HA-QT-Coldheads.docx

TO BE COMPLETED FOR WORK INVOLVING SUBCONTRACTORS

Subcontractor (if applicable)         Fermilab

Company                             Project Eng/C.M.       SpinQuest                                    

Project Manager                       Phone                                                          

Phone                   Page                     TM/CC/SC                                                        

ESH Rep.                         Phone                         Page                                          

Phone                   Page                     ES&H Rep.                                                                    

              Phone                         Page                                          

AT LEAST TWO SIGNATURES ARE REQUIRED

  TM/CC/SC/Work Planner                                          Date                              

Print Name                                                        

  Authorizing Supervisor                                          Date                      

    Print Name                                                      

  Accepted as noted                                               Date                      

    Print Name                                                      

COVID-19 Protective Measures: (Check all that are required for the job.)

□ Maintain 6 ft. or greater social distance when possible    

□ Face Covering (Cloth Face Mask or Disposable Face Mask)

□ Face Shield

□ Safety Glasses / Goggles

□ Impervious Gloves  

□ Clean Surfaces Used  

□ Wash/Sanitize Hands

□ Other Protective Measures Not Listed Above

Industrial Hazards: (Check all that apply to the job.)

□ Flammable Gas Areas   □ Steel Erection  

□ Heat Stress / Cold Stress   □ Fall Exposures > 4ft (>6ft for construction)              

□ Structural Demolition   □ Heavy Equip. Ops. (crane, boom lift, excavator)              

□ Excavation   □ Critical Crane Lift                    

□ Scaffold Erection / Scaffold Use   □ Rotating Equipment

□ Ladder Use   x   High Pressure air / fluids

□ Non-ionizing radiation (lasers, RF, UV, magnets)   □ Welding / Cutting / Brazing / Grinding

□ Confined Space   □ Lead (paint, bricks, cutting sheets, soldering)

□ Silica   □ Chemical Use (cleaners, solvents, adhesives, etc.)

□ Asbestos (presumed or suspected materials)   □ Ergonomics (overexertion, repetition, lifting)

□ Nanomaterial (1-100nm, 3D print, etc.)   □ Loud Noise (continuous, instantaneous)

□ Beryllium   x   Potential Oxygen Deficiency – ODH 1 or 2 areas

Electrical Hazards: (Check all that are required for the job.)

□ Manipulative Energized Work       □ Diagnostic Energized Work (LOTO verification)              

□ Working within 10 ft of overhead utilities   □ Working within 25 ft of 345kV overhead utilities              

Environmental Hazards: (Check all that are required for the job.)

□ Impact or release to surface, sanitary, or ground water    

□ Impact to new or existing air emission sources, including equipment/generators              

□ Generation of regulated waste (hazardous, special, universal)  

□ Use of refrigerants

□ Use of Oil (> 55 gal) or new oil filled equipment  

□ Release of a chemical or use of a new chemical  

□ Impact to a naturally sensitive area or historical site        

Radiation Safety: (Check all that are required for the job.)

□ Posted Radiological Area (Radiation Area, HRA, Contamination, Airborne)                              

□ Radioactive Material, Ionizing Radiation, Radiation Sources, RGDs, RAW systems, Exhaust Systems, Beamline Components - including targets & absorbers

□ Area working in >= 100 mrem/hr

□ Worker receiving >= 50 mrem for the job  

General Hazards: (Check all that are required for the job.)

□ Traffic Control   □ Working above others  

□ Biological Hazards   □ Other Hazards not listed here?                                                                                                                                              

Personal Protective Equipment (PPE): (Check all that apply to the job.)

□ Hardhat   □ Bump cap  

□ Steel-toed boots   □ Steel-toed shoes  

□ Gloves - leather   □ Gloves - chemical  

□ Gloves - electrical   □ Gloves - Cryogenic  

□ Gloves - Nitrile   □ Tyvek Coveralls

□ Tyvek Boot Covers   x   Earmuffs / Ear Plugs  

□ High visibility clothing   x   Safety Glasses

□ Safety goggles   □ Safety goggles - chemical

□ Safety goggles - impact/face shield   □ Welding goggles/helmet

□ Fall Protection   □ Respirators (air purifying), cartridge

□ Respirators - supplied air   □ Long Sleeve Shirts

□ Long Pants without Cuffs   □ Arm - cut protection

□ Leg - cut protection   □ Apron - Cryogenic

□ Whole body - electrical   □ Whole body - Dust, chemical, heat

□ Other PPE not listed here?  

Controls: (Check all that are required for the job.)

□ Danger tape & signage       □ Barricades - solid  

□ Barricades - soft (caution tape)   □ Road Closure  

□ Soil/erosion control   □ Site dust control

Environmental Impacts ( Required - check one):  

□ Yes, I have thought about the potential environmental impacts (see Guidelines for Completing the HA on page 6) of this job and will document such impacts and mitigation steps within this document.

□ Yes, I have thought about the environmental impacts of this job and no such credible impacts exist and therefore do not need to be written in this document.