Sample Programs

Agency Safety & Health Policy 2.2

Safety & Health Rules 2.4

Employee Safety & Health Participation 2.6

Training 2.7

Orientation Safety & Health Checklist 2.8

Fire Emergency Procedures 2.9

Emergency Telephone Numbers 2.11

Inspection Checklist 2.12

Employee Incident Report 2.26

Supervisors Incident Report 2.27

Hazard Observation/Safety Suggestion Report 2.29

10/98 2.1
 Sample Safety & Health Policy

(Agency) , as a public employer, believes in the dignity and importance of

each employee. The prevention of occupational injuries, illnesses, and exposures will be given top prior-

ity at all times.

A health and safety program requiring accident prevention efforts, including the integration of health and

safety measures into each job description, has been implemented. It is accomplished through the cooper-

ative efforts of managers, supervisors and employees who seek to obtain the lowest possible work-relat-

ed injury, exposure, and illness rates. A management-employee safety & health committee, self-inspec-

tion program, and safety & health orientation and training are features of our effort. No employee will

be required to perform hazardous duties for which he/she has not been provided the appropriate equip-

ment, training and protection.

By accepting mutual responsibility to operate healthfully and safely we will all contribute to a reduction

in workplace incidents and the high cost of workers' compensation.

(Signature - Agency Head)

Date

2.2 10/98
Sample Reference Page

NOTE: You may wish to include a page listing the individual safety and health written pro-
grams for your agency. These would include such programs as Bloodborne Pathogens,
Respiratory Protection, Hazard Communication, Tuberculosis, Personal Protective Equipment,
Lockout-Tagout and Confined Space.

10/98 2.3
 Sample General Agency
Safety-Health Rules

1. Unsafe/unhealthy conditions are to be reported to the supervisor immediately.

2. Any and all injuries, exposures, and work-related illnesses are to be reported to the supervisor
immediately, using an official incident report form.

3. Smoking and food/drink is allowed only in designated areas. Smoking is prohibited in ignition-
source areas.

4. Equipment shall not be operated unless all guards and safety devices are in place and in proper
operating condition.

5. Defective tools and equipment shall not be used, and are to be reported to the supervisor at
once.

6. Maintenance and adjustments to equipment shall be made only when energy sources have been
properly isolated. Work shall only be performed by properly trained persons.

7. Compliance with all governmental standards/regulations is required.

8. Aisles, walkways, stairways, and exits shall be kept free of debris, storage or obstructions.

9. Good housekeeping shall be practiced at all times.

10. The use of, or being under the influence of, alcohol or illegal drugs while on the job is
prohibited.

11. All agency safety and health rules must be followed. Posters must not be covered, defaced, or
removed.

12. Training on equipment is required prior to unsupervised operation.

13. Horseplay on the job site is prohibited.

VIOLATIONS OF SAFETY & HEALTH RULES WILL RESULT IN DISCIPLINARY ACTION.

I HAVE READ AND UNDERSTAND EACH ITEM ABOVE.

Signature __________________________________ Date ____________________

2.4 10/98
Sample Items for Which You May Wish
To Include Specific Rules

• Chemical and flammable liquid storage

• Drill presses

• Electrical

• Forklifts

• Handling and use of flammable liquids

• Hearing protection

• Housekeeping

• Respirators

• Safe chemical work practices

• Sanders and grinders

• Saws/woodworking equipment

• Shears, lathes, and drill presses

• Welding equipment/cutting torches

10/98 2.5
 Sample Employee Safety
& Health Participation

Employee participation in the agency safety and health program is essential from planning to implemen-
tation. In order for this to be useful, employees must be informed about the safety and health statutory
requirements and safety issues within the agency.
At this point there must be a determination concerning the best method of employee participa-
tion. The agency may wish to set up a fully functioning safety committee to review problems
and suggestions and work with the safety coordinator to the degree desired in implementation
of the program. Regardless of the method used, communication with employees must be main-
tained and they must feel free to report any unsafe conditions and to refuse to perform work
requiring specialized training and equipment if the training and/or equipment is not available.
This section should include your agency’s specific employee participation information.

