CONTRACTOR SAFETY ORIENTATION & MANUAL REVIEW REPORT
Facility / Project Name:
Contractor Company Name:
Facility / Project Location:
Contractor Representative:
KM Representative:
Emergency Phone Number:
Location work will be performed:
Contractor ISNetworld #:
Length of project
(Estimated Days)
Normal work hours:
AM to
Not Applicable
Brief description of work:
PM
Subcontractors:
NOTE: Any Contractor or Contract employee has the authority to stop any unsafe act and halt the activity until resolved.
A. Topics Discussed During Orientation:
Training requirements/Training
Qualifications
Job hazard analysis (JHA)
Stop Work Authority (You Can Stop)
Operator Qualification Tasks
Security Requirements
Permit to begin work
Site Specific Abnormal Operating
Conditions (AOC’s)
Project Health and Safety
Plan (HASP)
Other: ______________
KM Safety Orientation Video Reviewed
Other:__________________________
1.
B. Company (KM) chemicals to which contract
2.
employees may be exposed:
Site-specific or business unit procedures
KM Contractor Environmental Safety
Manual made accessible
Other:__________________________
3.
KM Contractor Safety Brochure distributed
Other:____________________________
4.
Yes
Were SDS sheets provided to the Contractor?
No
N/A
(If No, the KM Representative must inform the Contractor of the location of the facility’s SDS files and provided the Contractor with access to the files.)
Location of SDS File:
This list may not include all chemicals to which contract employees may be exposed.
Contractor is responsible for identifying all chemicals and for protecting contract employees from exposure to chemicals that are or are not on this list.
C.
Contractor chemicals to which KM employees
may be exposed:
1.
2.
3.
4.
Were SDS sheets provided to the Company?
Does Contractor have all required PPE, tools and equipment required to safely perform the job?
Were known existing site hazards discussed?
Yes
Yes
Yes
No
No
No
N/A
N/A
N/A
Contractor is responsible for obtaining all required PPE, tools and equipment prior to conducting any work.
1.
2.
D. List known existing site hazards:
Note: Site hazards may include, but are not limited to:
 Hazardous Atmospheres
 Chemicals/Materials that may present a fire hazard or an exposure hazard
3.
4.
 Equipment used simultaneously in area where Contractor will be working
 Ground and overhead hazards, such as pits, trenches, electrical lines and booms
Contractor is not relieved of its duty to exercise due care while on Company job site or while performing work for Company.
Contractor is responsible for all site hazards caused or created by Contractor.
By signing below, I acknowledge that the contractor employees listed herein have completed the KM Safety Orientation & Manual Review in its entirety. Additionally,
any and all site specific orientation requirements have been satisfied following this process (if applicable);
Orientation conducted by:
Print Name:
Sign:
Contractor Representative(s):
Print Name:
Sign:
Distribution:
KM Representative/Job File
KM Contractor Safety
Contractor copy
Date:
Page 1 of 2
________________________
Date:
CSM-003
12/15
CONTRACTOR SAFETY ORIENTATION & MANUAL REVIEW
By signing below I acknowledge that I have viewed the KM Contractor Safety Orientation; that I have received the KM Contractor Safety Brochure; and that I have
been shown how and where to access the KM Contractor Environmental Safety Manual.
PRINT EMPLOYEE NAME
Distribution:
KM Representative/Job File
KM Contractor Safety
Contractor copy
COMPANY NAME
SIGNATURE
Page 2 of 2
ISN ID
DATE
CSM-003
12/15