Hawaii Written Safety and Health Program

2013 Americana Safety. All rights reserved.
Written Safety and Health Program

For

XYZ Company

Required for all Hawaii Businesses with 25 or More Employees
Incorporates Provisions of Hawaii Administrative Rules
Title 12, Subtitle 8, Part 2, Chapter 60

Hawaii - Written Safety and Health Program
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Table of Contents
Section Description Page
1 Management Commitment 3
2 Assignment of Responsibilities 4
3 Employee Participation 10
4 Hazard Recognition 13
5 Hazard Prevention and Control 23
6 Emergency Planning 33
7 Safety and Health Training 42
8 Company Required Safety Programs 46
9 Company Required Safety Training Courses 47
10 Company Required Safety Forms & Checklists 49

Appendices
Appendix A List of Training Subjects 51
Appendix B Hazard Assessment Checklist (Alpha sorted) 53
Appendix C Hazard Assessment and Correction Record 54
Appendix D Accident/Exposure Investigation Report 56
Appendix E Employee Training and Instruction Record 58
Appendix F Employee Acknowledgement Form 60

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Section 1
Management Commitment

Program Policy Statement
XYZ Company shall comply with all occupational safety and health laws of the State of Hawaii.
To accomplish this, we must constantly be aware of unsafe acts and conditions in all work areas
that can produce injuries. No employee is required to work at a job they know is not safe or
healthful.
As employees of XYZ Company, 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 written program is required for all businesses with 25 or more employees within the State
of Hawaii.
This program incorporates and complies with Hawaii Administrative Rules Title 12, Subtitle 8,
Part 2, Chapter 60
Proper use of this program requires the Program Administrator to carefully review the
requirements for each of the program sections, appendices and to modify, where necessary, to
accurately reflect specific company requirements as it relates to its operation and workforce.
This program must be maintained by the employer in order to be effective.

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Section 2
Assignment of Responsibilities

1. Program Administrator
Written Safety and Health Program administrator, Program Administrator has the authority and
responsibility for implementing the provisions of this program.
DECISION POINT Enter a name or position title (recommended)
The Program Administrator for XYZ Company is _______________________________________.
2. Company Responsibilities
XYZ Company responsibilities shall including the following:
a. Provide support from the top level down to first line supervisors in terms of time, effort,
and money.
b. Resolve scheduling and personnel conflicts.
c. Provide realistic dates for correcting safety and health concerns.
d. Support training for safety committee members.
e. Provide leadership and direction.
f. Participate in safety committee meetings.
g. "Talk up" the positive effects of safety committee activities, on a one-on-one basis or in-
group meetings.
h. Respond to recommendations in a timely manner.
i. Ensure lines of communication are open and non-threatening.
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j. Consider expanding the safety committee's responsibilities and authority to better serve
the company.
3. Management Responsibility
XYZ Company management is responsible for the following:
a. Establish rules and programs designed to promote safety and make known to all
employees the established rules and programs.
b. Provide all supervisors with copies of appropriate rules and regulations.
c. Make available training necessary for employees to perform their tasks safely.
d. Provide protective equipment for employees where required.
e. Impress upon all employees, subcontractors and suppliers, the responsibility and
accountability of each individual to maintain a safe workplace.
f. Record all instances of violations and investigate all accidents.
g. Discipline any employee disregarding safety and loss prevention policies.
h. Require all subcontractors as a matter of contract and all material suppliers through
purchase order terms, to follow established safety rules.
i. Require all subcontractors to submit for review their safety programs and encourage
them to work safely.
j. Conduct safety inspections, maintain records and continually monitor the program for
effectiveness.
4. Safety Representative Responsibility
XYZ Company Safety Representative is responsible for the following:
a. Manage the program.
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b. Ensure the companys compliance with all applicable federal, state, and local safety and
health requirements.
c. Ensure that each employee is provided with adequate and appropriate occupational
safety and health training and personal protective equipment.
d. Inspect all workplaces, projects, and/or facilities periodically, but not less than once per
quarter.
e. Ensure that the safety and health policies are comprehensive and effective.
f. Review each accident and conduct any investigation wherein an accident has resulted in
serious occupational injury, illness or property damage.
g. Promote safety and health and serve as a resource to all staff.
h. Review the program on an annual basis.
5. Joint Safety & Health Committee Responsibility
XYZ Company Joint Safety and Health Committee are responsible for the following:
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 company Safety Representative.
e. Identify potential hazards.
f. Evaluate these potential hazards
g. Recommend corrective action
h. Follow up implemented recommendations.
i. Hold quarterly meetings as a minimum.
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j. The committee chairperson shall ensure membership includes:
1) Employees from different shifts
2) Employees from different locations, buildings, or areas
3) Employees from different job classifications and ranks
4) Union and non-union members
5) Maintenance employees
6) Management and Administrative representatives
7) Clerical staff
DECISION POINT If the employees at EXZ Company are represented by a labor organization,
the representatives of employees must be selected by the employees and not appointed by the
employer.
6. Employee Responsibilities
XYZ Company employees are responsible for the following:
a. Help identify safety and health hazards.
b. Listen to safety committee members. It is important!
c. Report all unsafe conditions and practices.
d. Contribute to or make suggestions for improving workplace safety and health.
e. Participate in committee activities when requested - be positive.
f. Keep an open mind and a positive attitude.
g. Follow procedures and practices adopted by the safety committee.
h. Cooperate with the safety committee members in the performance of their duties.
i. Consider being a member in support of the committee and to promote a safer working
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environment.
7. Employee Training Record Responsibilities
The XYZ Company employee responsible for training records shall ensure the following
documentation:
Employee Acknowledgement Form (See Appendix F)
Record of initial safety training will be recorded by having the new employee sign the
Employee Acknowledgement Form of the employee handbook. The Safety Representative
shall ensure these acknowledgement forms are filed and maintained in the employees
personnel file.
Employee Safety Training Record (See Appendix E)
Subsequent safety training will be documented by the employees printing and signing their
names as an addendum to the safety topic page(s) presented. The Safety Representative
will maintain copies of the safety training records in an employees personnel file and/or a
Safety Training folder.
Toolbox Safety Meeting (if applicable) Weekly Minutes Form (See Section 8)
Weekly safety training will be documented by the employees signing their names to the
weekly toolbox meeting form that states the safety topic presented. The Safety
Representative will maintain copies of the safety training records in an employees
personnel file and/or a Safety Training folder.
All Other Employee Safety Training Records and Documentation (See Section 8)
These other job task specific training records shall be kept with the employees personnel
file during the employees tenure with company.
DECISION POINT If applicable, otherwise delete.
State Workplace Safety Your Rights and Responsibilities
This pamphlet will be given to each new hire by the Safety Representative. Each new hire
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will read the pamphlet and complete any acknowledgement page. The acknowledgement
portion shall be retained in the employees personnel file.
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8. Subcontractor and Supplier Responsibilities
Subcontractors and suppliers doing business with XYZ Company shall:
a. Abide by safety rules and regulations as promulgated by Federal, State and local
authorities including those of XYZ Company and any General Contractor.
b. Notify all other contractors when their activities could affect the health or safety of
other employees in the workplace, project and/or facility.
c. Check in with XYZ Company site supervision when entering or leaving any job-site.
d. Inform XYZ Company site Safety Representative of all injuries to workers, immediately.
e. Report to XYZ Company site supervision or safety representatives any unsafe conditions.
f. Provide for review Safety and Hazard Communications Programs.
g. Provide a chemical inventory list and copies of Material Safety Data Sheets (MSDS) for
any hazardous materials - prior to bringing materials on-site.

