Cal OSHA 1A Inspections Form
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Transcript of Cal OSHA 1A Inspections Form
STATE OF CALIFO OIVISION OF OCCUPATIONAL SAFETYAND HEALTH1. CSE/|H Z. npt. No. l g. FY l 4. lnsp.6. Employer7. Management UllName
Present DuringOpening Inspect Closing
8. Union RepresenlNarne
rtives ContactedTitle Labor Union / Phone
Present DuringOpening lnspect Closing
9. Dates: Subsequent Visits: Close:
10. Smalf Employer Relief Ex-MOD Documentation Insurer
11 . Ooenina Confer'flshow lD
fl Explain PurposeE CaI/OSHA Progrl! Employee Right!D Inspection ProcelfJPoster l
I Insurance I
lLog I
! PermiWariance j
I PPEI Consent to Inspd
Tnce
tm
Cure
F+
15. llP Prooram ReviewIIPP:flwrittenE Effective! Previously ReviewedDate:f] vtooet Program Useda. (Required) Program ElementsI Responsible Person! Sanctions/EnforcementI CommunicationI Inspections! lnvestigation ProceduresD Correction Procedures! Trainingb. Record keepingfl lnspection RecordsI Training Records
19. Evaluation of Safetv & Health ProqramEffective Average
Safety Responsibility tr trEmployee Participation tr tlTraining tr nPPEtrNHousekeeping fl nFirstAid tr n
PoornDn!n!
20. Adiustment Factors In %o
'Good Faith Sizen 30 Good fl 40 1-10I 15Average E 30 11-2sE 0 Poor fl 20 26-60
[ 10 61-100
'History! 10 coodD 5 rairfl o Poor
fl 0 Over 100'Does not apply to penalties for accident related serious,willful, repeat, or a serious violation with lack of an operativeIniury & lllness Prevention Proqram.
12. Exit ConferencelDate: l
I Discuss ViolatiodfJ Closing Date Anqi
fl Corrective Actiod
s Obs.cipated
13. Closino ConferdtflEmployerflEmployees I
flViolations I
! Citations I
E Abate/Consult l
fl Penalties I
I Posting i
! InformalConferlrflAppeal I
! Fottow-up I
I Variance I
flDiscrimination I
rce
ce
16. Hazard Communication Prooram! Written ProgramLl rrarnrngn Labetingfl Storagefl MSDS Availabte
21. CommentslNotes
17. Other ReouirementsI CaYOSnn Poster PostedI CoOe of Safe PracticeC Tailgate Meetings! First Aid KitI Trained First AiderflLos 2oof] Posted - FebruaryI Emergency Action Plan 'E fire Prevention Plan! Respiratory ProgramE LockouVBlockoutfl Safety Process Mgmt.I Confined Spacef] Hearing ConservationE Bloodborne Pathogens
'ta
REASON
18. Cross Jurisdictional Referral
f} Proof of Workers' CompInsurance
E Industrial Welfare CommissionPoster Posted
Ca|/OSHA 1A (12/01/00)
STATE OF DIVISION OF OCCUPATIONAL SAFETY AND HEALTH 2of222. Emplovees/Pers0ns lnterviewed During lnspection. Enter name, home address and phone ru.rrnber below.
b.Name/Title:
Address: Address:
Phone: Phone:
c.Name/Title:
d.Name/Title:
Address: Address:
Phone: Phone:
23. Multi-Employer Yes LJNo l_l lf yes, obtain the following information on each employer involved.
a. Employen Employer:
Address:Address:
Activities: Activities:I Contract Employe/s Work at the Site E Contract Governing Employer's Work at the Site
I Awareness of Violation
fl Violation Foreseeable to Employer
I Awareness of
I Violation Foreseeable to Employer
E Steps Taken by Employer to Protect Employees fl Steps Taken by Employer to Protect Employeeslf yes, what specific steps? lf yes, what specific steps?Employer Category (Check all that apply)
Exposing flCreatipg ! Controlling E Conecting EEmployer Category (Check all that apply)
Exposing n Creating I Controlling ! Conecting E
b. Employer:
Address:
Activities:
d. Employen
Address:
Activities:I Contract Employer's Work at the Site f] Contract Governing Employer's Work at the Site
I Awareness of Violation
! Violation Foreseeable to Employer
f] Awareness of
fl Violation Foreseea to Employer
fl Steps Taken by to Protect Employees I Steps Taken by Employer to Protect Employeeslf yes, what specific lf yes, what specific steps?Employer Category (Check all that apply)
Exposing fl Creatifrg fl Controlling fl Conecting flEmployer Category (Check all that apply)
Exposing flbreating n Controlling E Correcting fi24. Opening and Clo: ng Conference Summary and Additional Comments: [_] Comprehensive LJ Partial
25. Previous Citation {istory: I Yes Ll No lf yes, attach citation history.
26. Publications Prov
I euide ro catlos
3.
A f]Poster fJotnerl. 2.
o.4 5.
27. lf additional shee are attached, Check this box: Ll
Cal/OSHA 1A (12l01/00)