TITLE:

ES&H Manual

 

DOCUMENT ID:

3330 Appendix T3

Stop Work Order for Safety Worksheet

 

 

Step One - Instructions

1.      The Worker’s supervisor/Subcontracting Officer’s Technical Representative (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):

X

List Work Control Documents (OSP, TOSP, TaskList) in use:

     

Describe the Perceived Hazard/Imminent Danger (as stated by identifier of the Hazard/ Imminent Danger):

X

Were existing procedures being followed?

Yes

No

Attach procedure used.

Were existing procedures Adequate?

Yes

No

Additional Observations:

X

Attach

Task Hazard Analysis

 

Reviewer Signatures:

Print

Signature

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 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:

X

 

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

X

 

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)

 

Text Box: Ensure that the operation is not resumed until the Restart Plan has been approved and distributed.  Make this worksheet and the restart notice part of the permanent Lessons Learned record.