2.6 10/98
Sample Employee Training Topics

• CPR

• Defensive driving

• Environmental health

• First aid training

• On-the-job training

• Orientation of new employees safety/health training

• Specialized training

• Supplemental training

10/98 2.7
 Sample Orientation Safety
and Health Information

During orientation of new employees there should be time devoted to reviewing the agency gen-
eral safety and health program, as well as any training specific for their job duties. Employees
who have been given different job duties must be given safety and health information specific to
the new job duties. This would include any required medical evaluation, training on machin-
ery/equipment and use of any personal protective equipment. This section should include at
least an outline of the contents of this orientation information. It should also include informa-
tion concerning who (by title, not name) provides the information and the means of documenta-
tion. For example, this could be Human Resources, the safety coordinator or immediate super-
visor.
Documentation of this training is important, as failure to follow the safety and health proce-
dures should be a personnel issue. It is important for employees to know, from the beginning,
that the agency will not tolerate ignoring these procedures.

2.8 10/98
Sample Fire Safety Information

Fire drills will be conducted. A fire safety program

can properly prepare you to guard against fire and
PORTABLE FIRE EXTINGUISHERS
what to do if a fire breaks out.
Fire extinguishers are only effective for small fires
in the early stages. Only properly trained employ-
FOUR CLASSIFICATIONS OF FIRE ees will use fire extinguishers.
CLASS A: Natural Materials Just as there are different kinds of fire, there are
different kinds of extinguishers. Using the wrong
Ordinary fires of paper stock, wooden skids, or
kind may cause more damage than good, and may
textiles. These fires require cooling, quenching, or
even cause the fire to spread.
smothering, and can be put out by water.
All employees must know what kind of fire extin-
CLASS B: Flammable or Combustible
guishers are at this establishment, and who is
Liquids
expected to use them.
Such as alcohol, printing inks, or solvents - may
Class A portable fire extinguishers can only put
catch fire. These fires must be smothered or blan-
out Class A fires. Some extinguishers are AB, and
keted. Water can make them worse. These fires
can be used for A or B fires. AB extinguishers can
can be very dangerous: Soiled press wipers can
be used for Class C fires if the electrical equip-
burst into flames from spontaneous combustion.
ment is not running and the current is off. Class D
They should be kept in metal containers with
fires require a Class D extinguisher.
spring lids.
Note: Be sure to include training in your fire
CLASS C: Electrical
alarm signal.
The substance burning in electrically energized
equipment may be paper, but using water can
cause electrocution if the current is on; water con-
ducts electricity. These fires require a nonconduct-
ing extinguishing agent, unless you are absolutely
sure the current is off.
CLASS D: Metals
Combustible metals, such as magnesium, titanium,
etc., are used in the printing industry. Class D fire
extinguishers are available, but these fires and
Class C fires probably need the attention of the
fire department.

10/98 2.9
 Sample Fire Emergency Procedures

Upon Observing Smoke or a Fire of Unknown Origin or Intensity

1. Sound the alarm and notify the Fire Department.
2. Follow procedures in the emergency evacuation plan (EAP).
3. Assemble outside, following instructions in the EAP.
4. Lead person account for all those assembling.

In Case of Minor Fire

1. Fight the fire IF IT CAN BE DONE SAFELY. (In the meantime, responsible person sounds the alarm
and notifies the Fire Department.)
2. If the fire is out of control, confine it to its immediate area by closing doors as you leave.
3. Provide assistance to anyone requiring it to clear the area.
4. Assemble at the designated location, following instructions in the EAP.
5. Lead person account for all those assembling.

In Case of Major Fire

1. Leave fire area. CLOSE DOOR BEHIND YOU.
2. Assist in evacuation.
3. Evacuate the building.
4. Assemble at the designated location, following instructions in the EAP.
5. Lead person account for all those assembling.

Note: Emergency procedures for natural disasters should also be included in a safety and health program.

