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Written Safety and Health Program

For


XYZ Company



Required for all Kentucky Construction Companies
Incorporates Provisions of Kentucky Revised Statutes 338.031








2013 Americana Safety. All rights reserved.


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Table of Contents

Section Description Page
1 Management Commitment and Policy 3
2 Assignment of Responsibilities 4
3 Safety Rules and Practices 9
4 Accident Reporting and Investigation 13
5 Accident Recordkeeping and Analysis 16
6 Safety Communication 20
7 Safety Committees and Meetings 22
8 Safety and Health Training 25
9 Hazard Recognition 28
10 Hazard Prevention and Control 37
11 Emergency Planning 47
12 Company Required Safety Programs 56
13 Company Required Safety Training Courses 57
14 Company Required Safety Forms & Checklists 59

Appendices
Appendix A List of Training Subjects 69
Appendix B Hazard Assessment Checklists 71
Appendix C Hazard Assessment and Correction Record 72
Appendix D Accident/Exposure Investigation Report 74
Appendix E Employee Training and Instruction Record 76
Appendix F Employee Acknowledgement Form 78



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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 Kentucky.
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 construction companies doing businesses within the State of
Kentucky.
This program incorporates and complies with Kentucky Revised Statutes 338.031.
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

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. Compliance shall include the aforementioned regulations, standards and codes
and all such regulations, standards and codes as included by reference. These responsibilities in-
clude, but are not limited to, the following:
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 _______________________________________.



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2. Safety Representative Responsibilities
The company safety representative, Safety Representative also has the authority and responsi-
bility for implementing the provisions of this program and be the same person or title as the
Program Administrator.
DECISION POINT Enter a name or position title (recommended)
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 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.
3. Manager Responsibilities
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.


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E. Impress upon all employees, subcontractors and suppliers, the responsibility and accounta-
bility 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 pur-
chase 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 effec-
tiveness.
4. Supervisor Responsibilities
A. Carry out safety programs at the work level.
B. Be aware of all safety requirements and safe working practices.
C. Plan work activities to comply with safe working practices.
D. Instruct new employees, existing employees, and subcontractors performing new tasks on
safe working practices.
E. Make sure protective equipment is available and used.
F Make sure work is performed in a safe manner and no unsafe conditions or equipment is
present.
G. Correct all hazards, including unsafe acts and conditions, which are within the scope of your
position.
H. Secure prompt medical attention for any injured employees.


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I. Report all injuries and safety violations to management.
5. Employee Responsibilities
A. Work safely in such a manner as to ensure your own safety as well as that of co-workers and
others.
B Request help when unsure about how to perform any task safely.
C. Correct unsafe acts or conditions within the scope of the immediate work.
D. Report any uncorrected unsafe acts or conditions to the appropriate supervisor.
E. Report for work in good mental and physical condition to safely carry out assigned duties.
F. Use and maintain all safety equipment provided.
G. Maintain and properly use all tools under your control.
H. Follow all safety and project rules.
I. Provide fellow employees help with safety requirements.
J. REPORT ALL WORK RELATED INJURIES OR ACCIDENTS TO YOUR SUPERVISOR -
IMMEDIATELY.
6. All Personnel (without regard to position or assignment):
A. Strive to make all operations safe.
B. Maintain mental and physical health conducive to working safely.
C. Keep all work areas clean and free of debris.
D. Assess result of your actions on the entire work place. Work will not be performed in ways
that cause hazards for others.


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E. Before leaving work, replace or repair safety precaution signs or barriers that have been re-
moved or altered. Unsafe conditions will not be left to imperil others.
F. Abide by the safety rules and regulations promulgated for this construction project.
DECISION POINT - delete if not applicable
7. Subcontractors and Suppliers Responsibilities
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
Safety Rules and Practices

Statistics maintained by Workers' Compensation show that many job injuries are caused by
neglecting fundamental safety precautions. The following list of safety rules will help you stay free of
injury.
1. General Safety
Know the job safety requirements.
Know your Agency Safety Representative and Agency Safety Officer. Contact him or her
with all safety problems and/or concerns.
If you cannot correct an unsafe condition, report it immediately.
Read thoroughly all safety materials distributed to you.
Be certain that all instructions are clearly understood before starting a task.
Avoid horseplay, and avoid distracting others.
Do not sacrifice safety for the sake of production.
Always use the handrail on stairs.
Drive defensively when operating motor vehicles. Observe posted speed limits and wear
seat belts.
Report all injuries to your supervisor, no matter how minor they seem.
Do not report for work under the influence of alcohol or drugs.



