TITLE:	ES&H Manual
DOCUMENT ID:	3330 Appendix T3 Stop Work for Safety Worksheet

Step One:

Instructions

1. The Worker’s supervisor/SOTR/sponsor fills out this form. (Document the incident objectively as possible.)

2. Review required by the individual identifying the Hazard/Imminent Danger.

3. Distribute to those listed as soon as possible.

Owner Division:	Department:
Location of Work Operations:	Date/Time:
Worker’s supervisor/ SOTR/sponsor:	Phone:
Name of Employee Initiating Stop Work:	Phone:

Describe Work Operation or Condition (include names of employees or subcontractors):
List Work Control Documents (OSP, TOSP, Task List) in use:
Describe the Perceived Hazard/Imminent Danger (as stated by identifier of the Hazard/ Imminent Danger):
Were existing procedures being followed?	Yes	No	Attach procedure used.
Were existing procedures Adequate?	Yes	No
Additional Observations:

Attach Task Hazard Analysis

Reviewer:	Signature	Print	Date
Worker(s):
Identifier:
Supervisor/SOTR/Sponsor:

Submit Copies to: Line Supervisor for the Work

Division Safety Officers

Chief Operating Officer

Division Associate Director

Office of Quality Assurance & Continuous Improvement

Employee initiating the stop work order (Identifier)

Step Two – Work Re-Start:

Instructions

1. The Worker’s supervisor/SOTR/sponsor fills out this form. (Document the incident objectively as possible.)

2. Review required by the individual identifying the Hazard/Imminent Danger.

3. Distribute to those listed as soon as possible.

Date/Time DSO Informed:

Date/Time Dept. Manager Informed:

Record of Follow-up Action:

Restart Plan: (Outline action steps, corrective measures, and who is responsible for each. Plan must be approved by the relevant Associate Director.)

Work Restart Approval: (To be signed upon completion of Restart Notice Actions)
Supervisor/SOTR/Sponsor:	Date:
ESH&Q Staff:	Date:
Dept Manager:	Date:
Associate Director:	Date:
Identifier:	Date:

Approved Copies to: Line Supervisor for the Work

Division Safety Officers

Chief Operating Officer

Division Associate Director

Office of Quality Assurance & Continuous Improvement

Employee initiating the stop work order (Identifier)

ISSUING AUTHORITY	APPENDIX AUTHOR	APPROVAL DATE	EFFECTIVE DATE	EXPIRATION DATE	REV.	Page 3 of 3
ESH&Q Division	Harry Fanning	10/05/09	01/01/10	10/05/12	0

This document is controlled as an on line file. It may be printed but the print copy is not a controlled document. It is the user’s responsibility to ensure that the document is the same revision as the current on line file. This copy was printed on 10/13/2009.