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Section 3
Employee Participation

DECISION POINT - If one is not established, state reason and/or justification, then edit the
text in this section as appropriate to your business.
1. Occupational Safety and Health 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.
A. The committee shall:
1) Promote a safe and healthy work environment at all times.
2) Encourage communication between employees and management.
3) Serve as an oversight committee on all issues relative to safety and health.
4) Make recommendations to the Safety Representative.
B. Functions: The committee has four principal functions:
1) Identify potential hazards;
2) Evaluate these potential hazards;
3) Recommend corrective action; and
4) Follow up implemented recommendations.
To carry out its functions, the committee is required to hold meetings and carry out regular
inspections of the workplace.
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C. Membership
The make-up of our 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 that their 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.
D. Member Responsibilities
In addition to committee responsibilities explained above, member responsibilities
include:
1) Perform a monthly self-inspection of the area they represent;
2) Communicating with the employees they represent on safety issues; and
3) Encourage safe work practices among co-workers.
E. Employer Responsibilities:
1) Provide support from the top level down to first line supervisors in terms of time,
effort, and money.
2) Resolve scheduling and personnel conflicts.
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3) Provide realistic dates for correcting safety and health concerns.
4) Support training for safety committee members.
5) Provide leadership and direction.
6) 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.
F. Frequency of Meetings
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.)
DECISION POINT Indicate the type meeting(s) if required.
2. 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 kept and
kept on file for one year.
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Section 4
Hazard Recognition

