Contractor_Safety_&_Mishap_Infomation.pdf

CONTRACTOR SAFETY & MISHAP INFORMATION

Contractor ________________________________________

Contract No._______________________________________

Project Title________________________________________

Contractor local representative: ___________________________________________________ (Print)

Phone number: _______________________Title: _____________________________________

Local Government Representative overseeing contractor: _______________________________ (Print)

Phone number: _____________________Title: _______________________________________

A. Brief description of work to be performed (Big picture): _____________________________

B. Location where work is to be accomplished: ______________________________________

C. Time line for work accomplishment: ____________________________________________

D. Point of contact for contractor mishap reporting: __________________________________

Attachment (6)

FOR OFFICIAL USE ONLY

FOR OFFICIAL USE ONLY

Phone number: ____________________Title:________________________________________

E. List of work processes or procedures which could impact other employees working in the area and controls or preventive measures to be taken to mitigate hazard:_________________

F. Safety and Health Plans. Identify and provide a copy of the safety and health plans applicable to the contracted work. (e.g., hazard communication program, confined space program, asbestos abatement plan, lead abatement plan, respiratory protection plan, and emergency response plan.)