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Safety Plan Template Form

Ensure Safety Compliance and Protect Your Workplace

Creating a comprehensive safety plan can be overwhelming, especially when ensuring compliance in your workplace. This editable safety plan template helps you develop a structured approach to safety management, specifically tailored for organizations looking to enhance their safety protocols. Use it to outline safety measures, communicate health programs clearly, and minimize workplace risks, all while adhering to industry regulations. Take the first step towards a safer environment by trying out this live template.

Use this Template (FREE) Live Preview
Full name
Primary phone number
Email address
Today's date
Primary emergency contact full name
Primary emergency contact phone
Secondary emergency contact full name
Relationship to primary emergency contact
Please Specify:
Healthcare provider name
Healthcare provider phone
Medical information (conditions, medications, allergies)
Personal warning signs that I may be in distress
Common triggers or stressors for me
Internal coping strategies I can use on my own
People and places that help me feel safe
Ways others can support me during difficult moments
Do I have access to weapons, medications, or other hazardous items?
Yes
No
Steps I will take to reduce access to hazardous items
Do I prefer to be with others when I am distressed?
Yes
No
Unsure
Prefer not to say
Local emergency number in my area
Crisis hotline number to save
Actions I will take if I feel in immediate danger
Call the local emergency number
Go to the nearest emergency department
Contact a crisis hotline
Contact my emergency contact
Go to a pre-identified safe place
Use a trusted ride or transport service
Other
Please Specify:
Do I know safe exit routes and assembly points at my work or school?
Yes
No
Unsure
Not applicable
I want to share this plan with the contacts listed
Yes
No
Undecided
Signature (type your full name)
Date signed
This plan reflects my preferences today
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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Paper art illustration related to safety plan template for FormCreatorAI article

When to use this form

Use this form whenever you need to prepare for a risky task, new process, or site change. Supervisors planning confined space entry, lab leads introducing a new chemical, or principals organizing drills can set clear steps, roles, and timelines. You capture hazards, controls, communication, and emergency actions in one place so your team acts fast and in sync. To size up risk, pair it with the Army risk assessment form. If the job requires protective gear, confirm needs with the PPE Assessment form. After rollout, track attitudes and gaps with the Safety culture survey form to keep improvements on track.

Must Ask Safety Plan Questions

  1. What tasks, locations, and conditions does this plan cover?

    Defining scope narrows focus and reduces blind spots. It ensures permits, access, and resources match the actual work and environment.

  2. What hazards could cause harm, and what is the risk level for each?

    Listing hazards and rating risk lets you prioritize the most serious threats. It drives the level of control you choose and the speed of response.

  3. What controls and PPE will you use, and who is responsible for each action?

    Assigning controls and owners turns intentions into action and accountability. It also makes sure required PPE, tools, and signage are ready before work starts.

  4. How will you communicate the plan and emergency procedures to everyone on site?

    A clear briefing plan avoids mixed messages during routine and emergency situations. It sets who will brief, when, and how updates reach contractors, visitors, and night shifts.

  5. How will you verify compliance and follow up on issues or near misses?

    Defined checks and follow-ups help you measure if the plan works in the field. For coaching and pattern insights, tie results to the Employee safety performance review form.

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