1. Recordkeeping and Review
A. 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
Employees Injury/Illness Report Form to report more serious injuries.
B. Supervisors will: 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 Employees Report and Incident Investigation Report to the company
Safety Representative.
2. 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.
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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:
a. An initial danger identification survey;
b. A system for danger identification (such as inspections at regular intervals);
c. An effective system for employees to report conditions which may be dangerous (such
as a safety committee or a safety representative);
d. An equipment and maintenance program;
e. A system for review or investigation of workplace accidents, injuries and illnesses;
f. A system for initiating and tracking danger corrective actions; and
g. A system for periodically monitoring the place of employment.
3. Danger Identification Methods
DECISION POINT - If one has not been done, have it accomplished as soon as
possible. If one has been accomplished, so state, and where its maintained.
A. Initial Danger Survey
A knowledgeable safety and health person should conduct the initial safety and health
survey (audit) to identify existing or potential workplace dangers.
B. 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.
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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,
through experience or training, can identify actual and potential dangers and who
understands safe work procedures should do an inspection.
C. 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 a safety committee or a safety and health representative.
Prompt attention to identified dangers and positive feedback to employees will reaffirm
your personal commitment to workplace safety and health. That will encourage
employees to continue to report dangers promptly and assure them that their reporting
will not have negative consequences.
4. 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 maintenance
can prevent costly breakdowns.
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5. Accident Investigation and Reporting
A system must be established for investigating all workplace accidents, near misses,
injuries and illnesses. Someone who can identify the causes and recommend corrective
actions should complete the investigation system. It is important to keep records of
accident investigations. They can help to determine the types of accidents that occur,
where they happen, their causes and any accident trends. Such information is invaluable
in preventing future accidents and may also help reveal flaws in operating procedures.
A. Program Introduction
At XYZ Company accident investigation is an integral part of our total occupational
safety and health program. It is especially important as a means to determine root
causes, document facts, provide information on costs, and promote safety. All serious
occupational injuries and illnesses shall be thoroughly investigated by the company
Safety Representative with the underlying goal of preventing recurrence.
If an employee dies while working or is not expected to survive, or when three or more
employees are admitted to a hospital as a result of a work-related incident, or when
there is property damage exceeding $25,000, (Customize by adding the name or title of
person responsible for reporting to L&I) will contact HIOSH within 8 hours after
becoming aware of the incident.
On Oahu, the telephone number is 586-9102. Toll free numbers are available from the
neighbor islands (Kauai 274-3141, Maui 984-2400, Hawaii 974-4000, Molokai/Lanai
1-800-468-4644.) (Add the name or title of the responsible person) must talk with a
representative of the department. Fax and answering machine notifications are not
acceptable. (Add the name or title of the responsible person) must report: the
employer name, location and time of the incident, number of employees involved, the
extent of injuries or illness, a brief description of what happened and the name and
phone number of a contact person.
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B. 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 other persons 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 where the 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.
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C. 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.
D. 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 life threatening 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.
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6. 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:
A. The Safety Representative shall maintain for a period of 5 years:
1) Safety accident investigation reports for all lost workday occupational injuries,
illnesses or equipment damage;
2) Safety accident investigation reports for company property damage, as a result of
accidents;
3) Records of formal claims against the company for injury, illness, personal loss,
and/or damage to personal property; and
B. 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.
C. 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-301are
kept for five years.
D. 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.
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E. Accident Review: 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.
7. Corrective Actions
DECISION POINT - State your method of corrective action here.
A. Timely Correction of Dangers
Once remedial measures to control or eliminate dangers have been agreed upon, you
should make sure that they are implemented 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 who is responsible for correction, the correction
target date and when it was corrected. Such information will assist in developing safe
work practices and training programs.
B. Responsibility for Corrective Action
1) Actions necessary to correct or remedy accident causal factors shall rest with the
XYZ Company Safety Representative.
2) The XYZ Company Safety Representative shall have the broad authority to
recommend corrective actions to abate an identified hazard or deficiency to prevent
injury or illness to employees, and to prevent property damage or personal loss.
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DECISION POINT - State how frequently you will accomplish this.
C. Frequency of Monitoring the Place of Employment
You have the responsibility of monitoring the workplace regularly the work procedures,
equipment and machines to ensure that all dangers to workers are eliminated or
controlled or, alternatively, to ensure that the workers are protected from exposure to
the dangers.
8. 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 to employees. We will take prompt action to
eliminate any hazards we find. In addition to reviewing injury records and investigating
incidents for their causes, management and the safety committee will regularly check the
workplace for hazards as described below:
A. 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.
B. 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 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.
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C. 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.
D. 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 task our employees do. This analysis
will be done by the supervisor of that job task or a knowledgeable member of the safety
committee. We will change how the job is done as needed to eliminate or control any
hazards. We will also check to see if the employee needs to use personal protective
equipment (PPE) while doing the job. Employees will be trained in the revised operation
and to use any required PPE. The results will be reported to the safety committee. Each
job task will be analyzed at least once every two years, or whenever there is a change in
how the task is done or if there is a serious injury while doing the task.

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Section 5
Hazard Prevention and Control

1. 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.
2. Safety Rules and Work Procedures
A. 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:
1) Personal protective equipment requirements;
2) Clothing appropriate for the work;
3) Behavior expected of all employees;
4) How to leave the workplace safely, with particular reference to emergency
procedures; and
5) Danger areas that are: off-limits for employees.
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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.
B. 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.
1) Never do anything that is unsafe in order to get the job done. If a job is unsafe,
report it to your supervisor or safety committee representative. We will find a safer
way to do that job.
2) Do not remove or disable any safety device! Keep guards in place at all times on
operating machinery.
3) Never operate a piece of equipment unless you have been trained and are
authorized.
4) Use your personal protective equipment whenever it is required.
5) Obey all safety warning signs.
6) Working under the influence of alcohol or illegal drugs or using them at work is
prohibited.
7) Do not bring firearms or explosives onto company property.
8) Smoking is only permitted outside the building away from any entry or ventilation
intake.
9) Horseplay, running and fighting are prohibited
10) Clean up spills immediately. Replace all tools and supplies after use. Do not allow
scraps to accumulate where they will become a hazard. Good housekeeping helps
prevent injuries.
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C. 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 can be 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.
3. Company Specific Safety Programs
A. 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.
B. Housekeeping
XYZ Company will enforce housekeeping requirements daily. This will include:
1) Requiring subcontractors to keep their work areas orderly and clean up daily.
2) Keeping walkways and access areas clear.
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3) Run cords and hoses so as not to pose a trip hazard. Do not run cords or hoses
through doorways or other openings where they could be pinched and damaged.
4) Combustible materials and debris will be properly stored or disposed of daily. Trash
will not be permitted to accumulate and will be placed in covered containers or
furnished dumpsters.
5) Form and scrap lumber will be stored and cleared away from the work area daily. All
protruding nails will be hammered in, removed or bent over to prevent injury.
6) Spills involving combustible or flammable liquids, oils or grease will be cleaned up
immediately.
C. 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.
1) 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.
2) Types and Frequency of Safety Inspections and Surveys. Safety Inspections shall be
conducted at periodic intervals of all work locations.
3) When established, safety committee members are responsible for conducting self-
inspections of their areas and other areas, as assigned by the Safety Representative.
4) Supervisors are responsible for conducting self-inspections of their assigned work
area(s).
D. Governmental Inspections
In the event of a governmental inspection, the compliance officer will be directed to any
General Contractors office. If not the General Contractor, XYZ Company will follow the
prescribed General Contractor procedures.
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1) 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.
2) 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.
3) Supervisors shall also be notified and will be encouraged to accompany outside
agency inspections of their areas of responsibility.
E. 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.
F. 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.
G. 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.
1) 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.
2) Job Hazard Analysis shall be produced by the superintendent and appropriate crew
foremen and reviewed by XYZ Company Safety Representative.
29

