Safe Plan of Action – Line Division

Date

Nearest Hospital or Medical Facility:*

Voltage being worked on or in proximity of:

Nearest Protective Device:*

Voltage of equipment being worked on or near:

Designated Observer (DO) if required

Hydration Monitor (if required)

Project:*

Location of Job:

Job/Task:

Work Area:

TASKS TO BE PERFORMED:

TASKS TO BE PERFORMED:*

HAZARDS ASSOCIATED WITH TASK:

HAZARDS ASSOCIATED WITH TASK:*

SAFE PLAN:

SAFE PLAN:*

Foreman*

Foreman Email to receive copy of SPA for reference:

Foreman signature:*

Team Members:

Team Member signatures:*

Team Member signatures:

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Team Member signatures: