IIP Program for High-Hazard Industry Employers

8/3/2019 IIP Program for High-Hazard Industry Employers

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XYZ Company

Injury and Illness Prevention

Program

For

High-Hazard Industry EmployersAs determined by OSHA

Complies with Provisions of

OSHA 29 CFR Part 1910 – General Industry StandardsOSHA 29 CFR Part 1926 – Construction Industry Standards



Injury & Illness Prevention Program(For High-Hazard Industry Employers)

© Safety Office Depot. All rights reserved.

© Safety Office Depot. All rights reserved. 2




Table of Contents

Section DescriptionPage

1 Program Policy & Requirement 3

2 Program Responsibility 4

3 Employee Compliance and Discipline 8

4 Safety Communication 11

5 Safety Committee and Meetings 13

6 Hazard Identification and Assessment 16

7 Accident/Exposure Investigation 26

8 Hazard Prevention and Control 33

9 Safety Training and Instruction 43

10 Accident Recordkeeping 47

11 Company Required Safety Programs 50

12 Company Required Safety Training Courses 51

13 Company Required Safety Forms & Checklists 53

Appendices

Appendix A List of Training Subjects 55

Appendix B Hazard Assessment Checklists 57

Appendix C Hazard Assessment and Correction Record 58

Appendix D Accident/Exposure Investigation Report 60

Appendix E Employee Training and Instruction Record 62

Appendix F Codes of Safe Practice (General and ConstructionIndustries) 64

Appendix G Employee Acknowledgement Form 75





Section 1

Program Policy &

Requirement

Program Policy

It is intent of XYZ Company to comply with all laws. To do this, we must

constantly be aware of conditions in all work areas that can produce

injuries. No employee is required to work at a job he/she knows is not

safe or healthful. Your cooperation in detecting hazards and, in turn,

controlling them, is a condition of your employment. Inform your

supervisor immediately of any situation beyond your ability or authority

to correct.

Program Requirement

This program has been prepared for use by employers in industries

which have been determined by OSHA to be HIGH-HAZARD .

Employers in an industry which has been determined by OSHA as High-Hazard and who

adopts and implements this program in good faith shall be deemed in compliance with IIP

Program requirements, unless mandated otherwise by a State law . Once this

program has been implemented, a copy must be maintained at each

workplace or at a central worksite if the employer has non-fixed

worksites.

Proper use of this program requires the IIP Program administrator to

carefully review the requirements for each of the eight IIP Program

elements found in this program, fill in the appropriate blank spaces and

check those items that are applicable to your workplace. The





recordkeeping section requires that the IIP Program administrator select

and implement the category appropriate for your establishment.

This program must be maintained by the employer in order to be

effective.





Section 2

Program Responsibili ty

Safety and Health Responsibilities

XYZ Company is responsible for ensuring that all onsite and offsite work

activities, equipment, and facilities operated or maintained by XYZ

Company our subcontractors or suppliers conform fully with safety and

health regulations promulgated by the U.S. Department of Labor in Title

29 CFR 1910 and 1926, Occupational Safety and Health Act of 1970, and

provisions of all state approved plans and safety procedures. Complianceshall include the aforementioned regulations, standards and codes and

all such regulations, standards and codes as included by reference.

These responsibilities include, but are not limited to, the following:

A. Program Administrator

Written Accident Prevention Program administrator, ProgramAdministrator has the authority and responsibility for implementingthe provisions of this program.

è DECISION POINT – Enter a name or position title (recommended)

The Program Administrator for XYZ Company is ____________________________________.

B. Safety Representative Responsibilities

The company safety representative, Safety Representative also hasthe authority and responsibility for implementing the provisions of this program and may be the same person or title as the ProgramAdministrator.


The Safety Representative for XYZ Company is ___________________________________.

A. The XYZ Company Safety and Health compliance program shall be





managed and administered by the Safety Representative.

B. Ensure the company’s compliance with all applicable federal,

state, and local safety and health requirements.

1. Ensure that each employee is provided with adequate and

appropriate occupational safety and health training and personal

protective equipment.

2. Inspect all workplaces, projects, and/or facilities periodically, but

not less than once per quarter.

3. Ensure that the safety and health policies are comprehensive and

effective.

4. Review each accident and conduct any investigation wherein an

accident has resulted in serious occupational injury, illness or

property damage.

5. Promote safety and health and serve as a resource to all staff.

6. Review the program on an annual basis.

C. Manager Responsibilities

1. Establish rules and programs designed to promote safetyand make known to all employees the established rules andprograms.

2. Provide all supervisors with copies of appropriate rules andregulations.

3. Make available training necessary for employees to performtheir tasks safely.

4. Provide protective equipment for employees whererequired.

5. Impress upon all employees, subcontractors and suppliers,the responsibility and accountability of each individual to maintaina safe workplace.





6. Record all instances of violations and investigate allaccidents.

7. Discipline any employee disregarding safety and lossprevention policies.

8. Require all subcontractors as a matter of contract and allmaterial suppliers through purchase order terms, to followestablished safety rules.

9. Require all subcontractors to submit for review their safetyprograms and encourage them to work safely.

10. Conduct safety inspections, maintain records andcontinually monitor the program for effectiveness.





D. Supervisor Responsibilities

1. Carry out safety programs at the work level.

2. Be aware of all safety requirements and safe workingpractices.

3. Plan work activities to comply with safe working practices.

4. Instruct new employees, existing employees, andsubcontractors performing new tasks on safe working practices.

5. Make sure protective equipment is available and used.

6. Make sure work is performed in a safe manner and no

unsafe conditions or equipment is present.

7. Correct all hazards, including unsafe acts and conditions,

which are within the scope of your position.

8. Secure prompt medical attention for any injured employees.

9. Report all injuries and safety violations to management.

E. Employee Responsibilities

1. Work safely in such a manner as to ensure your own safetyas well as that of co-workers and others.

2. Request help when unsure about how to perform any tasksafely.

3. Correct unsafe acts or conditions within the scope of theimmediate work.

4. Report any uncorrected unsafe acts or conditions to theappropriate supervisor.

5. Report for work in good mental and physical condition to

safely carry out assigned duties.6. Use and maintain all safety equipment provided.

7. Maintain and properly use all tools under your control.

8. Follow all safety and project rules.





9. Provide fellow employees help with safety requirements.

10. REPORT ALL WORK RELATED INJURIES OR ACCIDENTS

TO YOUR SUPERVISOR - IMMEDIATELY.

F. All Personnel (without regard to position or assignment) :

1. Strive to make all operations safe.

2. Maintain mental and physical health conducive to working safely.

3. Keep all work areas clean and free of debris.

4. Assess result of your actions on the entire work place. Work willnot be performed in ways that cause hazards for others.

5. Before leaving work, replace or repair safety precaution signs or

barriers that have been removed or altered. Unsafe conditions will

not be left to imperil others.

6. Abide by the safety rules and regulations promulgated for this

construction project.

è DECISION POINT - delete if not applicable

G. Subcontractors and Suppliers Responsibilities

1. Abide by safety rules and regulations as promulgated by Federal,

State and local authorities including those of XYZ Company and

any General Contractor.

2. Notify all other contractors when their activities could affect the

health or safety of other employees in the workplace, project

and/or facility.

3. Check in with XYZ Company site supervision when entering orleaving any job-site.

4. Inform XYZ Company site Safety Representative of all injuries to

workers, immediately.





5. Report to XYZ Company site supervision or safety representatives

any unsafe conditions.

6. Provide for review Safety and Hazard Communications Programs.

7. Provide a chemical inventory list and copies of MaterialSafety Data Sheets (MSDS) for any hazardous materials - prior tobringing materials on-site.





Section 3

Employee Compliance &

Discipline

XYZ Company management is responsible for ensuring that all safety

and health policies and procedures are clearly communicated and

understood by all employees. Managers and supervisors are expected to

enforce the rules fairly and uniformly.

All XYZ Company employees are responsible for using safe work

practices, for following all directives, policies and procedures, and for

assisting in maintaining a safe work environment.

A. Employee Compliance

OSHA requires that you include a system for ensuring that employees

comply with safe and healthful work practices.

Substantial compliance with this provision includes recognition of

employees who follow safe and healthful practices, e.g., incentive

programs, training and retraining programs, disciplinary actions,

infraction notices; or any other means that ensure employee

compliance with safe and healthy work practices. Though sample

procedures are provided, you must modify them to suit your

requirements.

As part of this compliance, you should provide employees with a codeof safe practices that reflect your company’s specific operations more

exactly. The Code of Safe Practices we have provided is a suggested

format.





B. Employee Enforcement Procedures and

Systems

The XYZ Company safety rules and work procedures shall be

practiced and enforced.

We have established a system to ensure that violations of rules are

dealt with fairly but firmly, that all employees are aware of the

requirements, and that reorientation or retraining may be provided

when needed. Incentive programs may be initiated and will be used

in conjunction with a good enforcement program.

Discipline

No safety program can be effective without some form of discipline.

There are no rules that must be followed, only guidelines.

The first preventable accident or safety rule violation observed

should result in a discussion with the employee and the supervisor or

manager. This verbal reprimand should be documented, dated, and

signed by those involved.

A second preventable accident or safety rule violation observedwithin a 12-month period should result in another discussion with the

employee accompanied by a written reprimand. Time off without

pay, up to a maximum of 5 days, should be considered.

A third preventable accident or safety rule violation observed within

a 12-month period should result in another discussion with the

employee and a serious evaluation needs to be made. This is

probably grounds for termination.

Compliance

One point must be very clear: discipline has to be administered

uniformly and consistently.





Violations of safety rules and policies should be addressed in the

following manner:

a. First Incident: Verbal warning, documented discussion.

b. Second Incident: Written reprimand, up to 5 days suspension.

c. Third Incident: Written reprimand, grounds for termination.

Each XYZ Company supervisor or manager shall be responsible for

administering this policy to his/her subordinates.

All written reprimands and records of violations shall be held

confidential and maintained in the employees’ personnel files.





Accountability

Each supervisor’s efforts and performance will be evaluated relative

to reaching XYZ Company safety objectives and assigned

responsibilities. This evaluation will be part of the supervisor’sperformance review and will be used in part to determine his or her

job assignments, merit increases or promotions.





Section 4

Safety Communication

Communication between management and employees on matters of

safety is of primary importance in order to have an effective Safety

Program. The primary means of communicating with employees will

include: Safety committee(s); personal safety contacts; group safety

meetings; written communications; bulletin boards and posted notices;

and a safety suggestion system.

A. Safety Committee (See Section 5)

B. Individual Contacts

1. Individual contacts between the supervisor and employee to

instruct or discuss some safety topic related to the employee's

work are powerful tools for developing favorable employee

behavior toward safety and accident prevention. They are

continuing reminders that management is concerned about

employee safety

2. Individual contacts with employees on matters of safety and

health should be documented.

3. Important : Keeping a record of personal contacts on safety

rules and job procedures is necessary for a number of reasons.

The record is a history of what has been discussed with an

employee, on what dates, and by what supervisors. Such

information is useful to establish the fact that a person has been

properly instructed. Secondly, a record can be a tool to help

decide future topics to discuss with the employee. Thirdly, they

provide a record of training for statutory compliance





safety rules and important policies and procedures.

2. XYZ Company bulletin boards will be conspicuously located.

a. The boards are to be properly maintained..

b. One individual will be responsible for maintaining the bulletin

board and controlling the notices placed thereon.





Section 5

Safety Committee and

Meetings

è DECISION POINT - If you have 25 or more employees, a Safety Committee should be established. If you do not meet this threshold,delete this sub-section.

A. Safety Committee

XYZ Company has formed a safety committee to help employees and

management work together to identify safety problems, develop

solutions, review incident reports and evaluate the effectiveness of

our safety program. The committee is made up of management-

designated representatives and employee-elected representatives.

1. The committee shall:

a. Promote a safe and healthy work environment at all times.

b. Encourage communication between employees and

management.

c. Serve as an oversight committee on all issues relative to

safety and health.

d. Make recommendations to the Safety Representative.

2. Functions: The committee has four principal functions:

a. Identify potential hazards;

b. Evaluate these potential hazards;





c. Recommend corrective action; and

d. Follow up implemented recommendations.

To carry out its functions, the committee is required to hold meetings

and carry out regular inspections of the workplace.





3. Membership

The make-up of an occupational safety and health committee shall

be a cross section of the membership of our organization.

Everyone who is a member of this organization should feel thattheir needs are being adequately and fairly represented through

the safety committee. If the XYZ Company employees are

represented by a labor organization, the representatives of

employees must be selected by the employees and not appointed

by the employer.

Employee representatives will serve for one year before being re-

elected or replaced. If there is a vacancy then an election will be

held before the next scheduled meeting to fill the balance of the

term.

In addition to the employee-elected representatives, management

will designate no more than three representatives but a minimum

of one who will serve until replaced by management.

A chairperson will be selected by majority vote of the committee

members each year. If there is a vacancy, the same method will

be used to select a replacement.

In addition to committee responsibilities, duties of safety

committee members include:

Perform a monthly self-inspection of the area they

represent;

Communicating with the employees they represent on

safety issues; and

Encourage safe work practices among co-workers.

4. Employer Responsibilities





Provide support from the top level down to first line

supervisors in terms of time, effort, and money.

Resolve scheduling and personnel conflicts.

Provide realistic dates for correcting safety and health

concerns.

Support training for safety committee members.

Provide leadership and direction.

Participation in safety committee meetings.

The management commitment/interest/good faith to safety

committees must be vocal, visible, and continuous - from the top

to the lowest level.

5. Frequency

Once established, the XYZ Company safety committee shall meet

at least quarterly. An agenda shall be developed by the

chairperson and distributed to the members at least 10 workdays

prior to the scheduled meeting. Meeting minutes shall be

prepared and distributed to the membership within 5 days

following the meeting. Meeting minutes shall be posted in a

conspicuous location convenient to all employees to view (i.e.,

lunch room, bulletin board, etc.)

B. Employee Safety Meetings

All trade employees are required to attend a monthly safety meeting.

The meeting is to help identify safety problems, develop solutions,

review incident reports, provide training and evaluate the

effectiveness of our company safety program. Minutes will be keptand kept on file for one year.





Section 6

Hazard Identification &

Assessment

A. Recordkeeping and Review

1. Employees will:

Employees will report any injury or work-related illness to their

immediate supervisor regardless of how serious. Minor injuries

such as cuts and scrapes can be entered on a “Minor Injury Log”posted in a conspicuous location. The employee must use an

“Employee’s Injury/Illness Report Form” to report more serious

injuries.

2. Supervisors will: è DECISION POINT

a. Investigate a serious injury or illness using procedures in

the “Incident Investigation” section.

b. Complete an “Incident Investigation Report” form.

c. Give the “Employee’s Report” and “Incident Investigation

Report” to the company Safety Representative.

B. Hazard Recognition Methods

Hazard recognition is a vital element in the program. It is a system to

identify any existing or potential dangers in the workplace, then

following through to eliminate or control them. If dangers occur (or

reoccur), there is a breakdown in the danger control system, and in

turn the safety and health program. The danger control system also

serves as the basis for developing safe work procedures and safety





and health training.

Correcting or controlling dangers can be accomplished in a variety of

ways. However, to work properly, a danger control system must have

the following components:

1. An initial danger identification survey;

2. A system for danger identification (such as inspections at

regular intervals);

3. An effective system for employees to report conditions

which may be dangerous (such as a safety committee or a safety

representative);

4. An equipment and maintenance program;

5. A system for review or investigation of workplace accidents,

injuries and illnesses;

6. A system for initiating and tracking danger corrective

actions; and

7. A system for periodically monitoring the place of

employment.

C. Danger Identification Methods

è DECISION POINT - If one has not been done, have it accomplished as soon as possible. If one has been accomplished, sostate, and where it’s maintained.

Initial Danger Survey

A knowledgeable safety and health person should conduct the initialsafety and health survey (audit) to identify existing or potential

workplace dangers.

è DECISION POINT - If one has not been done, have it





accomplished as soon as possible. If one has been accomplished, sostate, and where it’s maintained.

Periodic Danger Surveys (Monitoring)

A Scheduled a walk-through of the XYZ Company workplace is

performed at regular intervals to ensure that established work

procedures are being followed, and those unsafe conditions or

practices are identified and promptly corrected. These inspections

are in addition to the everyday safety and health checks that are part

of the routine duties of supervisors and managers.





The frequency of the inspections depends on the type of operations,the magnitude of the dangers, the proficiency of employees and supervisors, changes in equipment or work processes, and the history of the workplace injuries and illnesses. Someone who, throughexperience or training, can identify actual and potential dangers and

who understands safe work procedures should do an inspection.è DECISION POINT - If one has not been done, have it accomplished as soon as possible. If one has been accomplished, sostate, and where it’s maintained.

Employee Reports of Danger

Perhaps the best source of danger information is the employees.Employees should be trained to recognize danger situations and instructed to bring them to the attention of their supervisors or to asafety committee or a safety and health representative.

Prompt attention to identified dangers and positive feedback toemployees will reaffirm your personal commitment to workplacesafety and health. That will encourage employees to continue toreport dangers promptly and assure them that their reporting will not have negative consequences.

è DECISION POINT - If one has not been done, have it accomplished as soon as possible. If one has been accomplished, so state, and whereit’s maintained.

D. Equipment Monitoring and Maintenance

Program

Equipment, particularly all safety controls and safety equipment must be properly maintained. A program must be established to monitor the operation of workplace equipment and make sure that routine

preventive maintenance is conducted. That not only makes good safety and health sense, it is good for business. Proper maintenancecan prevent costly breakdowns.

è DECISION POINT - If one has not been done, have it accomplished as soon as possible. If one has been accomplished, so state, and where

it’s maintained.E. Accident Investigation and Reporting

A system must be established for investigating all workplaceaccidents, near misses, injuries and illnesses. Someone who canidentify the causes and recommend corrective actions should





involved, the extent of injuries or illness, a brief description of

what happened and the name and phone number of a contact

person.

2. Accident Investigation

Do not disturb the scene except to aid in rescue or make the

scene safe.

Whenever there is an incident that results in death or serious

injuries that have immediate symptoms, a preliminary

investigation will be conducted by the immediate supervisor of the

injured person(s), a person designated by management, an

employee representative of the safety committee, and any otherpersons whose expertise would help the investigation.





