ĐĎॹá>ţ˙ }ţ˙˙˙|€˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ @ đżżKbjbj{Î{Î _ˆ¤¤¤C˙˙˙˙˙˙ˆ0000000$T)))Pl)$)ĚTT7h*h*"Š*Š*Š*2,2,2,Ó6Ő6Ő6Ő6Ő6Ő6Ő6$d9Rś;|ů602,,"2,2,2,ů600Š*Š*†7P0P0P02,0Š*0Š*Ó6P02,Ó6P0P0:6,00Ł6Š*\* 0}05Ę Ę)D-*G6 Ó6$70T7Q6R2<n.Ě2<Ł6TT00002<0Ł602,2,P02,2,2,2,2,ů6ů6TT$&x(¤:0TTx( RESPONDING DEPARTMENT APPENDIX Health and Safety Plan for Hazardous Material Emergency Response This Appendix addresses health and safety protection for: (Circle One) Fire Department Police Department Emergency Medical Services Public Works/Road Department Local Health Department … personnel in the: Municipality of: __________________________________________________ Department of: ___________________________________________________ Emergency Responders from this department will adhere to the content of this Appendix and the Coordinated Worker Protection Emergency Response Plan for this municipality when responding to hazardous materials incidents under the scope of the Public Employees Occupational Safety and Health Act Standard, 29 CFR 1910.120. Prepared by: _____________________________________ (Name) ___________________________________ (Title) _____________________________________ (Date of Preparation) _____________________________________ (Last update) RESPONDING DEPARTMENT APPENDIX This department's highest ranking response official will ensure that the provisions of the Coordinated Worker Protection Emergency Response Plan and this Appendix are followed by all responding personnel from this department. Although many responders perform different levels of activities during hazardous materials (HazMat) incidents (e.g., notification, defensive and/or offensive), the basic provisions of this ERP will apply to all personnel. ===================================================================== Please indicate the appropriate HazMat incident response level taken by this department. (Check One) A. ______ Although employees from this department are likely to witness or discover a HazMat incident, the ONLY action to be taken is to notify authorities of the release and then leave the scene. (If this item is checked, complete sections (A) through (C) ONLY) OR B. ______ During a HazMat incident, employees from this department may take offensive and/or defensive actions throughout the incident response effort. Circle this department's response activities from the statements below and skip to Sections (I) through (X) (beginning on Page 2). 1. Taking defensive action without actually trying to terminate the release or other cold zone support activities 2. Terminating the release (e.g., plugging and patching, air monitoring, decontamination, etc.) or other warm or hot zone activities. 3. Both of the above {(B)(1) and (B)(2)}. ==================================================================== A. Upon detection of a release, the following appropriate department(s) will be notified to respond to the HazMat incident: RESPONDING DEPARTMENT PHONE NUMBER ______________________________________ ___________________ ______________________________________ ___________________ ______________________________________ ___________________ ______________________________________ ___________________ SOP REFERENCE NUMBER: _______________________ (attach) A description of this initial notification procedure is as follows: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ SOP REFERENCE NUMBER: _________________________ (attach) B. All responding personnel from this department, who are likely to witness such a HazMat incident and would be responsible for notifying authorities, have been trained or have demonstrated competency at the Awareness Level in accordance with 29 CFR 1910.120. A listing of such personnel is available for review upon request. C. Because this department is not responsible for taking action in an incident, but only notifies appropriate agencies of the incident and then leaves the scene, this department has no responsibility in the areas listed below during a HazMat incident: 1. Safe distances and places of refuge 2. Site security and control 3. PPE and emergency equipment 4. Emergency alerting and response procedures 5. Evacuation routes and procedures 6. Emergency medical treatment and first aid 7. Decontamination 8. Critique of response and follow-up **NOTE: Departments Responsible Only For Notifying Authorities - Stop Here** ===================================================================== I. Pre-emergency planning and coordination with outside parties: A. Upon detection of this release, ___________________________________ (Name or Title) of this department, will be notified to initiate appropriate response action. B. The following devices will be used to initiate a HazMat response within this department: 1. Telephone contact/confirmation 2. Radio contact (list frequency/channels) a. ____________________________ ____________________________ b. ____________________________ ____________________________ c. ____________________________ ____________________________ 3. Audible alarms 4. Other _________________________________________________________ SOP REFERENCE NUMBER: _________________________________ (attach) C. A detailed description of this notification process, as it applies to responding employees within this department, is described below: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ SOP REFERENCE NUMBER: _________________________________ (attach) D. The following responding personnel within this department will also be notified: NAME TITLE DAY/EVENING PHONE # ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ ___________________________ ______________________ ___________________ SOP REFERENCE NUMBER: _____________________________________ (attach) E. The person initially notified, within this department of the release, will then notify _______________________________________, (Name or Title or Department) who will in turn initiate response and notify appropriate authorities (e.g., local, county, State and/or Federal Agencies). The notification procedure to be utilized is outlined in section (I)(D) of the Coordinated Worker Protection ERP. (Not Applicable: No employees from this department engage in the activity outlined above {(I)(E) of APPENDIX}. (Circle if Applicable) II. Personnel roles, lines of authority, training and communication: Chain of Command: A. In the event of a HazMat incident, the following responding personnel and alternates at this department are responsible for functions as indicated below (indicate N/A for functions not conducted by this department. PRIMARY ALTERNATE NAME OR TITLE NAME OR TITLE 1. Incident Commander ______________________ ______________________ 2. Safety Official ______________________ ______________________ 3. Entry Teams ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 4. Back-up/Rescue ______________________ ______________________ teams ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 5. Support Personnel ______________________ ______________________ ______________________ ______________________ 6. Other ______________________ ______________________ SOP REFERENCE NUMBER: ________________________________ (attach) B. The highest ranking responder of this department at the scene will secure the HazMat incident and direct the activities of each role until the Incident Commander arrives and relieves him. The Incident Commander or designee will use information provided by the Safety Official to ensure protection of all responding