Trench Rescue Tactical Worksheet Page 1 of 2 initial o n-sc ene oper atio ns Approach from Head of Trench Ladders Edge Protection Clear Spoil (2’ Back) Assign Safety Officer Date______________________________ Start Time______________________________ Incident # �� Number of Victims_________________ Time Last Seen_____________ Shut Down All Equipment/Evaluate Workers�� Purpose of Trench____________________ Depth of Trench �� Site Location�� Victim Location____________________ Victim Marking________________ Victim Protection______________ Victim Condition�� Trenc h H a za r d s Spoil-In Shear-In Slough-In Lip-In Water Vibration Soil Conditions Other �� Shoring Failure Hazmat Utilities USA Markings Atmospheric Monitoring: % O2______________________ % LEL__________________ CO________________ H2S �� Pre-E ntr y O per ations Pre-Entry Briefing Edge Protection: Ladders Fall Protection PPE Planks (2'' x 12'') Plywood Monitoring Ventilation Clear Spoil LOTO Other�� OSB Lighting Bridges Perimeter Pro tec tive S ystems Trench Data Worksheets Shoring Type: Panels Timber Struts Walers Pipe/Post Screw Hogsheads Pneumatic Supplemental Sheeting and Shoring Hydrualic 2-4-2 Box/Shield Victim R esc u e a nd R ec o ver y Soil Removal: Shovels Buckets Air Knife Victim Packaging: Backboard Hasty Chest Harness Victim Extrication: Ladder Slide Rescue Litter Vacuum Truck LSP Half-Back Other�� Spec Pak Wristlets SKED Victim Harness Other�� Moving Ladder Slide High Point Anchor Sce ne M a na gement Incident Commander�� Operations�� Rescue Group Supervisor�� Site Safety Officer�� Cutting Station�� Rescue Squad 1 Leader_________________________________ Rescue Squad 2 Leader�� Rescue Squad 3 Leader_________________________________ Rescue Squad 4 Leader�� Logistics�� Medical Group�� Industry or Contractor’s Name�� Company Address________________________________________City/State�� Phone_________________________________________________Reporting Party/Contact Person �� Provided by CMC Rescue, Inc. Copies of this form can be downloaded at cmcrescue.com/forms. Trench Rescue Tactical Worksheet Page 2 of 2 I n c i d e n t T e r m i n at i o n Personnel Accountability Equipment Removed Scene Secured Debriefing OSHA Contacted Time_______________ Date___________________ Rescue Group Supervisor Signature�� Monitor Log Time Level %O 2 %LEL CO H 2S Monitoring Officer�� s c e n e d i a g r a m/ n o t e s Rescue Group Supervisor Signature:�� Provided by CMC Rescue, Inc. Copies of this form can be downloaded at cmcrescue.com/forms.