2.10 10/98
Sample Emergency Telephone Numbers

AMBULANCE

LOCAL HOSPITAL EMERGENCY NUMBER

OKLAHOMA POISON CONTROL CENTER

PHYSICIAN

POLICE

FIRE DEPARTMENT

UTILITIES

ELECTRICITY

NATURAL GAS

WATER

LP GAS

AGENCY MANAGERS

(Name)

(Name)

10/98 2.11
 Sample Inspection Checklist Items

• Electrical • Housekeeping

• Equipment guards • Lift trucks

• Equipment maintenance • Personal protective equipment

• Firefighting equipment • Recordkeeping, notices, poster

• First Aid • Stairs, ramps, and platforms

• Floors • Storage

• Guardrails and ladders • Tools and equipment

2.12 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

FIRE FIGHTING EQUIPMENT

Flammable and explosive materials stored and handled safely.

Checked for physical condition and for proper charge.

Tagged and documented with monthly and annual inspection dates.

All vehicles and other mobile equipment provided with extinguishers.

You may add items specific to your facility here.

10/98 2.13
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

ELECTRICAL

Visible wiring unfrayed, in good condition and properly grounded.

Switch panels and breaker boxes doors closed.

Switch panels and fuse boxes not hot.

Extension cords of proper type and in good condition.

Temporary use only.

Extension light sockets of insulated material.

Portable tools grounded or double insulated.

Lines marked for voltage.

Lockout/tagout devices provided and used.

All electrical disconnects and breaker boxes properly labeled.

You may add items specific to your facility here.

2.14 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

EQUIPMENT GUARDS

Point of operation guards provided on all equipment and machinery.

Enclosure guards provided for all gears, chains, pulleys, belts, etc.

Guards in place and functioning when machines are in operation.

Tool rests in place on bench grinders and properly adjusted.

You may add items specific to your facility here.

10/98 2.15
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

FLOORS

Floor surfaces free from protruding nails, splinters, holes

and loose boards.

Openings permanent and temporary properly covered or barricaded.

Aisles clearly designated.

Aisles unobstructed.

Load limits posted and adhered to.

You may add items specific to your facility here.

2.16 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

STAIRS, RAMPS, AND PLATFORMS

Light adequate and maintained.

Surfaces unobstructed, non - slip.

Toeboards provided where required.

You may add items specific to your facility here.

10/98 2.17
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

PERSONAL PROTECTIVE EQUIPMENT

Eye protection clean and available at point of operation.

Eye wash station lines flushed weekly and station unobstructed.

Employees wearing safety shoes, eye protection, gloves, etc.

where required.

You may add items specific to your facility here.

2.18 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

LIFT TRUCKS

Overhead guard racks properly installed on all forklifts used for

stacking of any kind.

Maintenance and storage.

Operator training.

You may add items specific to your facility here.

10/98 2.19
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

STORAGE

Bagged materials properly stacked with no leaning piles.

Drums properly stacked.

All overhead storage areas properly guarded and weight limits posted.

You may add items specific to your facility here.

2.20 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

HOUSEKEEPING

Floors clean and free of hazards.

Trash receptacles emptied regularly.

Outside ground free of trash, etc.

Weeds and grass removed regularly and chemically controlled.

You may add items specific to your facility here.

10/98 2.21
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

FIRST AID

Adequate equipment, properly stored and used.

Qualified first-aid/CPR responders on each shift.

You may add items specific to your facility here.

2.22 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

RECORDKEEPING, NOTICES, POSTER

PEOSH Safety & Health Poster kept posted on bulletin board.

OK 200 Log current and up to date

OK 200 Log information posted for previous year during

month of February.

You may add items specific to your facility here.

10/98 2.23
 Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

GUARDRAILS AND LADDERS

Runways (4 feet or more above ground level) equipped with

standard railing or equivalent.

Wall openings (with a drop of more than 4 feet) properly guarded.

Openings properly barricaded or covered.

Ladders free from defects, and blocked, cleated or otherwise secured.

Ladder bases out from wall 1/4 working length of ladder.