personnel throughout the HazMat incident. Following the arrival of the Incident Commander (indicated in this appendix), the highest ranking responder will ensure that the provisions of the Coordinated Worker Protection ERP are met for this department's employees. Training: A. All responding personnel have been trained or demonstrated competency appropriate to their level of activity in accordance with 29 CFR 1910.120. A listing of such personnel is available for review upon request. B. All personnel described above will receive annual refresher training or demonstrate competency at their appropriate training level. C. No responding personnel will engage in response activities beyond their respective level of training or equipment available. D. All Hazardous Materials Technicians/Specialists are enrolled in an ongoing medical monitoring program which includes baseline and annual examinations, examinations for responders who exhibit signs or symptoms which may have resulted from exposures and/or examinations upon termination of employment. Communications: A. The ________________________________ is responsible for establishing (Name or Title) and maintaining communication procedures during the HazMat incident for this department. B. Responding personnel within this department will follow communication procedures contained in Section (II) of the Coordinated Worker Protection Emergency Response Plan. C. The following is a description of any additional communication procedures utilized by members of this department during a HazMat incident which are not contained in the Coordinated Worker Protection ERP: (Not Applicable: No additional communication procedures are utilized by members within this department. (Circle if Applicable) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ SOP REFERENCE NUMBER: ______________________________ (attach) Emergency alerting and response procedures: A. In the event of an emergency during the HazMat incident, responding personnel of this department will follow emergency alerting procedures contained in Section (II)(alerting) of the Coordinated Worker Protection Emergency Response Plan (ERP). B. The following are additional alerting and response procedures used by this department which may be different than those contained in the Coordinated Worker Protection ERP. (Indicate N/A if no additional alerting and response procedures are used) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ SOP REFERENCE NUMBER: ___________________________________ (attach) III. Emergency recognition and prevention: A. The highest ranking official or his designee will assure that responding personnel from this department are notified of the identity, associated health hazards, physical and chemical properties etc, of the released substances prior to each HazMat response. This will be accomplished using pre-entry briefings with all responding personnel using the appropriate references outlined in Section (III) in the Coordinated Worker Protection ERP. IV. Safe distances and places of refuge: A. Depending on the HazMat incident, should this department be the first to arrive at the scene, the highest ranking official or his designee will be responsible for establishing command centers, work zones, staging areas, safe distances and places of refuge for responding personnel. Responding personnel will be informed of these zones at the onset of each HazMat incident. B. These zones will be clearly marked utilizing methods described in Section (IV) of the Coordinated Worker Protection ERP and using the following resources available at this department: (Circle/list all that apply if different from those outlined on Section (IV)(C) of the Coordinated Worker Protection ERP): 1. Markers 2. Barricade tape 3. Flags 4. Signs 5. Maps 6. Other_________________________________________________________ 7. Not Applicable: No employee from this department engages in the activities outlined in Section (IV)(B) of this Appendix) SOP REFERENCE NUMBER: _____________________________ (attach) V. Site Security and control: A. Should this department be the first to arrive at the HazMat scene, the highest ranking official or his designee will be responsible for limiting and controlling the number of responding personnel (depending on training level, appropriate PPE and/or equipment) entering each zone (e.g., cold, warm and/or hot) using the following equipment which is available at this department: (Circle/list all that apply) 1. Use of barricade tape/fences 2. Other_________________________________________________________ SOP REFERENCE NUMBER: ______________________________ (attach) VI. PPE and emergency equipment: A. The highest ranking official or his designee will be responsible for ensuring that responding personnel, from this department, are provided with (and use) PPE and respiratory protection as described in Section (VI) of the Coordinated Worker Protection ERP. B. During each HazMat incident, the following PPE, respiratory protection and emergency equipment is available at this department for use: TYPE OF EQUIPMENT EQUIPMENT LOCATION _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ SOP REFERENCE NUMBER: ________________________________ (attach) VII. Evacuation routes and procedures for Responding Personnel: A. If this department is the first to arrive at a HazMat incident, the highest ranking official or his designee will be responsible for establishing evacuation routes at the onset of the response for appropriate exiting of emergency responders (where applicable). Alternate routes, should normal exiting routes become blocked, will also be established. Procedures, notifying responding personnel of such routes, will also be established. VIII. Emergency medical treatment and first aid: A. If this department is the first to arrive at a scene, first aid equipment and back-up personnel will be available prior to any entry into the hot zone. The following equipment is maintained by this department for this purpose: ___________________________________ ______________________________ ___________________________________ ______________________________ ___________________________________ ______________________________ IX. Decontamination: A. All department responders will be properly decontaminated upon exiting the hot zone as described in Section (IX) of the Coordinated Worker Protection ERP. The following disposal outer garments are available at this department and will be used, where feasible, to reduce contamination of chemical resistant clothing and increase the effectiveness of decontamination procedures: (Circle all that apply) 1. Disposable clothing 2. Disposable gloves 3. Disposable boot covers 4. Other ________________________________________________________ X. Critique of response and follow-up: A. Following each HazMat incident, ________________________________________ (Name or Title) of this department, will assemble all responding personnel to review and critique all response activities that occurred. Documentation regarding critique and follow-up procedures will be maintained by ________________________________________. (Name or Title) This Responding Department Appendix will be updated and modified regularly based on the following conditions: 1. New hazardous substances are produced or can be potentially encountered 2. Personnel roles, training levels and functions are changed 3. Outside party responsibilities are changed 4. 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