The investigation team will take written statements from

witnesses, photograph the incident scene and equipment involved.

The team will also document as soon as possible after the

incident, the condition of equipment and any anything else in the

work area that may be relevant. The team will make a written

“Incident Investigation Report” of its findings. The report will

include a sequence of events leading up to the incident,

conclusions about the incident and any recommendations to

prevent a similar incident in the future. The report will be

reviewed by the safety committee at its next regularly scheduled

meeting.

When a supervisor becomes aware of an employee injury wherethe injury was not serious enough to warrant a team investigation

as described above, the supervisor will write an "Incident

Investigation Report" to accompany the "Employee's Injury/Illness

Report Form" and forward them to (Add the name or title of

the responsible person) .

Whenever there is an incident that did not but could have resulted

in serious injury to an employee (a near-miss ), the incident will be

investigated by the supervisor or a team depending on the

seriousness of the injury that would have occurred. The "Incident

Investigation Report" form will be used to investigate the near-

miss. The form will be clearly marked to indicate that it was a

near miss and that no actual injury occurred. The report will be

forwarded to the bookkeeper to record on the incident log.

3. Occupational Injury, Illness Investigation

The Supervisor, if initially notified, shall report to the scene of an

occupational injury, illness, and property damage and immediately

secure and protect the accident scene. Drawings and

photographs, if needed, shall be used to record and document





where and how the accident occurred and the extent of injuries

and damage to property sustained. A preliminary and/or final

incident report shall be accomplished and a copy provided to the

company Safety Representative. The initial accident report shall

become a permanent part of the formal accident investigation.





The Safety Representative shall report to and investigate all

serious occupational injuries, illnesses and property damage. A

formal Incident Investigation Report shall be prepared to

determine the cause, document facts and recommend corrective

actions to prevent recurrence.

4. Occupational Injury, Illness Reporting

Employees shall report all occupational injuries, illnesses and

property damage, initially through their supervisor to the XYZ

Company Safety Representative.

This is the preferred method, which will ensure employees receive

medical treatment, if required, because of a serious and/or lifethreatening occupational injury and/or illness, and damage to

property can be documented and repaired.

Supervisors will immediately notify the XYZ Company Safety

Representative of any serious and/or life threatening occupational

injury and/or illness, and property damage. All other minor

occupational injuries and/or illnesses, and property damage will

also be reported to the Safety Representative the following day.

The Safety Representative will ensure the company person

responsible for Benefits Administration and/or Workers’

Compensation claims receives copies of the final report for all-

occupational injuries and/or illnesses.

F. Injury and Illness Recordkeeping

In order to establish meaningful goals and objectives for mishap

reduction, we must first know where we, as a company, have been in

terms of previous mishap experience. For that reason and to comply

with federal recordkeeping requirements, the following

documentation shall be maintained:





1. The Safety Representative shall maintain for a period of 5

years:

a. Safety accident investigation reports for all lost workday

occupational injuries, illnesses or equipment damage;

b. Safety accident investigation reports for company

property damage, as a result of accidents;

c. Records of formal claims against the company for injury,

illness, personal loss, and/or damage to personal property; and

2. OSHA Form No. 300, Log of Work-Related Injuries and

Illnesses , shall be used to record injuries or illnesses that result in

fatalities, lost workdays, require medical treatment, involve loss of

consciousness, or restrict work or motion. The annual report of

this form must be posted by February 1st in a centralized area

visible to all employees, and remain there for at least 3 months.

3. OSHA Form No. 301, Injury and Illness Incident Report ,

shall, when used, be used to give details of each recordable

occupational injury and illness. Records must be available for

examination by representatives of the U.S. Department of Laborand the Department of Health and Human Services. Note: This

record and/or the SF-301are kept for five years.

4. OSHA Form No. 300A, Summary of Work-Related Injuries

and Illnesses , provides additional data to make it easier for

employers to calculate incidence rates. Employers must review

the OSHA 300 Log information before it is summarized on the

300A form.

5. Accident Review: è DECISION POINT

Following an injury or near miss accident, the incident will be

reviewed with the Project Manager and onsite supervision . This





review will address the effectiveness of our program, any

additional task training that may be needed and measures to

prevent recurrence.

Once each month the Safety Representative shall report on the

effectiveness of XYZ Company safety program to the project or

company manager. This report can include data on the number of

man-hours worked, the numbers of accidents, injuries and near

miss incidents for the month and measures taken to prevent

recurrences.

G. Corrective Actions

è DECISION POINT - State your method of corrective action here.

1. Timely Correction of Dangers

Once remedial measures to control or eliminate dangers havebeen agreed upon, you should make sure that they areimplemented with minimum delay. Interim protection for employees may be necessary until the danger is eliminated or controlled.

Keep a record of steps taken to control or eliminate a danger.

Records should contain the danger, who reported it and when whois responsible for correction, the correction target date and whenit was corrected. Such information will assist in developing safework practices and training programs.

2. Responsibility for Corrective Action

a. Actions necessary to correct or remedy accident causal

factors shall rest with the XYZ Company Safety Representative.

b. The XYZ Company Safety Representative shall have the

broad authority to recommend corrective actions to abate anidentified hazard or deficiency to prevent injury or illness to

employees, and to prevent property damage or personal loss.

è DECISION POINT - State how frequently you will accomplish this.





1. Annual Site Survey -- Once a year an inspection team made up

of members of the safety committee will do a wall-to-wall walk

through inspection of the entire workplace. They will write down

any safety hazards or potential hazards they find. The results of

this inspection will be used to eliminate or control obvious

hazards, target specific work areas for more intensive

investigation, assist in revising the checklists used during regular

monthly safety inspections and as part of the annual review of the

effectiveness of our accident prevention program.

2. Periodic Change Survey -- We will assign a supervisor or form a

team to look at any changes we make to identify safety issues.

Changes include new equipment, changes to production processesor a change to the building structure. A team is made up of

maintenance, production, and safety committee representatives. It

examines the changed conditions and makes recommendations to

eliminate or control any hazards that were or may be created as a

result of the change.

3. Monthly Safety Inspection -- Each month, before the regularly

scheduled safety committee meeting, safety committee members

will inspect their areas for hazards using the standard safety

inspection checklist. They will talk to co-workers about any safety

concerns they may have. Committee members will report any

hazards or concerns to the whole committee for consideration.

The results of the area inspection and any action taken will be

posted in the affected area. Occasionally, committee members

may agree to inspect each other's area rather than their own. This

brings a fresh pair of eyes into the workplace area to look for

hazards.

4. Job Hazard Analysis -- As a part of our on-going safety program,

we will use a “Job Hazard Analysis” form to look at each type of job





A “Safety Inspection Guide Checklist” can be a useful tool to help the

supervisor carry out his/her responsibilities as described above.

B. Investigating Occupational Injury, Illness, and

Property Damage

1. The XYZ Company supervisor, if initially notified, shall report to the

scene of an occupational injury, illness, and property damage and

immediately secure and protect the accident scene. Drawings and

photographs, if needed, shall be used to record and document

where and how the accident occurred and the extent of injuries

and damage to property sustained. A preliminary and/or final

incident report shall be accomplished and a copy provided to thecompany Safety Representative. The initial accident report shall

become a permanent part of the formal accident investigation.

2. The Program Administrator/Safety Representative shall report to

and investigate all serious occupational injuries, illnesses and

property damage. A formal Incident Investigation Report shall be

prepared to determine the cause, document facts and recommend

corrective actions to prevent recurrence.

C. Reporting Occupational Injury, Illness and

Property Damage

1. XYZ Company employees shall report all occupational injuries,

illnesses and property damage, initially through their supervisor to

the Program Administrator/Safety Representative.

2. This is the preferred method, which will ensure employees receive

medical treatment, if required, because of a serious and/or life

threatening occupational injury and/or illness, and damage to

property can be documented and repaired.





The annual report of this form must be posted by February 1st in a

centralized area visible to all employees, and remain there for at

least 3 months.

3. OSHA Form No. 301, Injury and Illness Incident

Report , shall, when used, be used to give details of each

recordable occupational injury and illness. Records must be

available for examination by representatives of the U.S.

Department of Labor and the Department of Health and Human

Services. Note: This record and/or the SF-301must be kept for five

years.

4. OSHA Form No. 300A, Summary of Work-Related

Injuries and Illnesses , provides additional data to make it easier

for employers to calculate incidence rates. Employers must

review the OSHA 300 Log information before it is summarized on

the 300A form.

5. Accident Review


reviewed with the Project Manager and onsite supervision. This



prevent recurrence.

Each month the company Program Administrator/Safety

Representative shall report on the effectiveness of XYZ Company

safety program to the project or company manager. This report

can include data on the number of man-hours worked, the

numbers of accidents, injuries and near miss incidents for themonth and measures taken to prevent recurrences.

E. Corrective Actions







Once remedial measures to control or eliminate dangers have been

agreed upon, you should make sure that they are implemented withminimum delay. Interim protection for employees may be necessary until the danger is eliminated or controlled.