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2. Ergonomics and Workplace Safety
Learn to lift and handle materials safely. Do not hesitate to ask for help in lifting heavy
loads. Always push rather than pull a load.
Keep walking surfaces free from tripping hazards. Keep work areas dry, clean and orderly.
Do not leave desk and file cabinet drawers open.
Open one file drawer at a time. Place heavier drawers at the bottom of the cabinet.
The top of the computer monitor should not be higher than the user's eyes for normal
vision.
Bifocal and trifocal users may prefer to have their monitor at a lower position.
The screen and document holder should be the same distance from the eye and at the same
level to avoid constant changes in focus and close enough together so the operator can look
from one to the other without excessive movement of the neck or back.
The preferred viewing distance for monitors ranges between 18 and 24 inches.
The preferred working position for most keyboard operators is with the forearms parallel to
the floor and elbows at the sides.
The mouse should be positioned at the operator's side with his or her arm close to the body
for support, while maintaining a straight line between the hand and forearm.
Do not use office furniture or other objects instead of a ladder. Inspect ladders before use.
Be certain they are in good repair and of the correct height.
3. Personal Protective Equipment
Use appropriate respirators when working with hazardous materials.
Wear safety glasses, goggles, or face-shields when there is a risk of eye injury.
Never do a task or operate equipment without the required personal protective equipment.
Wear hard hats when there is a hazard from falling objects.
Wear substantial shoes when walking on rough or uneven surfaces. Steel-toed shoes are
required when working around heavy loads that could fall on feet.
Wear appropriate gloves to prevent cuts and protect from hazardous materials.
Wear shoes with slip resistant soles that provide maximum surface traction.


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4. Emergency Procedures
Know what to do in case of fire or other emergency.
Know the locations of fire extinguishers and how to use them.
5. Equipment Safety
Operate only equipment for which you are qualified and authorized.
Do not wear jewelry or loose clothing around machinery or equipment.
Do not use defective or unguarded equipment. Report the condition to your supervisor.
Ensure that machine safety guards are always in place when operating equipment.
Maintain hand tools in good repair. Inspect them regularly.
Top heavy equipment should be properly anchored to the floor.
All pedestal/bench grinders should be equipped with properly adjusted tongue guards, tool
rests, and peripheral spindle guards.
Shield ventilation and exhaust fan blades with mesh (1/2 inch in diameter or smaller) when
fans have been installed within seven feet of the work area floor.
Do not use powered industrial trucks/forklifts that are defective in any manner (horn,
brakes, etc.).
6. Hazardous Materials
Separate compressed gas cylinders by type when storing them, and secure with valve
protection caps in place. Separate oxygen cylinders from fuel gases by 20 feet.
Post "NO SMOKING" signs near all flammable liquids.
Report chemical spills to appropriate personnel immediately.
Store flammable liquids such as fuels and solvents (i.e., paint thinner) in approved safety
cans. Quantities are also limited by KYOSH standard.
Ensure compliance with the KYOSH hazard communication standard. This includes a written
program, labeling, material data sheets, and training.



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7. Electrical Safety
Use portable electric tools outdoors only if they are grounded or double insulated and GFCI
protected.
Ground all fixed electrical equipment.
Use extension cords to temporarily furnish power to portable tools or appliances. Cords
must be free of defects and without splices.
Always put live electrical parts in proper enclosures and under no condition use exposed
electrical parts.



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Section 4
Accident Reporting and Investigation

DECISION POINT - If this investigation system is not in place, it must be created.
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.
1. 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 Safety
Representative with the underlying goal of preventing recurrence.
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.