3) A copy of each Job Hazard Analysis shal1 be maintained onsite and available for
review.
4) Who should participate in a hazard analysis?
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.
5) 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
H. 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 to equipment or property.
I. Requirements for "Reporting" Workplace Hazards
All workplace hazards, which cannot be immediately controlled (barricaded, placement
of warning/danger signs, etc.) or corrected on the spot, shall be immediately reported
30

to the supervisor in charge and the company Safety Representative.
31

J. 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.
4. 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 provided when needed. Incentive programs may be initiated and will be
used in conjunction with a good enforcement program.
A. 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.
1) 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.
2) 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.
3) 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.
32

B. Compliance
1) One point must be very clear: discipline has to be administered uniformly and
consistently.
2) 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.
3) Each supervisor or manager shall be responsible for administering this policy to
his/her subordinates.
4) All written reprimands and records of violations shall be held confidential and
maintained in the employees personnel files.
C. Accountability
Each supervisors efforts and performance will be evaluated relative to reaching XYZ
Company safety objectives and assigned responsibilities. This evaluation will be part of
the supervisors performance review and will be used in part to determine his or her job
assignments, merit increases or promotions.
5. Medical and First Aid
Medical treatment plans.
A. Key XYZ Company personnel should be trained in first aid and CPR. 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.
B. 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.
33

C. 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.
D. Vehicle size first aid kits shall be maintained in each XYZ Company construction/project-
use vehicle.
E. All first aid supplies shall be inspected at least monthly and replenished as required.
F. Accident / Injury reporting: All accidents, near miss incidents and injuries shall be
reported to XYZ Company Safety Representative. Following an injury:
1) The employees injury will be evaluated and first aid rendered.
2) If the injury requires medical attention the employee will be escorted to the onsite
clinic. Further evaluation and treatment will be rendered.
3) 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.
4) 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.
5) A supervisor's report or Statement of Injury will be completed by the employees'
supervisor.
6) An investigation into the incident will be completed by XYZ Company Safety
Representative, even if no serious injury occurred.
7) A copy of any applicable State document on Employer's Initial Report of Industrial
Injury, Accident and Property Damage form, Supervisor's report or Statement of
34

Injury will be submitted to the XYZ Company Safety Representative for the employer
provided workers' compensation coverage.
8) All first aid cases may be recorded on a First Aid Log maintained by XYZ Company
Safety Representative.
6. Disciplinary Policy
XYZ Company employees 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 the same rule or the same unacceptable behavior:
First Instance -- verbal warning, notation in employee file, and instruction on proper actions
Second Instance -- 1 day suspension, written reprimand, and instruction on proper actions
Third Instance -- 1 week suspension, written reprimand, and instruction on proper actions
Fourth Instance -- Termination of employment.
An employee may be subject to immediate termination when a safety violation places the
employee or co-workers at risk of permanent disability or death.

35

Section 6
Emergency Planning

DECISION POINT
1. Emergency Planning and Procedures
An evacuation map for the building is posted (Customize by adding location, if this applies
to your company). It shows the location of exits, fire extinguishers, first aid kits, and where
to assemble outside (Customize by adding meeting location for your location). A copy of
the map is attached to this program.
All XYZ Company employees will receive training on how to use a portable fire extinguisher
as part of their initial orientation. Buildings will display a map that shows the location of
exits, fire extinguishers, first aid kits, and where to assemble outside.
At XYZ Company, advance planning and preparation for emergencies is good insurance.
Some emergency planning is mandated by regulations, such as for first aid and fire
evacuation and for certain situations in specific industries or operations.
A list of possible emergencies shall be prepared and procedures established to respond to
those emergency situations.
Emergency plans shall be reviewed with individuals such as doctors, fire and explosives
experts or special consultants where possible, and on an as needed basis.
Emergency procedures shall be updated whenever changes are made in materials,
equipment or building structures.
36