Keep a record of steps taken to control or eliminate a danger.Records should contain the danger, who reported it and when who isresponsible for correction, the correction target date and when it wascorrected. Such information will assist in developing safe work

practices and training programs.


a. Actions necessary to correct or remedy accident causalfactors shall rest with the XYZ Company Safety Representative.


broad authority to recommend corrective actions to abate an

identified hazard or deficiency to prevent injury or illness to


F. Monitoring the Place of Employment .

You have the responsibility of monitoring the workplace regularly –the work procedures, equipment and machines – to ensure that alldangers to workers are eliminated or controlled or, alternatively, toensure that the workers are protected from exposure to the dangers.

G. Safety Inspection and Hazard Control

Procedures

XYZ Company is committed to aggressively identifying hazardous

conditions and practices which are likely to result in injury or illness toemployees. We will take prompt action to eliminate any hazards we

find.





In addition to the Program Administrator/Safety Representative

reviewing injury records and investigating incidents for their causes,

area supervisors and the safety committee will regularly check the

workplace for hazards in the manner described below:

1. Annual Site Survey

Once each year an inspection team made up of members of the

safety committee will do a wall-to-wall walk through inspection of

the entire worksite. They will write down any safety hazards or

potential hazards they find.

The results of this inspection will be used to eliminate or control

obvious hazards, target specific work areas for more intensive

investigation, assist in revising the checklists used during regular

monthly safety inspections and as part of the annual review of the

effectiveness of our accident prevention program.

2. Periodic Change Survey

The Program Administrator/Safety Representative will request a

supervisor to form a team to look at any changes we make to

identify safety issues. Changes include new equipment, changes

to production processes or a change to the building structure. A

team is made up of maintenance, production, and safety

committee representatives.

It examines the changed conditions and makes recommendations

to eliminate or control any hazards that were or may be created as

a result of the change.





3. Monthly Safety Inspection

Safety committee members will inspect their areas for hazards

using the standard safety inspection checklist. They will talk to co-

workers about their safety concerns. Committee members will

report any hazards or concerns to the whole committee for

consideration. The results of the area inspection and any action

taken will be posted in the affected area. Occasionally, committee

members may agree to inspect each other's area rather than their

own. This brings a fresh pair of eyes to look for hazards.





Section 8

Hazard Prevention and

ControlA. Eliminating Workplace Hazards

XYZ Company is committed to eliminating or controlling workplace

hazards that could cause injury or illness to our employees. We will

meet the requirements of state safety standards where there are

specific rules about a hazard or potential hazard in our workplace.

Whenever possible we will design our facilities and equipment to

eliminate employee exposure to hazards. Where these engineering

controls are not possible, we will write work rules that effectively

prevent employee exposure to the hazard. When the above methods

of control are not possible or are not fully effective we will require

employees to use personal protective equipment (PPE) such as safety

glasses, hearing protection, foot protection etc.

B. Safety Rules and Work Procedures

1. General Safety Rules

The XYZ Company Written Safety and Health Program apply to all

employees.

The rules may be very simple or extremely complex, depending on

the nature of the work processes and the number and kinds of

employees involved. Some items that are addressed by general

safety rules are:

a. Personal protective equipment requirements;

b. Clothing appropriate for the work;

c. Behavior expected of all employees;





d. How to leave the workplace safely, with particular reference toemergency procedures; and

e. Danger areas that are: “off-limits” for employees.

As part of our initial safety and health survey, existing rules are

always evaluated. New rules may be necessary. All rules will be

reviewed and updated periodically to make sure they reflect

present conditions. Those no longer applicable will be dropped.

2. Basic Safety Rules

The following basic safety rules have been established to help

make our company a safe and efficient place to work. These rules

are in addition to safety rules that must be followed when doing

particular jobs or operating certain equipment. Those rules are

listed elsewhere in this program. Failure to comply with these

rules will result in disciplinary action.

a. Never do anything that is unsafe in order to get the job done.If a job is unsafe, report it to your supervisor or safetycommittee representative. We will find a safer way to do that

job.

b. Do not remove or disable any safety device! Keep guards inplace at all times on operating machinery.

c. Never operate a piece of equipment unless you have beentrained and are authorized.

d. Use your personal protective equipment whenever it isrequired.

e. Obey all safety warning signs.

f. Working under the influence of alcohol or illegal drugs or usingthem at work is prohibited.

g. Do not bring firearms or explosives onto company property.

h. Smoking is only permitted outside the building away from anyentry or ventilation intake.

i. Horseplay, running and fighting are prohibited

j. Clean up spills immediately. Replace all tools and supplies after





use. Do not allow scraps to accumulate where they willbecome a hazard. Good housekeeping helps prevent injuries.





3. Standard Work Procedures

Effectiveness in safety and health performance results our

commitment to establish standard work procedures that fix

accountability. These directives or standard work procedures canbe oral or written but in all case communicated to each worker,

defining specific responsibilities and objectives where safety and

health are concerned.

It is not uncommon in business operations for individual groups

such as quality control, production control, safety and other

groups to have their own procedures for doing the same work.

The objective is to use results of a work analysis to establish one

standard procedure for each job, which is on record and available

for reference and continued use.

Ideas can often be obtained from equipment and tool

manufacturers. It is strongly recommended that those

departments consult with employees and use their ideas,

particularly those employees who have experience in the work

being studied.

Standard work procedures provide the tools for teaching how to

work consistently with a maximum of efficiency and safety.

C. Company Specific Safety Programs

1. Personal Protective Equipment (PPE)

XYZ Company will insure that all employees and subcontractors

will use appropriate PPE while on-site. This will include appropriate

hard hats, safety glasses, hearing protection, body harnesses and

positioning belts and all other necessary equipment as required by

site and working conditions.

2. Housekeeping





XYZ Company will enforce housekeeping requirements daily. This

will include:

a. Requiring subcontractors to keep their work areas orderly andclean up daily.

b. Keeping walkways and access areas clear.

c. Run cords and hoses so as not to pose a trip hazard. Do notrun cords or hoses through doorways or other openings wherethey could be pinched and damaged.

d. Combustible materials and debris will be properly stored ordisposed of daily. Trash will not be permitted to accumulateand will be placed in covered containers or furnisheddumpsters.

e. Form and scrap lumber will be stored and cleared awayfrom the work area daily. All protruding nails will be hammeredin, removed or bent over to prevent injury.

f. Spills involving combustible or flammable liquids, oils orgrease will be cleaned up immediately.

3. Self-Inspections

XYZ Company safety and supervisory personnel will perform daily

walk-through inspections. Inspections will be documented and

deficiencies noted. Equipment operators will inspect their

equipment daily, and a log will be kept in the piece of equipment.

All inspection logs will be available for review.

a. The XYZ Company Safety Representative is the authority on

all company Occupational Health and Safety inspections and

safety training, and is responsible for ensuring all required

safety inspections are promptly conducted.

b. Types and Frequency of Safety Inspections and Surveys.

Safety Inspections shall be conducted at periodic intervals of all

work locations.





c. When established, safety committee members are responsible for

conducting self-inspections of their areas and other areas, as

assigned by the Safety Representative.

d. Supervisors are responsible for conducting self-inspections

of their assigned work area(s).

4. Governmental Inspections

In the event of a governmental inspection, the compliance officer

will be directed to any General Contractor’s office . If not the

General Contractor, XYZ Company will follow the prescribed

General Contractor procedures.

Outside Agency Inspections. These may include:

State Occupational Safety & Health Inspector.

City/County/State Fire Inspector.

Insurance Company Loss Control Consultant.

Other bonified inspectors with a contractual or legal

interest.

a. The Safety Representative shall be immediately notified by

any employee who has knowledge of an outside agency

inspection, and accompany all inspectors while they are on the

property.

b. Supervisors shall also be notified and will be encouraged to

accompany outside agency inspections of their areas of

responsibility.

5. Audits

XYZ Company will cooperate fully with any General Contractor,

and the insurance authority with regard to monthly and periodic





safety audits. Additionally, XYZ Company will conduct a monthly

audit of all subcontractors under our contract, which are on-site.

6. Planning

All project activities will include planning for safety concerns

throughout the project. A "Job Hazard Analysis" will be generated

with the project superintendent and foremen for all hazardous

operations. Subcontractors will be required to provide a

documented Job Hazard Analysis for their work prior to

commencing operations.

7. Job Hazard Analysis

XYZ Company will actively promote and develop a complete Job

Hazard Analysis for all construction programs within the scope of

our work.

a. Those operations, which do not fall in the “analysis loop”,

will be designated as non-hazardous and filed in the

appropriate order along with the Job Hazard Analyses.

b. Job Hazard Analysis shall be produced by the

superintendent and appropriate crew foremen and reviewed by

XYZ Company Safety Representative. A copy of each Job

Hazard Analysis shal1 be maintained onsite and available for

review. Who should participate in a hazard analysis?

c. To be fully effective and reliable, it should represent as

many different viewpoints as possible. Each person familiar

with a process or operation has gained insights concerning

problems, faults, and situations that can cause accidents.

These insights need to be recorded along with those of the

initiator of the hazard analysis, who is the superintendent,

appropriate crew foremen, company Safety Representative or a





contract safety professional.

What processes, operations, and tasks need to be analyzed?