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The company 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 XYZ Company 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 Program Administrator/Safety Representative.
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.
A Safety Inspection Guide Checklist can be a useful tool to help the supervisor carry out
his/her responsibilities as described above.
2. Investigating Occupational Injury, Illness, and Property Damage
A. 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 the
company Safety Representative. The initial accident report shall become a permanent part
of the formal accident investigation.
B. The Program Administrator/Safety Representative shall report to and investigate all serious


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occupational injuries, illnesses and property damage. A formal Incident Investigation Report
shall be prepared to determine the cause, document facts and recommend corrective ac-
tions to prevent recurrence.
3. Reporting Occupational Injury, Illness and Property Damage
A. XYZ Company employees shall report all occupational injuries, illnesses and property
damage, initially through their supervisor to the Program Administrator/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.
B. Supervisors will immediately notify the Program Administrator/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 Program Administrator/Safety Representative the following day.
C. The Program Administrator/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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Section 5
Accident Recordkeeping and
Analysis

1. 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 acci-
dents;
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.


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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-301 are 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.
E. Accident Review
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.
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.
2. Corrective Actions
DECISION POINT - State your method of corrective action here.
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.


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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 an identified hazard or deficiency to prevent injury or illness to
employees, and to prevent property damage or personal loss.
DECISION POINT - State how this will be accomplished.
3. 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.
4. 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 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:
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.



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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.
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.
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.
Job Hazard Analysis
The Program Administrator/Safety Representative in cooperation with an area supervisor will
conduct a Job Hazard Analysis where there has been a recent employee workplace injury that
is related to machinery or tool usage or a physical task assignment. The analysis will use the Job
Hazard Analysis form as a tool to systematically review a job task. The results of a Job Hazard
Analysis will be reported to the safety committee. Each hazardous job task will be analyzed at
least once every two years, 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 6
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.
1. Safety Committee (See Section 7)
2. Individual Contacts
A. 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
B. Individual contacts with employees on matters of safety and health should be documented.
C. 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 requirements.
3. General Safety Meetings
Group safety meetings with all the supervisors employees are another effective training tool
and shall be held at least on a monthly basis.
a. Topics should be chosen that are pertinent to the job safety or health of the group.


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b. The meeting should include open discussions of the topic to ensure employee
understanding.
c. It is also important to obtain suggestions from employees on means for improving their job
safety.
All XYZ Company group safety meetings are to be documented with the date, department/group
designation, topic, employees' names/signatures, name of the supervisor, and name of the
presenter if other than the supervisor. Supervisor Safety Meeting Record documentation is
again important for purposes of KYOSH compliance.
4. Written Communications
a. XYZ Company written communication of safety and health topics, practices, or matters of
interest will be used to convey important new or revised policies and procedures.
b. All communications should be dated and conform to state policy regarding such
communications.
5. Bulletin Boards and Postings
a. At least one company bulletin board shall be made available for posting of required
government postings such as the OSHA and Workers' Compensation required notices. They
will be used to post safety rules and important policies and procedures.
b. XYZ Company bulletin boards will be conspicuously located.
1) The boards are to be properly maintained..
2) One individual will be responsible for maintaining the bulletin board and controlling the
notices placed thereon.



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Section 7
Safety Committee and Meetings

DECISION POINT - If you have 25 or more employees, a Safety Committee should be established.
1. 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.
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 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
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.
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.
D. 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.


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The management commitment/interest/good faith to safety committees must be vocal,
visible, and continuous - from the top to the lowest level.
E. 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.)
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 8
Safety and Health Training

Safety and health training at XYZ Company imparts knowledge, generates new ideas, reinforces
existing ideas and principles and puts the other three elements of the program into action.
The answer to the question, How do I get new employees into the mainstream and build
productivity? is Training! On-the-job or through formal classroom instruction, training is a
necessity for improving performance. As time passes and processes or product lines change,
employees must be retrained.
Safety and health training implies training on specific job procedures. It can be given separately, but
it is better combined with regularly scheduled job-related training. Such training benefits the
employee through fewer work-related injuries and illness reduced stress, and worry caused by
exposure to dangers. Training must also be provided for supervisors.
1. Supervisor and Employee Safety Training
Supervisory Training
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, our supervisors 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