2. Emergency Planning
No Industrial, Commercial or Mercantile organization is immune to disaster. Emergencies
can arise at any time and from many causes, but the potential loss is the same - people and
property. Advance planning for emergencies is the only way to minimize this potential loss.
A. Planning is necessary - it is not a luxury, rather it is good insurance. Even though
professionally trained emergency help and assistance may be available, the need for in-
house emergency planning is still your first line of defense. A comprehensive
management plan is intended to take care of all expected emergencies. This includes
both the natural disasters and the common accident situation. Quite often emergency
planning is assigned solely to the safety and health professional. This is fine, but there is
a real need for the corporate management to be fully involved in the many decisions
that must be made.
B. The safety of our employees, visitors, and customers must be the first concern in
planning for an emergency. Care for the injured must be available immediately. In
some situations, evacuation may be necessary.
C. Careful consideration shall be given to protecting the property and the operation. In a
new facility, consideration shall be given to arranging and locating certain facilities and
operations to provide greater inherent safety to the entire operation. In general, all
emergency plans will include cleanup details necessary for the situation.
D. Finally, planning may be concerned with restoring business to normal. In emergencies
likely to damage or close a facility or job site, the question of resuming operations under
conditions of temporary wiring, lack of heating, or repair and construction work shall
always be considered.
E. Regardless of the size of the XYZ Company project workforce, management will be
responsible for developing and operating a program, which is designed to meet these
eventualities.
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An effective plan requires the same good organization and administration as any
business undertaking. There is no one emergency plan that will do all things for all
organizations. Therefore, a plan that fits the needs of the workplace, project and/or
facility will be developed.
F. Emergency plans involve organizing and training of small groups of people to perform
specialized services, such as fire fighting or first aid. Small, well-trained groups can
serve as a nucleus to be expanded to any size needed to meet any kind of emergency.
Even with outside help available, a self-help plan is the best assurance that losses will be
kept to a minimum.
G. An organization will need to develop several plans to control different types of
emergencies. Although certain basic elements would be common to all plans, the same
complete plan could not, for example, be used for a natural disaster, an in-house fire, or
the common accident situation.
H. Before an organization initiates an emergency plan, it is necessary to evaluate the types
of emergencies, potential disasters or accidents that could occur, and the potential
harm to people and property.
I. DECISION POINT The basic emergency preparedness plan for XYZ Company will
include:
1) A chain of command;
2) An alarm and/or communication system;
3) Medical treatment plans;
4) Shutdown procedures; and
5) Evacuation procedures.
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3. Types of Emergencies
A. Work Accidents. The "chain reaction" from a so-called "routine" work accident can
result in an emergency. For example, a break in a chemical line or toxic vapors from
outside the facility entering the ventilation system may create an emergency. Panic
caused by a rumor or lack of knowledge can also creates an emergency. Plans for such
situations should include establishment of auxiliary areas in the building to be used for
medical treatment, a method of notifying employees of the actual situation, a method
of quickly taking a head count from shift leaders, and sources of oxygen supplies
available on short notice.
B. Fire and explosion. Except where fires result from large-scale explosions, the fire
emergency usually allows a short time for marshalling of firefighters and organizing an
evacuation if necessary. Many conflagrations originate as small fires, that is, fires that
could positively be controlled by in-house personnel. Therefore, prompt action by a
small, trained group can usually handle the situation. However, plans should include the
marshalling of extensive fire fighting forces upon first indication of any fire growing
beyond the "small fire" stage.
1) The main point is this; small fires should be checked as soon as they start. The first
five minutes are considered the most important. Good housekeeping, prompt action
by trained people, proper equipment, and common-sense precautions will prevent a
small fire from becoming a disaster.
2) Fire protection equipment, especially sprinkler heads and kitchen overhead grease
traps and fans, need to be periodically checked to ensure they are not blocked and
in working order
3) Obstructions, such as storage boxes, must remain at least 18 in. from sprinkler
heads in order for them to work as designed. Kitchens are the most likely source for
fires to originate. Overhead grease traps must be cleaned at least once daily, or
more often in heavy use areas.
39

4) Non-sparking system cooling fans, used to control the heated trapped grease
particles, must also be checked for operability on a regular basis.
C. Shutdowns. Although a shutdown is not an emergency per se, it can result from an
unscheduled action, such as a disaster or strike; hence a fast shutdown procedure
should be covered under an emergency plan. This plan should be based on a priority
checklist. That is, all of the tasks to be assigned and functions to be performed should be
arranged in order of importance so that if time is short, at least the most vital
precautions are completed. This "crash" procedure is usually an adaptation of the
routine procedure used for scheduled shutdowns, such as for preventive maintenance
inspections.
1) During the shutdown, continuous inspection of any maintenance or special
operations, such as remodelling, must be maintained. Gas cutting and welding
should be carefully supervised. Employees, who remain on duty in the area and
construction workers involved in any remodelling, should be briefed in effective
countermeasures in case a fire breaks out.
2) If there has not been sufficient notice to affect a normal shutdown, it may be
necessary to allow personnel into the area to perform necessary functions.
D. Hazardous Materials. Because there are many chemical substances being used today,
there must be concern with potential usage and handling problems. There are many
rules and procedures to be observed, but again one must ask the question, what if a
safeguard fails? What if the container cracks and substances leak out? In addition to
normal hazards, area there potential chemical reactions with other substances that
cause still further dangers to people and property? Any effective emergency plan must
also include recognition of the potential for a hazardous chemical spill and its
containment.
40

