Silica Exposure Control Plan
Complete this form to document silica-generating work, exposure risks, and the control measures used to protect workers on site.
Worksite and Project Information
Worksite Name
*
Project or Site Address / Location
*
Project Name
*
Date Plan Prepared
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact / Person Responsible
*
Silica Exposure Task Identification
Job/Task Name
*
Work Activity Description
*
Silica-Containing Materials or Products Involved
*
Concrete
Masonry
Brick
Mortar
Tile
Stone
Engineered Stone
Other
Task Frequency
*
One-time
Intermittent
Daily
Weekly
Ongoing
Locations/Areas Where the Task Occurs
*
Task Location Type
*
Indoors
Outdoors
Both
Workers and Exposure Circumstances
Number of workers exposed
*
Exposed job roles/trades
*
Laborer
Operator
Mason
Concrete cutter
Driller
Carpenter
Electrician
Plumber
Other
Typical exposure duration per shift (hours)
*
Work performed in occupied areas or near other trades?
*
Yes
No
Nearby activities that may increase exposure
Are subcontractors involved?
*
Yes
No
Subcontractor details
Exposure Control Measures
Engineering controls used
*
Wet methods
Local exhaust ventilation
Dust collection system
Tool shrouds
Enclosed cab
Isolation/barriers
Other
Administrative controls used
*
Limit time in area
Access restriction
Scheduling
Housekeeping procedures
Worker rotation
Other
Required personal protective equipment
*
Respirator
Eye protection
Protective clothing
Gloves
Other
Detailed control plan / instructions
*
Responsible person for implementing controls
*
Equipment, Monitoring, and Housekeeping
Tools/Equipment Used
*
Dust Capture or Water Supply Method
*
Please Select
Local exhaust ventilation
Integrated dust collection system
Water suppression
Wet cutting/wet methods
HEPA vacuum attachment
Other
Inspection/Maintenance Frequency for Controls
*
Please Select
Before each use
Daily
Weekly
Monthly
Per manufacturer recommendations
After repairs/adjustments
Other
Exposure Monitoring Required or Performed?
*
Required and performed
Required but not yet performed
Not required
Unknown
Monitoring Date and Result Summary
Housekeeping Method for Silica Dust Cleanup
*
Please Select
HEPA vacuuming
Wet cleaning methods
Vacuum with dust extraction
Damp wiping
Shoveling/collection while minimizing dust
Other
Training, Review, and Approval
Worker training on silica hazards and controls completed?
*
Yes
No
Training completion date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training method
Please Select
In-person
Online
Toolbox talk
On-the-job
Other
Reviewer or approver name and title
*
Review or approval date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Planned review frequency or update trigger
Acknowledgment
*
I confirm the information provided is accurate
I will follow the control plan
Submit Plan
Should be Empty: