COMPANY LOGO

COMPANY NAME AND

ADDRESS

HEALTH AND SAFETY PLAN

DD/MM/YYYY
 CONTENTS
Sl No. TOPIC

1 Health And Safety Policy/Statement

2 Organizational Chart

3 Risk Assessment

4 Critical activity safety plan- W@H

5 Standard Operating Procedures (Medical, Training, Equipment, etc)

6 Personal Protective Equipment (PPE) Management

7 Incident Reporting System

8 Resources

9 Auditing System

10 Medical and First Aid Arrangements

11 Contact Details
Company Name:
Address:
Client Name:
Circle/Cluster Work Location:
Description Of The Work :

Name Designation Contact Number Email Date

Plan prepared by:
Plan approved by:
1. Health And Safety Policy/Statement / Mission / Vision, etc
(Insert health & safety policy statement)
2. Organizational Chart- (showing Health and safety responsibility)

 Email ID’s and Contact numbers to be included in the organizational chart for each member.
 Mandatory to mention person responsible for health and safety of your organization , with contact details.
3. Risk Assessment
If available - submit the same
(Is risk assessment carried out for all field activities ? -
If not, refer the following format
Risk assessment leader:
Risk assessment team members:
Date of risk assessment / review date:

Severity Index

RISK MATRIX
Very Likely - 5 5 10 15 20 25
PROBABILITY

Likely - 4 4 8 12 16 20
Possible - 3 3 6 9 12 15
Unlikely - 2 2 4 6 8 10
Very Unlikely- 1 1 2 3 4 5
1 2 3 4 5
Negligible Slight Moderate High Very High

Risk Risk Level Action

May be acceptable but review task to see if risk can be reduced further.
1 to 6 Low Risk
Task should only be undertaken with appropriate management
8 to 12 Medium Risk
authorization after consultation with specialist personnel.
Task must not proceed. It should be redefined or further control measures
15 to 25 High Risk
put in place to reduce risk.
 Risk Assessment
Risk No. Severity Control Measures/Procedures/Methods to Manage the Risk
Description of Risk Probability Impact Index
Description Responsibility
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.
4. Work at Height Plan

4.1. Work at Height Risk Assessment

Work at Height Risk Assessment

Risk PI Control Measures/Procedures/Methods to Manage the Risk

Description of Risk Probability Impact
No. Index Description Responsibility
1.

2.

3.

4.

4.2. Fall Protection Plan

Type of tower(s)
Task
Hazards associated with W@H
Fall protection equipment required
Equipment provided to teams
Supervision process
Other Controls to ensure safety of teams
5. Standard Operating Procedures (Medical, Training, Equipment, etc)

Measures/Procedures/Requirements Schedule /
Responsibility (SPOC)

Physical & Psychological Fitness  Describe the measures to be taken/procedures to be followed to ensure that the
workmen performing work at elevated heights are physically & psychologically fit
of Workmen Working At Height to perform the work:

Training Requirements for Workmen  Define the training requirements / program / plan for workmen who will be working
Working at Height and other activities at elevated heights and other safety topics

Awareness and communication process  What are different methodologies being followed for awareness and
for safety communication on safety

PPE / Fall protection equipment -  List & describe the procedures/methods/requirements for ensuring that the fall
Inspection testing & maintenance. protection equipment is safe to use.

Any other procedure related to safety 

6. Personal Protective Equipment (PPE) Management

6.1. Personal Protective Equipment Requirements (These are the minimum requirements)

Protective Equipment Description For which activities it is provided

Hard Hat

Gum Boots

Safety Shoes

Gloves

Safety Goggles

Dust Mask

Hearing Protection

Safety Harness, Positioning belt

Reflective Jacket

Cross arm Strap & Carabiner

Other
PPE Procurement Plan:
(How org identify PPE requirement for employees, what standard of the product being followed, distribution mechanism,
periodic inspection process, responsibilities of inspection, records of issuing PPEs, etc.)
7. Health and Safety Reporting System-
For Reporting of incident / safety hazards / unsafe activities / unsafe conditions
(Include flowchart of reporting system of your organization)
8. RESOURCES (MANPOWER)

S No. Designation Location No. of employees

1. H&S Coordinator

2. Manager

3. Engineer

4. Technician

5. Rigger

6. Helper
MATERIAL (TOOLS & EQUIPMENTS) SAFETY

Describe tools and tackles, lifting tackles, ropes, slings, pulleys, etc. in use by team and safety measures needed for it

Item Description of Tools/Equipment Responsible

Measures & Procedures To Ensure Safe Condition & Use of Tool/Equipment Person

1 Electrical tools

2 Hand tools

3 Multi meter and Line Tester

4 Ropes, pulleys

4 Personal protective equipment

5 Others
9. Auditing and Inspection System

(This is a sample checklist, can be used for reference purpose)

10. Medical and First Aid Arrangements

Number of resources trained for first aid

Number of first aid boxes carried by team (one box per team)

Resources medical check -up system-Frequency

Details of other first aid/emergency medical arrangements made

11. Contact Details

S No. Name Designation Contact No Email

1. EHS Coordinator

2. HR

3. Head of Organisation
(MD/CEO..)

4. Other SPOC