Many processes, operations and tasks in any establishment are

good candidates for hazard analysis because they have the

potential to cause accidents. Eventually, hazard analyses

should be completed for all jobs, but the most potentially

threatening should have immediate attention. Those that are

making the decisions should consider:

Frequency of accidents

Potential for injury

Severity of injury

New or altered equipment, processes, equipment,and operations

Excessive material waste or damage to equipment

8. Responsibilities for "Controlling" Workplace Hazards

It is the responsibility of all employees to control the possibility of

hazards in their work area, which, if left uncorrected, could cause

injury to other employees, the public at large and damage toequipment or property .

9. Requirements for "Reporting" Workplace Hazards

All workplace hazards, which cannot be immediately controlled

(barricaded, placement of warning/danger signs, etc.) or correctedon the spot, shall be immediately reported to the supervisor in

charge and the company Safety Representative.

10. Procedures for "Correcting" Identified Workplace Hazards





It is the responsibility of each supervisor to ensure that identified

workplace hazards are corrected and employees informed.

Hazards that have been identified through safety inspections shall

be corrected within a reasonable time to make necessary repairs

or corrections to abate the hazard.

D. Enforcement Procedures and Systems

At XYZ Company, safety rules and work procedures shall be practiced

and enforced.

We have established a system to ensure that violations of rules are

dealt with fairly but firmly, that all employees are aware of the

requirements, and that reorientation or retraining may be providedwhen needed. Incentive programs may be initiated and will be used

in conjunction with a good enforcement program.

1. Discipline

No safety program can be effective without some form of

discipline. There are no rules that must be followed, only

guidelines. The following guidelines have been established by XYZ

Company.

a. The first preventable accident or safety rule violation

observed should result in a discussion with the employee and

the supervisor or manager. This verbal reprimand should be

documented, dated, and signed by those involved.





b. A second preventable accident or safety rule violation

observed within a 12-month period should result in another

discussion with the employee accompanied by a written

reprimand. Time off without pay, up to a maximum of 5 days,

should be considered.

c. A third preventable accident or safety rule violation

observed within a 12-month period should result in another

discussion with the employee and a serious evaluation needs to

be made. This is probably grounds for termination.

Compliance

a. One point must be very clear: discipline has to beadministered uniformly and consistently.

b. Violations of safety rules and policies should be addressed in

the following manner:

First Incident: Verbal warning, documented

discussion.

Second Incident: Written reprimand, up to 5 days

suspension.

Third Incident: Written reprimand, grounds for

termination.

c. Each supervisor or manager shall be responsible for

administering this policy to his/her subordinates.

d. All written reprimands and records of violations shall be held

confidential and maintained in the employees’ personnel files.

3. Accountability





Each supervisor’s efforts and performance will be evaluated

relative to reaching XYZ Company safety objectives and assigned

responsibilities. This evaluation will be part of the supervisor’s

performance review and will be used in part to determine his or

her job assignments, merit increases or promotions.





E. Medical and First Aid

Medical treatment plans.

1. Key XYZ Company personnel should be trained in first aid andCPR. The XYZ Company disaster plan coordinator shall maintain a

list of those trained and qualified personnel. Responsibility for

monitoring and ensuring initial and recurring training is

accomplished, shall be the responsibility of the Safety

Representative.

2. All supervisory personnel should be encouraged to enroll in a first

aid course and to learn CPR. Those employees who work around

high voltage equipment shall be required to be certified annually

in CPR.

3. Each XYZ Company construction office shall be equipped with a

standard first aid kit suitable for the size of the workforce.

Additional first kits may be strategically positioned throughout the

workplace and/or jobsite. The location of each kit will be

communicated to all employees and shall be clearly marked “First

Aid.”

4. Vehicle size first aid kits shall be maintained in each XYZ Company

construction/project-use vehicle.

5. All first aid supplies shall be inspected at least monthly and

replenished as required.

6. Accident / Injury reporting: All accidents, near miss incidents and

injuries shall be reported to XYZ Company Safety Representative.

Following an injury:

a. The employee’s injury will be evaluated and first aid

rendered.





b. If the injury requires medical attention the employee will be

escorted to the onsite clinic. Further evaluation and treatment

will be rendered.

c. A determination will be made by XYZ Company site supervision

and safety representative as to whether or not the injured, and

any other involved are to be drug tested. Usually a post-

accident drug test is required.





d. An Employer's Initial Report of Industrial Injury, Accident

and Property Damage form (as directed by your State) will be

completed for all injuries requiring medical attention, even if

only first aid, when rendered at either an onsite clinic or

outside medical facility.

e. A supervisor's report or Statement of Injury will be

completed by the employees' supervisor.

f. An investigation into the incident will be completed by XYZ

Company Safety Representative, even if no serious injury

occurred.

g. A copy of any applicable State document on Employer'sInitial Report of Industrial Injury, Accident and Property

Damage form, Supervisor's report or Statement of Injury will be

submitted to the XYZ Company Safety Representative for the

employer provided workers' compensation coverage.

h. All first aid cases may be recorded on a First Aid Log

maintained by XYZ Company Safety Representative.

F. Disciplinary Policy

XYZ Company e mployees are expected to use good judgment when

doing their work and to follow established safety rules. We have

established a disciplinary policy to provide appropriate consequences

for failure to follow safety rules. This policy is designed not so much

to punish as to bring unacceptable behavior to the employee's

attention in a way that the employee will be motivated to make

corrections. The following consequences apply to the violation of thesame rule or the same unacceptable behavior:

1. First Instance -- verbal warning, notation in employee file,and instruction on proper actions





2. Second Instance -- 1 day suspension, written reprimand,and instruction on proper actions

3. Third Instance -- 1 week suspension, written reprimand,and instruction on proper actions

4. Fourth Instance -- Termination of employment.

Section 9

Safety Training and

Instruction

Training at XYZ Company is an essential part of our plan to provide a

safe work place.

Training Administrator

The Injury and Illness Prevention Program training administrator,

Training Administrator has the authority and responsibility for

implementing the training provisions of this program.


The Training Administrator for XYZ Company is

_______________________________________.

The Training Administrator is responsible to verify that each employee

has received an initial safety orientation by their supervisor, has received

any training needed to do the job safely and that the employee file

documents the training. This administrator will make sure that an

outline and materials list is available for each training course we provide:

A. New-Hire Employee Orientation





1. All XYZ Company employees will attend the new-hire

employee orientation prior to commencing employment. New-

hires shall receive occupational health and safety training in the

following subject areas:

a. XYZ Company Safety Philosophy and Policy

b. Disciplinary procedures for non-compliance

c. Employee Danger Reporting System

d. Accident Reporting System

e. Personal Protective Equipment (when applicable)

f. Fall Protection -100% tie-off (when applicable)

g. Fire Prevention

h. Hazardous Communication Standard, Material Safety Data

Sheets, and Environmental Safety

i. Bloodborne Pathogens Program (if applicable)

j. Workplace housekeeping rules

k. Safety Incentive Program (when established).

B. Supervisor Safety Awareness Training

At XYZ Company, supervisory training is a logical first step since

supervisors will help in training the other employees. Supervisors are

key figures in the implementation and overall success of the safety

and health program. As a minimum, supervisors at XYZ Company

shall be trained in the following areas:

1. The need to establish and maintain safe and healthful working

conditions;





2. The dangers associated with a job, the potential effect on

employees, and the rules, procedures and work practices for

control of these dangers;

3. How to relate this information by example and instruction to

employees, to ensure that they understand and follow safe

procedures; and

4. How to investigate accidents, and to take corrective and

preventive action to prevent recurrence.

C. Employee Safety Training

At XYZ Company, we recognize that employees may create dangers

through their own actions if they have not been properly trained.

Dangerous situations can be avoided, or made less dangerous, when

our employees receive appropriate training and instruction in the

following subject areas:

1. Standard work procedures including safe work practices, and how

these procedures protect against exposure to dangers.

2. Personal protective equipment: why it is needed, how to use it,

and how to keep it in good condition.

3. What to do in case of fire or other emergency that may occur in

the workplace.

Training is as essential to the overall program as these elements:

management commitment; danger assessment and control; and safety

planning, rules and work procedures.

D. Required Occupational Safety and Health

Programs





Hazard Communication Program

1. All XYZ Company employees will receive training in compliance

with the OSHA Hazard Communication (HazCom) Standard. This

training will be part of the new-hire employee orientation and will

cover, at a minimum, the following areas:

a. A review of the requirements of the HazCom Standard.

b. Chemicals or hazardous materials likely to be found in their

workplace; their health effects and means of exposure or

routes of entry.

c. How to lessen or prevent exposure to hazardous chemicals

or materials through the use of control/work practices and

Personal Protective Equipment.

d. Emergency procedures to follow in the event of an accident

or exposure involving hazardous chemicals/materials.

2. Continuous HazCom training will be conducted via weekly toolbox

safety meetings when applicable.

3. Personnel regularly expose to hazardous chemicals as part of their job tasks will receive annual refresher training within 30 days of

their employment date or by department annual schedule. Note:

This annual refresher HazCom training shall be documented.