4. Plan-of-Action Considerations
Following the assessment of potential emergencies, the next step is to translate these needs
into a plan of action.
A. XYZ Company management will be in charge of drafting a policy and getting the plan
underway. It will usually be necessary that union leaders (if any) be involved in the
planning process. The Safety Representative or another member of the safety
committee will be appointed emergency planning coordinator.
B. Health and safety, medical, fire, and security personnel will be involved.
C. Production and maintenance supervision will be consulted.
D. Contacts with local law enforcement and fire departments are necessary.
E. The cost and effort involved in giving immediate attention to emergency planning can
be justified by weighing the cost of preparedness against the possibility of yearly losses
from accidents, fires and other unplanned events.
F. Program considerations. The preliminary aspects of emergency planning - the need for
advance planning and an evaluation of the type of emergencies and their potential harm
to people and property have already been discussed. The next logical step is to
translate this need into a working plan within the organizational structure. In some
cases, this will require working with other agencies to most fully protect the company's
operation.
1) Advance planning is the key. It is necessary to develop a written set of plans for
action. The plans should be developed locally within the company (and corporate
structure) and be in cooperation with other neighboring or similar organizations and
with government agencies. It may not always be possible for them to fully
cooperate or participate, but through planned action each organization should be
aware of certain available assistance. The company may need to plan to be largely
dependent upon its own resources to provide the internal safety.
41

2) A description of the expected disasters with a risk statement.
3) A map of the plant or facility showing equipment, medical and first aid, fire control
apparatus, shelters, command center, and evacuation routes.
4) A list (which may also be posted) of cooperating agencies and how to reach them. ---
A plant or facility warning system.
5) A central communication center, including home contacts of employees.
6) A shutdown procedure, including internal security procedures.
5. Chain of Command
A XYZ Company disaster plan coordinator should be appointed and an advisory committee,
representing various departments, established.
A. The disaster plan coordinator should be a member of top management, because he/she
will have to be able to delegate authority and speak for the company. The coordinator's
regular duties should be such that the greater part of their time will normally be spent
at the workplace he/she is responsible for.
B. An alternate disaster plan coordinator will also be named in the plan. The alternate
should be a person who has authority and qualifications similar to the primary
coordinator and must be trained in their responsibilities.
C. Assigned personnel must be trained to carry out their duties in accordance with the
overall emergency disaster plan. The number of members on each of the teams
depends on the size and diversity of the employee work force and normal number of
visitors and customers within their area of the facility
D. Training. One of the most important functions of the disaster plan coordinator and
staff, on both the corporate and plant levels is training. Training for each type disaster is
essential in developing a disaster-control plan and keeping it functioning. Employees
must realize that an emergency plan is vital and real.
42

The plan cannot be usefully if it remains a remote idea. Training and rehearsals are time
consuming, but they keep the program in good working order. Training of key people
will be of little value unless it reaches all employees. The better informed and prepared
the work force is, the less panic and confusion during the emergency.
E. Practice alerts, even in a classroom environment, should be conducted to make sure
that the employees know where to report and what their duties are. Even the most
carefully developed and prepared plans can develop flaws when put into practice, and
only periodic rehearsals can reveal them. If this is not done, all the planning effort will
have been wasted.
F. Management should assure employees that the company is doing everything possible to
prevent injury to them, that every employee is an essential and necessary part of the
team, and that the disaster-control organization is ready for any emergency. Such
assurance will go a long way toward developing a state of mind that will not panic. Then
when disaster does strike, emergency forces snap into action, workers gather visitors
and customers and file quietly to their designated safe areas away from the facility.
Such planning is further evidence of management's concern for everyone's safety.
G. Command headquarters. A command headquarters should be planned for any
emergency, which may occur. Coordination of the disaster control organization should
come from a well-equipped and well-protected control room. The headquarters should
be equipped with telephones, sound-powered phones, public address system, maps of
the facility, emergency lighting and electric power, and two-way radios for
communication locally.
6. Communications System
Good communications are necessary for effective control and flexibility in a disaster
situation. Communications include the telephone, radio, messengers, and a facility alarm
system.
43

The emergency plan should provide for adequate telephones in an emergency headquarters
to handle both incoming and outgoing calls. Panic and disintegration of the organization will
develop quickly if these calls are not handled with dispatch.
The disaster plan must anticipate the possibility of losing normal telephone communications
and electric power.
7. Shutdown Procedures
Key department personnel should be knowledgeable of where emergency shutdown
switches and valves are located. Depending on the type of emergency, main electricity to
machines and natural gas may need to be shutdown to the effected area within the facility.
8. Evacuation Procedures
Safe evacuation routes should be conspicuously posted in internal work areas where direct
access to an exterior emergency exit may not be obvious. An emergency exit notice should
also be posted. Newly assigned employees must be briefed on the safest evacuation route
from his or her designated work area.
Detailed Emergency Procedures DECISION POINT
A. XYZ Company employees and subcontractors will abide by the project emergency
procedures prescribed by any General Contractor Safety Manager. All employees will
receive a review of emergency procedures during the project safety orientation.
B. Emergency telephone numbers for any General Contractor safety and security, as well
as local emergency services, shall be posted in the jobsite office or in conspicuously
designated areas.
C. In the event of an evacuation all XYZ Company employees will meet at a designated
location. Each foreman will be responsible to verify that his crew has safely evacuated.
No XYZ Company employee is to return to the jobsite until the project superintendent
gives an all clear.

