Professional Documents
Culture Documents
This section includes forms and checklists that you can use to develop, implement,
and maintain your health and safety program.
Sample health and safety program for wineries ...................................................39
Annual review of health and safety program .......................................................41
Sample worker orientation checklist ....................................................................43
Sample inspection checklist .................................................................................45
Sample inspection report ......................................................................................48
Form 52E40 Incident investigation report ......................................................49
Sample monthly health and safety meeting record ..............................................53
Level 1 frst aid kit ...............................................................................................54
Level 3 frst aid kit ...............................................................................................55
Sample frst aid record .........................................................................................56
Forms and checklists
Topic Initials
(trainer)
Initials
(worker)
Comments
6. Procedures for working alone or in isolation
7. Measures to reduce the risk of violence in the workplace
and procedures for dealing with violent situations
8. Personal protective equipment (PPE) what to use, when
to use it, and where to find it
a) __________________________________________
b) __________________________________________
c) __________________________________________
d) __________________________________________
9. First aid
a) First aid attendant name and contact information
b) Locations of first aid kits and eye wash facilities
c) How to report an illness, injury, or other accident
(including near misses)
10. Emergency procedures
a) Locations of emergency exits and meeting points
b) Locations of fire extinguishers and fire alarms
c) How to use fire extinguishers
d) What to do in an emergency situation
11. Where applicable, basic contents of the occupational
health and safety program
12. Hazardous materials and WHMIS
a) What hazardous materials are in the workplace
b) Purpose and significance of hazard information on
product labels
c) Location, purpose and significance of material safety
data sheets (MSDSs)
d) How to handle, use, store, and dispose of hazardous
materials safely
e) Procedures for an emergency involving hazardous
materials, including clean-up of spills
13. Where applicable, contact information for the occupational
health and safety committee or the worker health and
safety representative
Date
remedied
Use this sample to develop a report for recording the results of your regular workplace inspections.
Company name:
Date:
Inspectors names:
Type of hazard
(critical, urgent,
or important)
Describe hazard and
precise location
Recommended
corrective action
Person responsible
for remedial action
Sample Inspection Report
6240 (P01J07) 4 ol 4
what hazard(s) wasJwere the worker(s) exposed to?
what hazards may have contr|buted to the |nc|dent occurr|ng?
what hazards d|d the worker(s) encounter?
what persona| lactors may have contr|buted to the |nc|dent occurr|ng?
Other /nformat/on.
Other observat|ons
Other re|ated |nlormat|on
WH |rom the answers to "what, |dent|ly any unsale cond|t|ons, acts, or procedures that |n any manner
contr|buted to the |nc|dent. why d|d the unsale cond|t|ons, acts, or procedures occur? why were the
persona| lactors not |dent|l|ed andJor addressed belore the |nc|dent occurred?
HOW An |nvest|gat|on report shou|d recommend correct|ve act|ons to prevent s|m||ar |nc|dents lrom
occurr|ng. Once |t |s known why an |nc|dent occurred, determ|ne how to prevent recurrence.
|or examp|e:
|mprove workp|ace |nspect|on and ma|ntenance programs
Pepa|r or rep|ace equ|pmentJbu||d|ng
|nsta|| saleguards
Lstab||sh or rev|se sale work procedures
1ra|nJretra|n person(s)
|mprove superv|s|on
Additional information for determining why an incident happened
1o determ|ne the most probab|e cause(s) ol an |nc|dent, cons|der a|| deta||s ol the |nvest|gat|on, |nc|ud|ng w|tness
statements and, where poss|b|e, the |njured worker's statement.
Ueterm|ne |l the |nc|dent was due to an unsale act, an unsale cond|t|on, unsale or |nadequate procedures, or a
comb|nat|on ol these. Oons|der whether the acceptedJcurrent procedures adequate|y address salety concerns
assoc|ated w|th the act|v|ty that was tak|ng p|ace when the |nc|dent happened. Oons|der tra|n|ng, superv|s|on,
equ|pment contro|s, saleguards, and |ock-out.
Unsate acts An unsale act |s a spec|l|c act|on or |ack ol act|on by an |nd|v|dua| that |s under the |nd|v|dua|'s
contro|. Lxamp|es ol unsale acts |nc|ude: know|ng|y not lo||ow|ng estab||shed ru|es, know|ng|y not lo||ow|ng
estab||shed procedures, know|ng|y d|sregard|ng a hazard, w|||lu| m|sconduct, abus|ng equ|pment, know|ng|y
us|ng equ|pment |ncorrect|y, choos|ng not to use persona| protect|ve equ|pment, and not |ock|ng out when
requ|red. Oenera||y, v|o|at|ng a salety ru|e, not lo||ow|ng a sale work procedure, or d|sregard|ng a hazard are
cons|dered unsale acts.
Unsate cond|t|ons Lxamp|es |nc|ude poor housekeep|ng, congested areas, del|c|ent equ|pment, equ|pment
|ack|ng saleguard|ng or hav|ng |nellect|ve saleguard|ng, |ack ol persona| protect|ve equ|pment, poor v|s|b|||ty,
poor weather cond|t|ons, and |ack ol or |nadequate tra|n|ng. |nadequate tra|n|ng shou|d be cons|dered an unsale
cond|t|on as opposed to a del|c|ency |n sk||| or ab|||ty (persona| lactors).
Inadequate procedures |nd|cat|ons that procedures are |nadequate |nc|ude:
Procedures are not ava||ab|e |n wr|tten lorm
Procedures do not |dent|ly |nherent hazards
Procedures do not |dent|ly hazard contro| methods
Procedures do not |dent|ly saleguards that must be |n p|ace
Procedures do not address pre-operat|on |nspect|on requ|rements
Procedures do not address |ock-out requ|rements
Procedures d|rect |mproper use ol equ|pment or too|s
Persona| tactors A persona| lactor |s a del|c|ency |n sk||| or ab|||ty, a phys|ca| cond|t|on, or a menta| att|tude.
|t |s a lactor |nherent |n an |nd|v|dua| at the t|me ol the |nc|dent. Lxamp|es |nc|ude work lat|gue due to manua|
exert|on, d|stress due to emot|ona| prob|ems, the |nl|uence ol a|coho| or drugs, or |||ness. A cond|t|on caus|ng an
a||erg|c react|on |n some but not most workers shou|d be cons|dered a persona| lactor, not an unsale cond|t|on.
These items must be kept clean and dry and must be ready to take to the scene of an accident. A weatherproof
container is recommended for all items except the blankets. Blankets should be readily available to the rst
aid attendant.
3 blankets
24 14 cm x 19 cm wound cleaning towelettes, individually packaged
60 hand cleansing towelettes, individually packaged
100 sterile adhesive dressings, assorted sizes, individually packaged
12 10 cm x 10 cm sterile gauze dressings, individually packaged
4 10 cm x 16.5 cm sterile pressure dressings with crepe ties
2 7.5 cm x 4.5 m crepe roller bandages
1 2.5 cm x 4.5 m adhesive tape
4 20 cm x 25 cm sterile abdominal dressings, individually packaged
6 cotton triangular bandages, minimum length of base 1.25 m
4 safety pins
1 14 cm stainless steel bandage scissors or universal scissors
1 11.5 cm stainless steel sliver forceps
12 cotton tip applicators
1 pocket mask with a one-way valve and oxygen inlet
6 pairs of medical gloves (preferably non-latex)
rst aid records and pen
Level 1 First Aid Kit