E. Other Company Required Safety Programs (See

Section 11)

F. Company Required Safety Training Courses(See Section 12)





G. Company Required Safety Program Forms (See

Section 13)





Section 10

Accident Recordkeeping

A. Injury and Illness Recordkeeping

In order to establish meaningful goals and objectives for mishap

reduction, we must first know where we, as a company, have been in

terms of previous mishap experience. For that reason and to comply

with federal recordkeeping requirements, the following

documentation shall be maintained:

1. The Safety Representative shall maintain for a period of

5 years:

a. Safety accident investigation reports for all lost workday

occupational injuries, illnesses or equipment damage;

b. Safety accident investigation reports for company property

damage, as a result of accidents;

c. Records of formal claims against the company for injury,

illness, personal loss, and/or damage to personal property; and

2. OSHA Form No. 300, Log of Work-Related Injuries and

Illnesses , shall be used to record injuries or illnesses that result in

fatalities, lost workdays, require medical treatment, involve loss of

consciousness, or restrict work or motion.

The annual report of this form must be posted by February 1st in a

centralized area visible to all employees, and remain there for at

least 3 months.





3. OSHA Form No. 301, Injury and Illness Incident

Report , shall, when used, be used to give details of each

recordable occupational injury and illness. Records must be

available for examination by representatives of the U.S.

Department of Labor and the Department of Health and HumanServices. Note: This record and/or the SF-301 are kept for five

years.

4. OSHA Form No. 300A, Summary of Work-Related

Injuries and Illnesses , provides additional data to make it easier

for employers to calculate incidence rates. Employers must

review the OSHA 300 Log information before it is summarized on

the 300A form.

5. Accident Review


reviewed with the Project Manager and onsite supervision. This



prevent recurrence.

Each month the company Program Administrator/Safety

Representative shall report on the effectiveness of XYZ Company

safety program to the project or company manager. This report

can include data on the number of man-hours worked, the

numbers of accidents, injuries and near miss incidents for the

month and measures taken to prevent recurrences.

B. Corrective Actions



Once remedial measures to control or eliminate dangers have





been agreed upon, you should make sure that they areimplemented with minimum delay. Interim protection for employees may be necessary until the danger is eliminated or controlled.

Keep a record of steps taken to control or eliminate a danger.

Records should contain the danger, who reported it and when whois responsible for correction, the correction target date and whenit was corrected. Such information will assist in developing safework practices and training programs.


a. Actions necessary to correct or remedy accident causal

factors shall rest with the XYZ Company Safety Representative.


broad authority to recommend corrective actions to abate an

identified hazard or deficiency to prevent injury or illness to







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Section 12

Company Required

Safety TrainingCourses

Due to the nature of work and operations

performed by XYZ Company, it is necessary that

the following safety training courses are included

in our Injury and Illness Prevention

Program:

For convenience, courses listed in the 3 tables

below are alpha sorted.

è DECISION POINT – Review and select those

courses that apply or included others not listed

Company Required Safety Training Courses – Sorte d

A-EAccident Investigation Construction Safety ManagementAccident Prevention Signs & Tags Crane Safety – RefresherAsbestos Safety Cranes & Derricks in ConstructionBloodborne Pathogens –

Initial/Refresher Electrical SafetyBloodborne Pathogens – Train-the-

Trainer Emergency Exit RoutesChemical Spills Emergency Response TeamCompetent Persons Ergonomics – Basic Human Factors

Compressed Gas CylinderErgonomics – Advanced HumanFactors

Concrete & Masonry Excavation SafetyConfined Space Entry Eye & Face Protection





Table 2


All Safety Training Courses are available through Safety Office Depot www.SafetyOfficeDepot.c






Company Required Safety Training Courses – Sorted

F-LFall Protection Hexavalent Chromium

Portable Fire Extinguisher Hot Work Permit SafetyFlammable & Combustible Liquids Indoor Air QualityForklift Safety – Classroom (English) Introduction to OSHAForklift Safety – Classroom

(Spanish) Job Hazard AnalysisHand & Power Tools Laser SafetyHazard Communication Lead ExposureHazard Vulnerability Liquid NitrogenHazardous Materials Management Lockout-TagoutHearing Protection

Table 3

Company Required Safety Training Courses – Sorted

M-WMachine Guarding Safety Representative TrainingMaterial Handling Safety Supervisor TrainingOffice Safety Awareness ScaffoldingPandemic Preparedness Slip, Trip & Fall PreventionPersonal Protective Equipment Stairway & Ladder SafetyPowered Industrial Truck TB Respiratory ProtectionRadiation Safety Walking & Working SurfacesRespirator Protection Warehouse SafetySafe Lifting Awareness – Back

Safety

Workplace Violence Prevention -

Healthcare

Safety Audit Training

Workplace Violence Prevention -

Retail

Table 4





Section 13

Company Required

Safety Forms &Checklists

Due to the nature of work and operations

performed by XYZ Company, it is necessary that

the following safety forms and checklists are

included in our Injury and Illness Prevention

Program :

For convenience, forms listed below are subject

sorted.

è DECISION POINT – Review and select those

forms that apply or included others not listed

CONFINED SPACE

Confined Space Entry PermitConfined Space – Class A & B PermitConfined Space – Class C PermitList of Authorized Entrants

Permit Required Confined Space – Inventory LogCONSTRUCTION INDUSTRY - SAFETY MANAGEMENT

Construction Industry Inspection ChecklistJob Start-Up ChecklistContractors Job Site ChecklistContractor Safety Performance ReportConstruction Equipment ChecklistForklift Service ChecklistOperator Performance Evaluation ChecklistSafety Nets Inspection ChecklistBody Harness & Lanyard Inspection ReportCompetent Person Evaluation – Fall Protection

CRANE OPERATIONSCranes, Derricks or Material Handling Devices WorksheetCrane Inspection ChecklistCrane Pre-Lift ChecklistSling (Chain) Inspection ReportMonthly Hoist Rope Inspection ReportMonthly Hoist Hook Inspection Report





EMERGENCY ACTION AND RESPONSECrisis Management Response Team - Contact LogSafety Representatives - Contact LogExternal Resources – Contact LogVulnerability Analysis ChartBomb Threat ChecklistEmployee Evacuation - Accounting Log

Physically Challenged – Employee ListCommand Post Equipment Inventory LogPress Information LogPost Exercise Evaluation Report





EMPLOYEE SAFETY RECORDSEmployee Acknowledgement FormEmployee Orientation Checklist – ConstructionEmployee PPE Assessment FormEmployee PPE Issue FormEmployee Safety Training RecordErgonomic Workstation Analysis Form

Employee Ergonomic Workstation QuestionnaireEmployee Safety Suggestion FormEXCAVATION OPERATIONS

Pre-Excavation ChecklistTrenching Design ChecklistTrench Safety – Daily Field ReportCompetent Person Evaluation – Excavation

FIRE PREVENTIONHot Work PermitFire Safety Inspection ChecklistFire Drill Post Response ReportEmergency HAZMAT Inventory LogHazardous Waste Disposal Request Form

GENERAL INDUSTRY – SAFETY MANAGEMENTGeneral Industry Safety Inspection ChecklistOffice Safety Inspection ChecklistJob Safety Analysis Worksheet & InstructionsAccident Prevention Program AnalysisForklift Service ChecklistHearing Conservation Program LogScaffolding Safety ChecklistSite Safety Meeting RecordSupervisors Monthly Meeting RecordReport of Safety Hazard FormProperty Security Survey

INCIDENT REPORTING FORMSOSHA 300 LogEmployee Injury & Illness ReportEmployee Injury Cost Accounting Matrix

Vehicle Accident & Property Damage ReportCompiling Direct and Indirect CostsOCCUPATIONAL HEALTH FORMS

Medical Evaluation Questionnaire – Respirator UseRespirator Fit Testing RecordHepatitis B Vaccine - Accept/Decline FormBloodborne Pathogens Risk Classification FlowchartBBP Employee Annual Training RecordBBP Source Patient Consent Form

RADIATION PROGRAM FORMSRadioactive Material Use LogPregnancy Declaration FormLaboratory Contamination Survey RecordRadiation Producing Device - Authorization FormTraining Guide for Radiation WorkersTraining Guide for Ancillary Radiation Works

TRAINING RECOGNITION CERTIFICATECertificate of Completion


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Appendix A

List of Training

Subjects

è DECISION POINT – Select applicable training

subjects - Strikethrough/delete those that do not

XYZ Company trains our workers about the

following selected training subjects:

1. The employer's Code of Safe Practices.

2. Confined spaces.

3. Safe practices for operating any

agricultural equipment.

4. Good housekeeping, fire prevention, safe

practices for operating any construction

equipment.

5. Safe procedures for cleaning, repairing,

servicing and adjusting equipment and

machinery.

6. Safe access to working areas.

7. Protection from falls.

8. Electrical hazards, including working

around high voltage lines.

9. Crane operations.





10.Trenching and excavation work.

11.Proper use of powered tools.

12.Guarding of belts and pulleys, gears and

sprockets, and conveyor nip points.

13.Machine, machine parts, and prime

movers guarding.

14.Lock-out/tag-out procedures.

15.Materials handling.

16.Chainsaw and other power tool operation.

17.Tree falling/bucking procedures and

precautions, including procedures for

recognizing and working with hazard trees,

snags, lodged trees, and unsafe weather

conditions.

18.Yarding operations, including skidding,

running lines, unstable logs, rigging and

communication.

19.Landing and loading areas, including

release of rigging, landing layout, moving

vehicles and equipment, and log truck

locating, loading and wrapping.

20.Fall protection from elevated locations.

21.Use of elevated platforms, includingcondors and scissor lifts.

22.Safe use of explosives.

