Example of a completed Hazard Identification Form

THE GEOLOGICAL ASSOCIATION OF CANADA AND THE MINERALOGICAL ASSOCIATION OF CANADA

FIELD TRIP SAFETY POLICY AND PROGRAM -SAMPLE FORMS

APPENDIX 1

HAZARD IDENTIFICATION SAMPLE FORM

(to be filled out by trip leader and filed with LOC Safety Officer or Appropriate Section/Division Head or designate prior to trip departure )

Field Trip Name _____Ore Deposits of Moosepasture County____________

Date _____May 20-22, 2000________________________________

Field Trip Leader ___Jim Geo_______________________________________

Responsible Safety officer ____Joe Desksitter, (LOC Safety Officer)___________

General Hazards

Nature of Hazard Location of Hazard Mitigation
Chips from rock hammers All outcrops Safety glasses
Possible cold rain/wet snow Warn participants, ask for wet weather gear to be brought
Vehicle safety – especially getting in and out of vans In and around vans Emphasize in safety presentation to participants


Stop _1___

Nature of Hazard Location of Hazard Instructions to participants
Road cut (traffic hazard) Roadway between cuts Keep to shoulder, stay off pavement, obey instructions of leaders
Outcrop cliff (loose boulders) North roadcut, east end where the cut is highest Keep away from this area; wear hardhats


Stop _2___

Nature of Hazard Location of Hazard Mitigation
Industrial hazards in an operating quarry On quarry grounds Obey company safety officer, use hard hats, safety boots as directed


Stop _3___

Nature of Hazard Location of Hazard Mitigation
Rough, steep trail to outcrop with loose rocks Upper part of trail Avoid loosening stones on trail, warn those below


Stop __4__

Nature of Hazard Location of Hazard Mitigation
Abandoned mine site – open holes Immediately behind main trench Avoid this area, Have ropes on hand in case of accident
Abandoned mine site – trenches, loose rock on trench walls Do not climb on the trench walls, wear hard hats, when on top, take care not to knock loose rocks on those below


Stop ____

Nature of Hazard Location of Hazard Mitigation


Stop ____

Nature of Hazard Location of Hazard Mitigation


Stop ____

Nature of Hazard Location of Hazard Mitigation


Stop ____

Nature of Hazard Location of Hazard Mitigation


APPENDIX 2 – SAMPLE FORM

COMMUNICATION PLAN

(to be filled out by trip leader and filed with LOC Safety Officer or Appropriate Section/Division Head or designate prior to trip departure

Field Trip Name _____Ore Deposits of Moosepasture County__________

Date _____May 20-22, 2000_____________________

Field Trip Leader ___________ Jim Geo__________________________________

Responsible Safety officer Name____Joe Desksitter, (LOC Safety Officer)______ Phone ______456-6565____________________

Location and phone numbers of accommodations during the trip:

Date Accommodation Name Accommodation Phone
May 20 Nitefite Hotel, Mooseville 567-5454
May 21 Sparklyrock Inn, Oretown 465-8745


Cell Phone Information (trip leaders):

Cell Phone Number Cell Phone owner
766-4345 Jim Geo
766-2347 Jane Rockhammer (alt. Leader)


Mobile Radio Information

Radio model Radio location Area of operation Emergency contact Hours of availability


Other Communication

Location of public telephones

Lobby of Nitefite Hotel Mooseville (most of Day 1)
Outside Post office, Oretown
In Gastro Diner, Hwy 6 east of Mooseville


Location and phone of Emergency facilities (police, emergency, medical, fire)

Facility Location Phone
Mooseville Police Mooseville 567-6535
Moosepasture County Hospital South Mooseville 765-4556
Oretown Medical Clinic (8AM-5PM weekdays) Oretown 564-7634
Mooseville and Area Volunteer Fire Department Upper Mooseville 456-3452
RCMP Sulphide City 445-7985


Other Communications options

Gas Stations at west end of Mooseville and on Hwy 6 west of Oretown have phones


NB – no 911 service in this area


APPENDIX 3 – SAMPLE FORM
EVACUATION PLAN


(to be filled out by trip leader and filed with LOC Safety Officer or Appropriate Section/Division Head or designate prior to trip departure)

Field Trip Name _____Ore Deposits of Moosepasture County__________

Date _____May 20-22, 2000_____________________

Field Trip Leader ___________ Jim Geo__________________________________

Responsible Safety officer Name____Joe Desksitter, (LOC Safety Officer)___________

Phone ________456-6565____________________

General Information


Stop # Evacuation Challenge Evacuation procedures Nearest emergency medical facility Hours of operation
3 Rough trail to outcrop at top of steep hill. Injury in this area would be difficult to evacuate Injured person could be carried down by 3 people without stretcher Moosepasture County Hospital 24 hr Emergency
4 Someone may fall into abandoned mine opening Let down ropes if conscious; call fire department for help Oretown Medical Clinic 8-5 weekdays


APPENDIX 4 – SAMPLE FORM

FIELD TRIP SAFETY REPORT

(to be filled out by trip leader and filed with LOC Safety Officer or Appropriate Section/Division Head or designate within 2 weeks of the end of the trip)


Field Trip Name _____Ore Deposits of Moosepasture County__________

Date _____May 20-22, 2000_____________________

Field Trip Leader ___________ Jim Geo__________________________________

Describe any safety-related incidents that occurred on the trip:

Nature of the incident Nature of the response Injury response if any
Participant cut by rock chip from a rock hammer Band aid from first aid kit
Twisted ankle at stop 4 Participant carried out to vehicle by 3 leaders Ankle bound with elastic bandage, participant taken to Oreville clinic for examination


Describe any safety-related issues that arose during or as a result of the trip:


Are there any measures you can recommend to avoid similar issues on other GAC®/MAC field trips?


How can GAC®/MAC improve its safety program?

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