You may add items specific to your facility here.

2.24 10/98
Sample Safety/Health Checklist

DATE OF INSPECTION DATE OF LAST INSPECTION

PREPARED BY REVIEWED BY

All NO answers require comments and a completion date for corrective action.

CONDITION AND PROTECTION SATISFACTORY? YES NO N/A COMMENTS

TOOLS AND EQUIPMENT

Tools/equipment inspected regularly to ensure safe operating condition.

Unsafe/unusable equipment tagged to indicate it must not be used.

Grinders properly guarded.

Tools stored properly.

Employees properly trained in the use of tools and equipment.

Tools used only for purpose for which they were designed.

Handles are replaced when they become cracked or broken.

Air hose connections have positive locking action or securing chain.

Air hose nozzles proper type.

Tools disconnected when relieving jams, making repairs, etc.

You may add items specific to your facility here.

10/98 2.25
 Sample Employee Incident Report

To be completed by the employee immediately, unless injury, illness, or exposure prevents comple-
tion, and forwarded to the Safety Coordinator.

Name __________________________________________ Date of Birth ___________

Job Title ________________________________________

Department_______________________________Supervisor___________________________________

Date of Incident_______________Time__________ AM PM

Nature of
Injury/Illness/Exposure____________________________________________________________

Body Part Injured____________________________________________

Do you need additional health or safety training? Yes ________ No ________

Did the activity require the use of Personal Protective Equipment? Yes ________ No _________

Was the personal protective equipment in use? Yes _____ No _____

Detailed narrative description: (WHAT happened, WHERE did it happen, and HOW did it happen?) (Be
specific):
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What might be done to prevent a recurrence of this type of incident?

____________________________________________________________________________________

____________________________________________________________________________________

Witness(es)___________________________________________________________________________

Date report prepared_______________Date given to immediate supervisor _______________

2.26 10/98
Sample Supervisor's Incident Report

To be completed immediately and forwarded to the Safety Coordinator.

Injury/illness/exposure? Yes_____ No_____ Unknown_____

Name________________________________________ Age________DOB____________________

Years of service__________ Time on present job Yrs_________Mos__________

Title/Occupation________________________________Department________________________

Date of Incident___________________ Time______________ AM ❑ PM ❑

CHECK ALL THAT APPLY:

Accident category ❑ Motor Vehicle ❑ Property Damage

❑ Fire ❑ Other

Severity of injury ❑ Non-disabling ❑ Disabling

❑ Fatality ❑ Medical

TREATMENT:

Nature of Injury _________________________________________________________

Body Part Injured ________________________________________________________

Estimated Time away from Duties or Work _________________________

Amount of damage $____________________ Location_______________________________

Cause: ❑ Unsafe Act ❑ Unsafe Condition

Describe the unsafe act or condition:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

____________________________________________________________________________________

10/98 2.27
 Did unsafe personal behaviors contribute to the accident? (Improper attitude, lack of knowledge or skill,
inattention) ❑ Yes ❑ No

Did the activity require the use of Personal Protective Equipment? ❑ Yes ❑ No

Was the personal protective equipment required in use? ❑ Yes ❑ No

Detailed narrative description: (WHAT happened, WHEN, WHERE, HOW did it happen?)

(Be specific):

What might be done to prevent a recurrence of this type of accident?

Witness(es) to incident__________________________________________________________________

Date report prepared_____________________________________

Signature of Foreman/Supervisor_____________________________________________________

2.28 10/98
Sample Hazard Observation
and Safety Suggestion Report

To be completed by the employee and forwarded to the Safety Coordinator through your supervisor.

Name __________________________________________

Job Title ________________________________________

Department______________________________________Supervisor____________________________

Nature of Hazard or Potential Exposure

Safety Suggestion

Is additional health or safety training needed? ❑ Yes ❑ No

Date report prepared__________________Date given to immediate supervisor__________________

To be completed by supervisor or safety coordinator

Action taken or measure to prevent occurrence of accident

Date completed_______________________ Signature______________________________________

10/98 2.29