44

Section 7
Safety and Health Training

Training at XYZ Company is an essential part of our plan to provide a safe work place.
Training Administrator
Written Safety and Health Program training administrator, Training Administrator has the
authority and responsibility for implementing the provisions of this program.
DECISION POINT Enter a name or position title (recommended)
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:
1. New-Hire Employee Orientation
A. 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:
1) XYZ Company Safety Philosophy and Policy
2) Disciplinary procedures for non-compliance
3) Employee Danger Reporting System
4) Accident Reporting System
5) Personal Protective Equipment (when applicable)
6) Fall Protection -100% tie-off (when applicable)
45

7) Fire Prevention
8) Hazardous Communication Standard, Material Safety Data Sheets, and
Environmental Safety
9) Bloodborne Pathogens Program (if applicable)
10) Workplace housekeeping rules
11) Safety Incentive Program (when established).
2. 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:
A. The need to establish and maintain safe and healthful working conditions;
B. The dangers associated with a job, the potential effect on employees, and the rules,
procedures and work practices for control of these dangers;
C. How to relate this information by example and instruction to employees, to ensure that
they understand and follow safe procedures; and
D. How to investigate accidents, and to take corrective and preventive action to prevent
recurrence.
3. 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:

46

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.
4. Required Occupational Safety and Health Programs
Hazard Communication Program
A. 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:
1) A review of the requirements of the HazCom Standard.
2) Chemicals or hazardous materials likely to be found in their workplace; their health
effects and means of exposure or routes of entry.
3) How to lessen or prevent exposure to hazardous chemicals or materials through the
use of control/work practices and Personal Protective Equipment.
4) Emergency procedures to follow in the event of an accident or exposure involving
hazardous chemicals/materials.
B. Continuous HazCom training will be conducted via weekly toolbox safety meetings when
applicable.
C. 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.
47

5. Other Company Required Safety Programs (See Section 8)
6. Company Required Safety Training Courses (See Section 9)
7. Company Required Safety Program Forms (See Section 10)
48

Section 8
Company Required Safety Programs

Due to the nature of work and operations performed by XYZ Company, it is necessary that the
following regulatory programs are included in our Injury and Illness Prevention Program:

For convenience, programs listed in the table below are alpha sorted.
DECISION POINT Review and select those programs that apply or included others not listed

Company Required Safety and Health Plans & Programs
Accident Prevention Program Forklift Safety Program
Asbestos Management Plan Hazard Communication Program
Bloodborne Pathogens Program Hearing Conservation Program
Chemical Hygiene Plan Hot Work Permit Program
Confined Space Entry Program Ladders and Stairways Work Plan
Control of Hazardous Energy Program Laser Safety Program
Cranes and Derricks Safety Program Lead Safety Program
Electrical Safety Program Personal Protective Equipment Plan
Emergency Action Plan Powered Industrial Truck Program
Excavation and Trenching Program Radiation Protection Program
Fall Protection Program Respiratory Protection Program
Fire Prevention Work Plan Scaffolding Safety Program
Flammable Storage / Compressed Gas Welding Safety Program

Table 1

All Safety Plans & Programs are available through Americana Safety
Supply www.SafetyOfficeDepot.com

49

Section 9
Company Required
Safety Training Courses

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.
DECISION POINT Review and select those courses that apply or included others not listed

Company Required Safety Training Courses Sorted A-E
Accident Investigation Construction Safety Management
Accident Prevention Signs & Tags Crane Safety Refresher
Asbestos Safety Cranes & Derricks in Construction
Bloodborne Pathogens Initial/Refresher Electrical Safety
Bloodborne Pathogens Train-the-Trainer Emergency Exit Routes
Chemical Spills Emergency Response Team
Competent Persons Ergonomics Basic Human Factors
Compressed Gas Cylinder Ergonomics Advanced Human Factors
Concrete & Masonry Excavation Safety
Confined Space Entry Eye & Face Protection

Table 2

All Safety Training Courses are available through Americana Safety

50

Company Required Safety Training Courses Sorted F-L
Fall Protection Hexavalent Chromium
Portable Fire Extinguisher Hot Work Permit Safety
Flammable & Combustible Liquids Indoor Air Quality
Forklift Safety Classroom (English) Introduction to OSHA
Forklift Safety Classroom (Spanish) Job Hazard Analysis
Hand & Power Tools Laser Safety
Hazard Communication Lead Exposure
Hazard Vulnerability Liquid Nitrogen
Hazardous Materials Management Lockout-Tagout
Hearing Protection

Table 3

Company Required Safety Training Courses Sorted M-W
Machine Guarding Safety Representative Training
Material Handling Safety Supervisor Training
Office Safety Awareness Scaffolding
Pandemic Preparedness Slip, Trip & Fall Prevention
Personal Protective Equipment Stairway & Ladder Safety
Powered Industrial Truck TB Respiratory Protection
Radiation Safety Walking & Working Surfaces
Respirator Protection Warehouse Safety
Safe Lifting Awareness Back Safety Workplace Violence Prevention - Healthcare
Safety Audit Training Workplace Violence Prevention - Retail

Table 4
51

Section 10
Company Required
Safety Forms & Checklists

following safety forms and checklists are included in our Injury and Illness Prevention Program:

For convenience, forms listed below are subject sorted.
DECISION POINT Review and select those forms that apply or included others not listed