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d. How to investigate accidents, and to take corrective and preventive action to prevent
recurrence.
Employee Training
XYZ Company recognizes 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:
a. Standard work procedures including safe work practices, and how these procedures
protect against exposure to dangers.
b. Personal protective equipment: why it is needed, how to use it, and how to keep it in
good condition.
c. 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.
2. New-Hire Employee Orientation
All XYZ Company new hires must attend a new-hire orientation prior to commencing
employment.
All new-hires shall receive occupational health and safety training in the following subject areas:
a. Company Safety Philosophy and Policy
b. Project Orientation (if applicable)
c. Disciplinary procedures for non-compliance
d. Employee Danger Reporting System
e. Accident Reporting System
b. Personal Protective Equipment (when applicable)
e. Fall Protection -100% tie-off (if applicable)
f. Scaffolding (if 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


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3. Mandatory Occupational Safety and Health Programs
Hazard Communication Program
All XYZ Company employees will receive training in compliance with the OSHA Hazard
Communication (HazCom) Standard, 29 CFR 1926.59. 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.
Continuous HazCom training will be conducted via weekly toolbox safety meetings when
applicable.
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.



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Section 9
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 sur-
vey (audit) to identify existing or potential workplace dangers.
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.
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.
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.
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.
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.
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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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.
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.
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 inci-
dent 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.


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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.
DECISION POINT Determine the person or title (recommended) below.
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 _______________________________________________________.
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.
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.



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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.
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


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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-301 are 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.
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.



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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.
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.



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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.
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 10
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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41

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.


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2) Job Hazard Analysis shall be produced by the superintendent and appropriate crew
foremen and reviewed by XYZ Company Safety Representative.
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.



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


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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.
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.



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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.
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.


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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 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.


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Section 11
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.


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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.
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.


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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.


Kentucky Written Safety and Health Program
50

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.
4) Non-sparking system cooling fans, used to control the heated trapped grease particles,
must also be checked for operability on a regular basis.



Kentucky Written Safety and Health Program
51

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.
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.


Kentucky Written Safety and Health Program
52

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.
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.


Kentucky Written Safety and Health Program
53

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. 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.



Kentucky Written Safety and Health Program
54

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.
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.



Kentucky Written Safety and Health Program
55

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.



Kentucky Written Safety and Health Program
56

Section 12
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



Kentucky Written Safety and Health Program
57

Section 13
Company Required
Safety Training Courses


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.
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
Supply www.SafetyOfficeDepot.com



Kentucky Written Safety and Health Program
58

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


Kentucky Written Safety and Health Program
59

Section 14
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.
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



Kentucky Written Safety and Health Program
60

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


All Subject Form Groups are available through Americana Safety
Supply www.SafetyOfficeDepot.com



Kentucky Written Safety and Health Program
61

Supervisor Safety Meeting Record

Department: Supervisor:
Location:
Date of Meeting: Date of Previous Meeting:
Safety Meeting Topic:
Safety Training Presented by:
Employee Name Employee Signature
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.


Kentucky Written Safety and Health Program
62

SAFETY ORIENTATION CHECKLIST

Employee's Name Date ____________________________

Date Employed Department ______________________

Job Title

Instructions to be given by Safety Coordinator
ITEMS COVERED INITIALS ITEMS COVERED INITIALS
STATE SAFETY POLICY EMERGENCY PROCEDURE
PROGRAM

SAFETY ORGANIZATION & PROGRAM Fire Protection
Employee Participation in Program Tornado or windstorm
Safety Performance - Past & Present Bomb Threat
Employee Safety Awareness Awards
Program
OVERVIEWS OF SPECIAL
PROGRAMS

Off-the-Job Safety Program Lock-out / Tag-out
Employee Safety Suggestion Program Confined Space Entry Program
Facility Safety Rules and Regulations Hot Work Permit Program
MEDICAL FACILITIES AND PROGRAM INTRODUCE DEPARTMENT
SUPERVISORS

Reporting of accidents and any resulting
injuries or illnesses
OTHER:
Location of Dispensary and/or first aid
room or stations

PERSONAL PROTECTIVE EQUIPMENT
PROGRAM

HEARING CONSERVATION PROGRAM




Kentucky Written Safety and Health Program
63

The above items checked were covered during my orientation:

Employee's Signature:

The above items checked were covered during the orientation of the above named.

