Check all the answers that apply.
Other:
ELEMENTS
No mandatory prevention plan Other: No other mandatory items Back-up plan Gas monitoring

Chrome
Radiation Silica Fall protection work plan Barriers Signage Labels Security data sheet
hexavalent
PARTICIPANTS IN THE Participation in a pre-intervention meeting is mandatory before signing the confirmation form prior to the completion of the intervention.
INTERVENTION
Pre-intervention confirmation form (to be completed after completing the back of this form) Confirmation form after the
intervention is completed
Skill needed for intervention
Signing prior to the completion of the
Team member's name Driver of cranes, equipment, forklift, site signaller, Were you hurt? Initial
intervention
spotter, signaller, rigger, etc.

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

S/O No Yes

MANAGEMENT'S INVOLVEMENT IN THE DISTRIBUTION Complete this section when members of management attend or verify the details of the security task
OF SECURITY-RELATED TASKS allocation meeting.
Management participated in the security-related task allocation meeting Management has verified that the work in progress is consistent with the details of the
distribution of security tasks

Comments:

Name of manager: Time: Signing of the manager:

POST-INTERVENTION REPORT Fill out this section after performing the procedure.
Foreman/Project Manager: Date : Time:
Has a person been injured or has an unforeseen incident (almost an accident) occurred? No, no, no, no, no, no Has this been reported to the SSE service? No Yes

Form 000.653.F0101 security-related task allocation (Recto)

Return this security task allocation form to the SSE service after the response is complete 31 Jan. 2020
 Breakdown of security-related tasks
This is an effort of the team with the participation of management, supervisors and employees

If so, please describe the incident:

Comments (changes in work, opportunities for improvement, concerns, etc.):

FINAL VERIFICATION Before finalizing and signing the security task allocation form, review the necessary measures and/or training opportunities.
Signature of the foreman or project manager: Signature of the general foreman/site manager:

Signing of the SSE service: Notes :

Form 000.653.F0101 security-related task allocation (Recto)

Return this security task allocation form to the SSE service after the response is complete 31 Jan. 2020
 Steps of Identifying Related Determine the professional
Identify known and potential hazards
practices/equipment needed to safely complete
intervention hazards associated with each step measures
the steps

Review the "Steps of Intervention" listed above and What steps can be taken to keep staff out of the line of fire in carrying out
LINE OF FIRE HAZARDS determine if any of them pose a danger to body parts.
LINE OF FIRE PREVENTION this task?
More effectiveMoins effective Describe the prevention measures or
Parts of the body measures
at risk Can the danger Can a tool be Can the Can the stages of the
be eliminated? used instead? danger be intervention or professional
Source of danger Describe the dangers of the line of fire
Locking/labelling, Cables, pushers, isolated? practices be improved?
ground work, etc. etc. Barriers, Hand placement, ergonomics,
Hands Other
protective etc.
devices, etc.
Stuck?

Hit?

Pinched?

Crushed?

Burned or opened?

Coupé(s) ?

Other?

PERSONAL PROTECTIVE EQUIPMENT Check all the answers that apply in addition to the standard PPE requirements. No additional PPE required
Standard EPI requirements Dress/Body Eyes/Visage Feet Main Hearing Respiratory functions Other

Safety shoes (covering the ankle) Fire retardant Protective Metatarsal Cut-resistant protection Disposable protection
High-visibility jacket or outfit protection visor Earplugs
Electrically insulated Chemical-resistant Air-supply device
Pants Welder mask protection protection

Form 000.653.F0101 security-related task allocation (Verso)

Return this security task allocation form to the SSE service after the response is complete 31 Jan. 2020
 Chemical-resistant Safety goggles Chemical-resistant Thermal or welding Noise- Respiratory protection device
Long-sleeved
Eye protection protection protection protection cancelling filtering
sweater
helmets
Safety helmet Safety harness Electrical protection Assisted ventilation filtering
Universal gloves
breathing apparatus

Form 000.653.F0101 security-related task allocation (Verso)

Return this security task allocation form to the SSE service after the response is complete 31 Jan. 2020