23.Driver safety.





24.Slips, falls, and back injuries.

25.Ergonomic hazards, including proper lifting

techniques and working on ladders or in a

stooped posture for prolonged periods at

one time.

26.Personal protective equipment.

27.Respiratory Equipment.

28.Hazardous chemical exposures.

29.Hazard communication.

30.Physical hazards, such as heat/cold stress,

noise, and ionizing and non-ionizing

radiation.

31.Laboratory safety.

32.Bloodborne pathogens and other biological

hazards.

33.Other job-specific hazards, such as __________________________________________





Appendix B

Hazard Assessment

Checklist

è DECISION POINT – Determine which

checklists apply to your operation and delete all

others

XYZ Company has determined the following

hazard assessment checklists apply to itsoperations

1. Abrasive Wheel

Equipment Grinders

2. Compressed Air

Receivers

3. Compressed Gas &

Cylinders4. Compressors &

Compressed Air

5. Confined Spaces

6. Control of Harmful

Substances by Ventilation

7. Crane Checklist

8. Electrical

9. Elevated Surfaces

10. Emergency Action

Plan

11. Environmental

Controls

12. Ergonomics

13. Exit Doors

14. Exiting or Egress

15. Fire Protection

16. Flammable &

Combustible Materials17. Floor & Wall Openings

18. Fueling

19. General Work

Environment

20. Hand Tools &

Equipment

21. Hazardous Chemical

Exposures

22. Hazardous

Substances

Communication





23. Hoist & Auxiliary

Equipment

24. Identification of Piping

Systems

25. Industrial Trucks –Forklifts

26. Infection Control

27. Lockout-Tagout

Procedures

28. Machine Guarding

29. Material Handling

30. Noise

31. Personal Protective

Equipment & Clothing

32. Portable (Power

Operated) Tools &

Equipment

33. Portable Ladders

34. Powder Actuated

Tools

35. Sanitizing Equipment

& Clothing36. Spraying Operations

37. Stairs and Stairways

38. Tire Inflation

39. Transporting

Employees & Materials

40. Ventilation for Indoor

Air Quality

41. Walkways

42. Welding, Cutting &

Brazing





Appendix C

Hazard Assessment

andCorrection Record





Hazard Assessment and

Correction Record

Date of Inspection:

________________________________________

Person Conducting Inspection:

_______________________________

Unsafe Condition or Work Practice:

_________________________________________________

_____________________________

_________________________________________________

_____________________________

_________________________________________________

_____________________________

Corrective Action Taken:

_________________________________________________

_____________________________

_________________________________________________

_____________________________

_________________________________________________

_____________________________





Appendix D

Accident/Exposure

Investigation Report





Accident/Exposure

Investigation Report

Date of Accident: _____________________________

Time of Accident: __________________

Location of Accident:

_________________________________________________

__________

Accident Description:

_________________________________________________

_____________________________

_________________________________________________

_____________________________

_________________________________________________

_____________________________

Employees Involved:

_________________________________________________

_____________________________

_________________________________________________

_____________________________

Preventive Action Recommendations:

_________________________________________________

_____________________________

_________________________________________________

_____________________________





Corrective Actions Taken:

_________________________________________________

_____________________________

_________________________________________________

_____________________________

Manager Responsible:

________________________________________

Date Corrective Actions Completed:

_____________________________





Appendix E

Employee Training and

Instruction Record





Employee Training and

Instruction Record

Employee Receiving Training:

(First Name) (Middle Initial)(Last Name)

(Safety Training Topic)

Select one:

Initial PeriodicAnnual/Refresher Special

This employee has received specific safety & health trainingin the following subject areas:

Person conducting the training:

(First Name) (Middle Initial)(Last Name)





Trainer’s SignatureDate

Qualification or Job Title of Trainer

Trainee’s SignatureDate





Appendix F

Codes of Safe

Practice

è DECISION POINT – Determine which of the

following Codes of Safety Practices apply to your

company’s operation, combine or edit them or

delete/strikethrough the codes that in your

opinion are non-applicable.





Codes of SafePractices

General Industry

It is our policy that everything possible will be

done to protect employees, customers and

visitors from injury. Safety is a cooperative

undertaking requiring participation by every

employee. Failure by any employee to comply

with safety rules will be grounds for corrective

discipline.

Supervisors shall insist that employees observe

all applicable Company, State and Federal safety

rules and practices and take action as is

necessary to obtain compliance. To carry out this

policy employees shall follow these safety rules

and practices:

1. Report all unsafe conditions and

equipment to your supervisor or safety

coordinator.

2. Report all incidents, injuries and illnesses

to your supervisor or safety coordinator

immediately.

3. Anyone known to be under the influence of

intoxicating liquor or drugs shall not be

allowed on the job while in that condition.

4. Horseplay, scuffling, and other acts which





tend to have an adverse influence on the

safety or well-being of the employees, are

prohibited.

5. Means of egress shall be kept unblocked,

well-lighted and unlocked during work

hours.

6. In the event of fire, sound alarm and

evacuate.

7. Upon hearing fire alarm, stop work and

proceed to the nearest clear exit. Gather

at the designated location.

8. Only trained workers may attempt to

respond to a fire or other emergency.

9. Exit doors must comply with fire safety

regulations during business hours.

10. Stairways should be kept clear of items

that can be tripped over, and all areas

under stairways that are egress routes

should not be used to store combustibles.

11. Materials and equipment will not be stored

against doors or exits, fire ladders or fire

extinguisher stations.

12. Aisles must be kept clear at all times.

13. Work areas should be maintained in aneat, orderly manner. Trash and refuse

are to be thrown in proper waste

containers.





14. All spills shall be wiped up promptly.

15. Always use the proper lifting technique.

Never attempt to lift, push, pull or carry

an object that is too heavy. You must

contact your supervisor when help is

needed to move a heavy object.

16. Never stack material precariously on top

of lockers, file cabinets or other relatively

high places.

17. When carrying material, caution should be

exercised in watching for and avoidingobstructions, loose material, etc.

18. Do not stack material in an unstable

manner.

19. Report exposed wiring and cords that are

frayed or have deteriorated insulation so

that they can be repaired promptly.

20. Never use a metal ladder where it could

come in contact with energized parts of

equipment, fixtures or circuit conductors.

21. Maintain sufficient access and working

space around all electrical equipment to

permit ready and safe operations and

maintenance.

22. Do not use any portable electrical tools

and equipment that are not grounded or

double-insulated.

23. All electrical equipment should be plugged





into appropriate wall receptacles or into

an extension of only one cord of similar

size and capacity. Three-pronged plugs

should be used to ensure continuity of

ground.

24. All cords running into walk areas must be

taped down or inserted through rubber

protectors to preclude them from

becoming tripping hazards.

25. Inspect motorized vehicles and other

mechanized equipment daily or prior to

use.

26. Shut off engine, set brakes and block

wheels prior to loading or unloading

vehicles.

27. Inspect pallets and their loads for integrity

and stability before loading or moving.

28. Do not use compressed air for cleaning off clothing.

29. Do not store compressed gas cylinders in

areas which are exposed to heat sources,

electric arcs or high temperature lines.

30. Identify contents of pipelines prior to

initiating any work that affects the

integrity of the pipe.

31. Wear hearing protection in all areas

identified as having high noise exposure.

32. Goggles or face shields must be worn





when grinding.

33. Do not use any faulty or worn hand tools.

34. Guard floor openings by a cover, guardrail,

or equivalent.

35. Do not enter into a confined space unless

tests for toxic substances, explosive

concentrations, and oxygen deficiency

have been taken.

36. Always keep flammable or toxic chemicals

in closed containers when not in use.

37. Do not eat in areas where hazardous

chemicals are present.

38. Be aware of the potential hazards

involving various chemicals stored or

used in the workplace.

39. Cleaning supplies should be stored away

from edible items on kitchen shelves.

40. Cleaning solvents and flammable liquids

should be stored in appropriate

containers.

41. Solutions that may be poisonous or not

intended for consumption should be kept

in well-labeled containers.

42. When working with a computer, have all

pieces of furniture adjusted, positioned

and arranged to minimize strain on all

parts of the body.





43. Never leave lower desk or a cabinet

drawer open, which presents a

tripping hazard. Use care when

opening and closing drawers to avoid

pinching fingers.

44. Do not open more than one upper

drawer at a time, particularly the top

two drawers on tall file cabinets.

45. Individual heaters at work areas

should be kept clear of combustible

materials, such as drapes, or waste

from waste baskets. Newer heaters

that are equipped with tip-over

switches should be used.

46. Appliances, such as coffee pots and

microwaves, should be kept in working

order and inspected for signs of wear,

heat or fraying of cords.

47. Fans used in work areas should be

guarded. Guards must not allow fingers to

be inserted through the mesh. Newer

fans are equipped with proper guards.





Codes of SafePractices

ConstructionIndustry

1. All persons shall follow these safe practices

rules, render every possible aid to safe

operations, and report all unsafe conditions or

practices to the supervisor or superintendent.

2. Supervisors or foremen shall insist on

employees observing and obeying every

applicable Company, State or Federal

regulation and order as is necessary to

the safe conduct of the work, and shall

take such action as is necessary to obtain

compliance.

3. All employees shall be given frequent injury

and illness prevention instructions.