CONFINED SPACE
Confined Space Entry Permit
Confined Space Class A & B Permit
Confined Space Class C Permit
List of Authorized Entrants
Permit Required Confined Space Inventory Log
CONSTRUCTION INDUSTRY - SAFETY MANAGEMENT
Construction Industry Inspection Checklist
Job Start-Up Checklist
Contractors Job Site Checklist
Contractor Safety Performance Report
Construction Equipment Checklist
Forklift Service Checklist
Operator Performance Evaluation Checklist
Safety Nets Inspection Checklist
Body Harness & Lanyard Inspection Report
Competent Person Evaluation Fall Protection
CRANE OPERATIONS
Cranes, Derricks or Material Handling Devices Worksheet
Crane Inspection Checklist
Crane Pre-Lift Checklist
Sling (Chain) Inspection Report
Monthly Hoist Rope Inspection Report
Monthly Hoist Hook Inspection Report
EMERGENCY ACTION AND RESPONSE
Crisis Management Response Team - Contact Log
Safety Representatives - Contact Log
External Resources Contact Log
Vulnerability Analysis Chart
Bomb Threat Checklist
Employee Evacuation - Accounting Log
Physically Challenged Employee List
Command Post Equipment Inventory Log
Press Information Log
Post Exercise Evaluation Report
52

EMPLOYEE SAFETY RECORDS
Employee Acknowledgement Form
Employee Orientation Checklist Construction
Employee PPE Assessment Form
Employee PPE Issue Form
Employee Safety Training Record
Ergonomic Workstation Analysis Form
Employee Ergonomic Workstation Questionnaire
Employee Safety Suggestion Form

EXCAVATION OPERATIONS
Pre-Excavation Checklist
Trenching Design Checklist
Trench Safety Daily Field Report
Competent Person Evaluation Excavation
FIRE PREVENTION
Hot Work Permit
Fire Safety Inspection Checklist
Fire Drill Post Response Report
Emergency HAZMAT Inventory Log
Hazardous Waste Disposal Request Form
GENERAL INDUSTRY SAFETY MANAGEMENT
General Industry Safety Inspection Checklist
Office Safety Inspection Checklist
Job Safety Analysis Worksheet & Instructions
Accident Prevention Program Analysis
Forklift Service Checklist
Hearing Conservation Program Log
Scaffolding Safety Checklist
Site Safety Meeting Record
Supervisors Monthly Meeting Record
Report of Safety Hazard Form
Property Security Survey
INCIDENT REPORTING FORMS
OSHA 300 Log
Employee Injury & Illness Report
Employee Injury Cost Accounting Matrix
Vehicle Accident & Property Damage Report
Compiling Direct and Indirect Costs

OCCUPATIONAL HEALTH FORMS
Medical Evaluation Questionnaire Respirator Use
Respirator Fit Testing Record
Hepatitis B Vaccine - Accept/Decline Form
Bloodborne Pathogens Risk Classification Flowchart
BBP Employee Annual Training Record
BBP Source Patient Consent Form

RADIATION PROGRAM FORMS
Radioactive Material Use Log
Pregnancy Declaration Form
Laboratory Contamination Survey Record
Radiation Producing Device - Authorization Form
Training Guide for Radiation Workers
Training Guide for Ancillary Radiation Works

TRAINING RECOGNITION CERTIFICATE
Certificate of Completion
All Subject Form Groups are available through Americana Safety

53

Appendix A
List of Training Subjects

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.
54

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, including condors 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 ___________________________________________
55

Appendix B
Hazard Assessment Checklist

DECISION POINT Determine which checklists apply to your operation and delete all others
XYZ Company has determined the following hazard assessment checklists apply to its operations

1. Abrasive Wheel Equipment Grinders
2. Compressed Air Receivers
3. Compressed Gas & Cylinders
4. 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 Materials
17. 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 & Clothing
36. 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
56

Appendix C
Hazard Assessment and Correction Record

57

Hazard Assessment and Correction Record

Date of Inspection: ________________________________________
Person Conducting Inspection: _______________________________
Unsafe Condition or Work Practice:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Corrective Action Taken:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

58

Appendix D
Accident/Exposure Investigation Report

59

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: _____________________________

60

Appendix E
Employee Training and Instruction Record

61

Employee Training and Instruction Record

Employee Receiving Training:

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

(Safety Training Topic)

Select one:

Initial Periodic Annual/Refresher Special

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

Person conducting the training:

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

Trainers Signature Date

Qualification or Job Title of Trainer

Trainees Signature Date
62

Appendix F
63


I hereby acknowledge that I have had the opportunity to read, review and ask questions on the
contents of the companys 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 companys Drug-Free Workplace Policy
shall also be grounds for termination of my employment.

Employee - Print Your Name Social Security Number

Signature of Employee Date

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 companys Injury and
Illness Prevention Program and company safety and health policies.

Witness Print Your Name

Duty Title of Witness

Signature of Witness Date

64

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In no event will Americana Safety, or the partners, agents or employees thereof be liable to you
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Given the changing nature of laws, rules and regulations, there may be omissions or inaccuracies
in information contained in this document. Accordingly, the information in this document is
provided with the understanding that the authors and publishers are proving guidance with
respect to the information contained herein and that the performance or non-performance of
this guidance shall be the responsibility of the user of this information.

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