Safety Coordinator's Signature:


Kentucky Written Safety and Health Program
64

SAFETY ORIENTATION CHECKLIST Page 1 of 2

Employee's Name

Date Employed Department ________________________

Job Title Shift _______________

Assigned Job and Instructed in Safe Job Procedure on (Date) ___________________________

Instructions to Be Given by Supervisor

ITEMS COVERED

DATE & INITIALS
OF SUPERVISOR

ORIENTATION
FOLLOW-UP
30 Days 60 Days
1. HAZARDS THAT EXIST IN DEPARTMENT
AND/OR AREA OR JOB

2. REPORTING OF UNSAFE CONDITIONS NOTED
3. GENERAL AND DEPARTMENT SAFETY RULES
AND REGULATIONS REVIEW

4. REVIEW EMERGENCY PROGRAM AND
PROCEDURES

Fire Prevention Rules for department or area
Location and use of fire extinguishers
Reporting of fires - location of fire alarm
Location of emergency exits
Evacuation procedures
Location of assembly area by department for
roll call

Tornado or windstorm
Bomb threat
5. REPORTING OF ACCIDENTS, INJURIES, AND
ILLNESSES



Kentucky Written Safety and Health Program
65



ITEMS COVERED

DATE & INITIALS
OF SUPERVISOR

ORIENTATION
FOLLOW-UP
30 Days 60 Days
6. LOCATION OF FIRST AID STATION AND/OR
DISPENSARY

7. IDENTIFICATION OF FIRST AID TRAINED
PERSONNEL

8. PERSONAL PROTECTIVE EQUIPMENT
PROGRAM

9. HEARING CONSERVATION PROGRAM
10. LOCK-OUT/TAG-OUT PROGRAM
11. CONFINED SPACE ENTRY PROGRAM
12. MAINTENANCE OF TOOLS AND EQUIPMENT
13. MACHINE GUARDING PROGRAM
14. INSTRUCTION IN PROPER MATERIAL
HANDLING

15. HOUSEKEEPING AND MATERIAL AND
EQUIPMENT STORAGE

16. SAFE OPERATION OF MATERIAL HANDLING
EQUIPMENT

17. PERSONAL HYGIENE AND CLEANLINESS
Appropriate Apparel & Wearing of Jewelry
18. REVIEW EMPLOYEE PARTICIPATION IN
FACILITY AND DEPARTMENT SAFETY
PROGRAMS

19. HAZARD COMMUNICATION PROGRAM
(Chemical Right-To-Know Law)

Labels Practice
Material Safety Data Sheets
Training on Precautions for Specific Hazards
20. OTHER

The above items have been thoroughly covered, and I understand them.



Kentucky Written Safety and Health Program
66



Note to the Supervisor: Copies of the completed and signed form are to be returned to the Personnel
Department and Safety Department after the employee's orientation. The form will be returned for the 30-
and 60-day follow-up.






Employee's Signature


Orientation Date Supervisor's Signature
Employee's Signature


30-Day Follow-Up Supervisor's Signature
Employee's Signature 60-Day Follow-Up Supervisor's Signature


Kentucky Written Safety and Health Program
67

OFFICE SAFETY INSPECTION CHECKLIST

Office Name: ____________________________________________

The importance of remedial follow-up, whether it be work practice, detection of hazardous physical
condition, or hazardous substance problem, cannot be over-emphasized if the inspection is to be
meaningful and effective. Response with an * will require corrective action and follow-up.