Instructions shall be given at least every 10

working days.

4. Anyone known to be under the influence of

drugs or intoxicating substance which

impair the employee’s ability to safely

perform the assigned duties shall not be

allowed on the job while in that condition.

5. Horseplay, scuffling, and other acts

which tend to have an adverse

influence on the safety or well-being of





the employees, shall be prohibited.

6. Work shall be well planned and supervised to

prevent injuries in the handling of materials

and in working together with equipment.

7. No one shall knowingly be permitted or

required to work while the employee’s

ability or alertness is so impaired by

fatigue, illness, or other causes, that

they might unnecessarily expose the

employee or others to injury.

8. Employees shall not enter manholes,

underground vaults, chambers, tanks,

silos, or other similar places that receive

little ventilation unless it has been

determined that it is safe to enter.

9. Employees shall be instructed to ensure that

all guards and other protective devices are in

proper places and adjusted, and shall report

deficiencies promptly to the supervisor or

superintendent.

10. Crowding or pushing when boarding or

leaving any vehicle or other conveyance

shall be prohibited.

11. Workers shall not handle or tamper with

any electrical equipment, machinery, or

air or water lines in a manner not within

the scope of their duties, unless theyhave received instructions from their

superintendent.

12. All injuries shall be reported promptly to the





supervisor or superintendent so that

arrangements can be made for medical or first

aid treatment.

13. When lifting heavy objects, the large muscles

of the leg, instead of the smaller muscles of

the back, shall be used.

14. Materials, tools, or other objects, shall not be

thrown from buildings or structures until

proper precautions are taken to protect others

from the falling objects.

15. Inappropriate footwear or shoes with thin or

badly worn soles must not be worn.

16. Hand protection, such as gloves, shall be worn

when there is excessive exposure to cuts,

burns, or other materials that could cause

injury (except where there is danger of the

hand protection becoming entangled in

moving machinery).

17. Hard hats shall be worn whenever overheadhazards exist and in all areas designated for

hard hat use.

18. Safety glasses, goggles, or other suitable eye

protection shall be worn when there is a

hazard to unprotected eyes (e.g., when using

a grinding wheel, etc.).

19. Employees shall cleanse themselves

thoroughly after handling hazardous

substances and follow special instructions

from authorized sources.

20. Carriers should avoid the use of extension





ladders when carrying loads. Such ladders

may provide adequate strength, but the rung

position and rope arrangement make such

climbing difficult and hazardous for this trade.

21. Work shall be so arranged that employees are

able to face a ladder and use both hands while

climbing.

22. Gasoline shall not be used for cleaning

purposes.

23. No burning, welding, or other source of

ignition shall be applied to any enclosed tank

or vessel, even if there are openings, until it

has first been determined that no possibility of

explosion exists and authority for the work is

obtained from the supervisor or

superintendent.

24. Any damage to scaffolds, false work, or other

supporting structures shall be immediately

reported to the supervisor and repaired before

use.

25. Personal fall arrest systems or restraints shall

be worn when working over 7 1/2 feet above

ground or surface which does not provide

protected sides, edges or openings (e.g., no

guardrails, etc.).

USE OF TOOLS AND EQUIPMENT

26. All tools and equipment shall be

maintained in good condition.





27. Damaged tools or equipment shall be

removed from service and tagged

“DEFECTIVE.”

28. Pipe or Stillson wrenches shall not be used

as a substitute for other wrenches.

29. Only appropriate tools shall be used for a

specific job.

30. Wrenches shall not be altered by the

addition of handle-extensions or

“cheaters”.

31. Files shall be equipped with handles and

not used to punch or pry.

32. A screwdriver shall not be used as a

chisel.

33. Wheelbarrows shall not be pushed with

handles in an upright position.

34. Portable electric tools shall not be lifted orlowered by means of the power cord.

Ropes shall be used.

35. Electric cords shall not be exposed to

damage from vehicles.

36. In locations where the use of a portable

power tool is difficult, the tool shall be

supported by means of a rope or similarsupport of adequate strength.





MACHINERY AND VEHICLES

37. Only authorized persons shall operate

machinery or equipment.

38. Loose or frayed clothing, long hair,

dangling ties, finger rings, etc., shall not

be worn around moving machinery or

other areas where they may become

entangled.

39. Machinery shall not be serviced, repaired

or adjusted while in operation, nor shall

oiling of moving parts be attempted,except on equipment that is designed or

fitted with safeguards to protect the

person performing the work.

40. Where appropriate, lock-out procedures

shall be used.

41. Employees shall not work under vehicles

supported by jacks or chain hoists withoutprotective blocking that will prevent injury

if jacks or hoists should fail.

42. Air hoses shall not be disconnected at

compressors until the hose line has been

bled.

43. All excavations shall be visually inspected

before backfilling to ensure that it is safeto backfill.





44. Excavating equipment shall not be

operated near tops of cuts, banks, or cliffs,

if employees are working below.

45. Tractors, bulldozers, scrapers and

carryalls shall not operate where there is a

possibility of overturning in dangerous

areas like edges of deep fills, cut banks,

and steep slopes.

46. When loading where there is a probability

of dangerous slides or movement of

material, the wheels or treads of loading

equipment, other than that riding on rails,

should be turned in the direction which

will facilitate escape in case of danger,

except in a situation where this position of

the wheels or treads would cause a

greater operational hazard.

ROOFING OPERATIONS

47. Knotted hand lines should not be used.

48. Roofers tending kettles, or carrying

buckets of hot tar, shall wear gloves

that fit snugly at the wrists, and long-

sleeved shirts fastened at the wrists.

49. At no time should a roofer, while

handling or exposed to injury from hot

tar, work without a shirt or appropriate

footwear.

50. Appropriate portable fire extinguishers

shall be kept at or near the kettle,





attached, if practicable, to the tongue

of the kettle, away from the danger

zone.

51. Kettle covers should be equipped with

a handle that projects at least fourteen

inches (14") away from the surface of

the cover or lid.

52. Kettle covers shall be closed and

latched when in transit and the kettle

should be slop-proof when cover is

closed.

53. When parked, means shall be provided

to prevent inadvertent movement of

the kettle.

54. Ladders should be used with great

caution, and roof gutters should not be

depended upon for support.

55. Workers handling buckets of hot tarshould not carry anything that will

interfere with the safety of this

operation.

56. The gallows frame shall be securely

anchored before hoisting materials.

57. Only muscular power shall be used to

hoist materials by means of a gallowsframe. A winch or power hoist shall

not be used.





BLASTING OPERATIONS

58. Cases that have contained explosives

shall be destroyed by burning out-of-

doors. Do not burn in a stove or

furnace.

59. Shoes with nails or metal plates shall not

be worn in magazines or near explosives.

60. Blasting caps shall only be carried in

approved containers.

61. The least amount of proper strength

explosive that will do the job

effectively shall be used.

62. Detonators and primers shall be

separated from the explosives until it

is necessary to bring together in

preparing for the blast.

63. Holes loaded during a shift should be fired

during that shift.

64. The operations of loading and firing should

be carried out with as few workers as

possible.

65. Drill holes shall be blown out and

made ready before explosives are

brought to the site.

66. In tamping explosives, steady, even

pressure should be used.

67. For electric blasting, the following shall





apply:

(a) Tight electrical connections.

(b) No short circuits or breaks in the

wires.

(c) Enough current to fire all shots.

(d) A strong, properly-applied force

when using a blasting machine

operated by physical effort.

(e) Care not to damage the insulation

of wires when tamping charges.

68. If misfires occur, the licensed blaster shall

be contacted.





Appendix G

Employee

Acknowledgement

Form





EmployeeAcknowledgement Form

I hereby acknowledge that I have had the opportunity to read,

review and ask questions on the contents of the company’s

Injury and Illness Prevention Program. I also acknowledge

that the provisions of this program and company safety and

health policies are part of the terms and conditions of my

employment and agree to abide by them.

Furthermore, I understand that failure to comply with any part

or parts of this program and any company safety and health

policies may be grounds for termination of my employment.

Additionally, I understand that failure to comply with the

company’s Drug-Free Workplace Policy shall also be grounds

for termination of my employment.

Employee - Print Your NameSocial Security Number

Signature of EmployeeDate

As an employee representative of the company, I hereby

attest that the employee named here was given the

opportunity to read, review and ask questions about the

company’s Injury and Illness Prevention Program and





company safety and health policies.

Witness – Print Your Name

Duty Title of Witness

Signature of WitnessDate





Safety Office Depot Disclaimer Notice

While we have made every attempt toensure that the information contained in thisdocument is reliable, Safety Office Depot isnot responsible for any errors or omissions,or for the results obtained from the use ornon-use of this information. All informationin this document is provided "as is", with no

guarantee of completeness, accuracy,timeliness or of the results obtained from theuse or non-use of this information, andwithout warranty of any kind, express orimplied, including, but not limited towarranties of performance, merchantabilityand fitness for a particular purpose.

In no event will Americana Safety Associates,Safety Office Depot, or the partners, agentsor employees thereof be liable to you oranyone else for any decision made or actiontaken in reliance on the information in this

document or for any consequential, specialor similar damages, even if advised of thepossibility of such damages.

Given the changing nature of laws, rules andregulations, there may be omissions or

IIP Program for High-Hazard Industry Employers

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