Physical Conditions
No Yes Correction
Requested
Date
Completed
Life Safety
Aisles/Walkways
Are aisles/walkways obstructed?
*


Exits
Are exits easily accessible?
*

Are exits free from obstructions?
*

Are exit signs illuminated?
*

Are exit signs clearly visible from employee areas?
*


Emergency Lights
Do they function?
*

Do they provide sufficient illumination?
*

Are they adequately located?
*


Stairways
Are there any cracked steps?
*

Do steps have a slip-resistant surface?
*

Are there missing or loose handrails?
*

Is lighting adequate?
*


Walking/Working Surfaces
Are employees exposed to slipping/tripping hazards from:
Electrical wiring and/or VDT cables?
*

Telephone wiring?
*

Electrical/telephone outlets?
*

Congestion in work areas?
*


Floors/Carpets
Are carpets frayed or torn?
*

Are mat edges curled?
*

Are the floors wet and/or slippery?
*

Are tiles missing or broken?
*

Is the floor cracked or are there holes?
*


Storage Techniques
Exposures to injury from falling objects or from lifting heavy
objects:

Are heavy boxes stored at waist height?
*

Is heavy, bulky or sharp material stored overhead?
*

Are bookcases/file cabinets anchored?
*

Are aisles in storage areas congested?
*
















Physical Conditions No Yes Correction
Requested
Date
Completed
Office Furniture
Are employees exposed to hazards from poorly maintained or
adjusted furniture including:

Defective chairs?
*

Inoperable desk drawers?
*

Unstable file cabinets?
*

Overloading file cabinets?
*


Machinery/Equipment
Unguarded moving parts?
*

Defective wiring on cords?
*

Sharp edges or burrs on equipment?
*


Lighting
Is lighting adequate?
*

Is there glare or excessive light?
*

Are there obstructions creating darkness or shadow areas?
*


Parking Lots/Sidewalks
Are there potholes?
*

Are there cracks or uneven surfaces?
*

Is lighting adequate?
*

Are there accumulations of snow or ice?
*


Work Practices
Unsafe practices observed in the office environment:
Leaving file or desk drawers open?
*

Standing on chairs?
*

Ignoring liquid spills?
*

Running?
*

Horseplay?
*


Hazard Communication
Material safety data sheets on file?
*

Employee right-to-know training provided?
*

Training logs on file?
*


Hazardous substance storage and use
Notice posted?
*

Containers properly labeled?
*

Following proper usage and storage procedure?
*


Additional comments:


Inspection completed by: Date:

Safety Committee Review
Comments:


Committee Chairperson Signature: Date:


Kentucky Written Safety and Health Program
69

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 machin-
ery.
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.


Kentucky Written Safety and Health Program
70

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 commu-
nication.
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 ___________________________________________


Kentucky Written Safety and Health Program
71

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


Kentucky - Written Safety and Health Manual
72

Appendix C
Hazard Assessment and Correction Record

Kentucky - Written Safety and Health Manual
73

Hazard Assessment and Correction Record

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

Corrective Action Taken:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Kentucky - Written Safety and Health Manual
74

Appendix D
Accident/Exposure Investigation Report

Kentucky - Written Safety and Health Manual
75

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: _____________________________
Kentucky - Written Safety and Health Manual
76

Appendix E
Employee Training and Instruction Record






Kentucky - Written Safety and Health Manual
77

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
Kentucky - Written Safety and Health Manual
78

Appendix F
Employee Acknowledgement Form
Kentucky - Written Safety and Health Manual
79

Employee Acknowledgement Form

I hereby acknowledge that I have had the opportunity to read, review and ask questions on the
contents of the companys Written Safety and Health 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 Written Safety
and Health Program and company safety and health policies.


Witness Print Your Name


Duty Title of Witness


Signature of Witness Date

Kentucky - Written Safety and Health Manual
80

Americana Safety Disclaimer Notice

While we have made every attempt to ensure that the information contained in this document
is reliable, Americana Safety is not responsible for any errors or omissions, or for the results ob-
tained from the use or non-use of this information. All information in this document is provided
"as is", with no guarantee of completeness, accuracy, timeliness or of the results obtained from
the use or non-use of this information, and without warranty of any kind, express or implied,
including, but not limited to warranties of performance, merchantability and fitness for a partic-
ular purpose.

In no event will Americana Safety, or the partners, agents or employees thereof be liable to you
or anyone else for any decision made or action taken in reliance on the information in this doc-
ument or for any consequential, special or similar damages, even if advised of the possibility of
such damages.

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 re-
spect 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.