HHBPO HEALTH & SAFETY

EVALUATION DATA SHEET

DATE EVALUATED

PLANT/LOCATION NAME
AND ADDRESS:

PRESENT EMPLOYEE COUNT: MANUFACTURING

OFFICE

CONTACT NAME:

TITLE:

PHONE:

EVALUATION PERFORMED BY:

 LOCATION STATISTICS FISCAL YEAR

1. WORKERS COMPENSATION CURRENT YEAR PREVIOUS YEAR SCORE

Number of Claims

Percent of Population With Claims

2. DOLLARS INCURRED

Dollars Incurred Goal

Incurred Cost YTD

Internal Incurred Cost Goal

Cost Per Capita Goal

Current Cost Per Capita

3. OSHA NUMBERS

NUMBER OF CASES YTD

NUMBER OF DAW CASES

NUMBER OF DART CASES

RECORDABLE RATE

DAW RATE

DART (LWDII) RATE

4. LEADING INJURIES

Struck By

Strains

Cuts/Puncture

Falls/Slips

Caught In/Between

Repeated Trauma

Each question is worth 5 Points if lower than previous year Total Points
 HEALTH AND SAFETY PROGRAM EVALUATION PROFILE

DESCRIPTION ELEMENTS POSSIBLE ACTUAL SCORE

POINTS POINTS %
I. Statistics 4 95
II. Management 17 151
Commitment 12
III. Employee 9 56
Involvement
IV. Hazard 11 123
Prevention
V. Accident 13 92
Investigation
VI. Safety and 12 118
Health Training
VII. Occupational 8 65
Illness Analysis
VIII. OSHA 20 166
Standards
IX. Medical 25 167
Programs
X. Emergency 21 191
Preparedness
XI. Accident 7 55
Recording
System
XII. Safety 9 92
Committee
XIII. Safety 5 35
Communication
XIV. Employee 7 80
Orientation

XV. Plant Hazard 9 93

XVI. Supervisor 12 150

XVII. Compliance 8 410

TOTALS 197 2139

II. MANAGEMENT COMMITMENT (151 Points) POINTS
POSSIBLE ACTUAL
1. Has upper management at this location provided a written statement,
which clearly states the safety and health policy?
a. Yes, to directors/managers only
b. Yes, to directors/managers and supervisors
c. Yes, to all plant employees (including contractors) 6
d. No formal written policy has been established

2. Is the written statement for safety and health current and signed by the top
management at this location?

a. Yes 4
b. No
c. Not current

3. Has management at this location communicated a clear goal for the safety and
health program?
a. Yes, overall goal has been communicated
b. Yes, to directors/managers and supervisors only
c. Yes, overall goal, explicit objectives and visible management support 6
d. No formal goal has been established for the safety and health program

4. Which statement most accurately reflects the assignment of the safety and health
responsibilities at your location
a. Verbal assignment at all levels
b. Written assignment of specific safety responsibilities at all levels
c. Written assignment, plus management evaluation to insure accountability 6
d. No specific assignment of safety responsibility has been made

5. How often does upper management (plant manager) issue statements reinforcing
the plant's policy or otherwise stressing the importance of safety?
a. Daily With documentation: _____ None ______ Yes 8
b. Weekly
c. Bimonthly
d. Every 6 months
e. Yearly

6. How often are the operations of the safety and health program reviewed by the
management team at your location?
a. Monthly 6
b. Bimonthly
c. Every 6 months
d. Yearly
MANAGEMENT COMMITMENT (Continued) (151 Points) POINTS
POSSIBLE ACTUAL
7. How often does the plant manager participate in safety meetings or other
safety and health related activities?
a. Regularly With documentation: _____ None _____ Yes 6
b. Sometimes
c. Seldom
d. Never

8. To what extent does management provide for enforcement of the safety and
health program?
a. Occasional enforcement but no documentation
b. Enforcement conducted on a selective basis with some documentation
c. All facets of program consistently enforced with full documentation 6

9. Has a specific individual been assigned responsibility by the plant manager for
administering this locations safety and health program?
a. Yes, full time 4
b. Yes, part time
c. No

10. Has the plant manager at your location included the safety and health
performance in the personnel evaluation and salary reviews?
a. Safety and health performance included on informal basis
b. Performance is monitored and used, but not universally
c. Performance is fully documented and is included in all reviews 6
d. Performance is not included in personnel evaluation/salary review

11. Does this location have an Executive Safety Committee?

Yes No
5

b. If yes, how often do they meet?

Monthly (20 pts.), Quarterly (15 pts.), Semi-annually (10 pts.) or Annually (5 pts.) 20

c. Are any of the top management officials members of the plant/location safety
committee
Yes No
5

12. a. Does top management receive reports on safety performance activity?

Yes No
5

b. How often? Monthly (20 pts.), Quarterly (15 pts.), Semi-annually (10 pts.) 20
Annually (5 pts.), None (0 pts.)
MANAGEMENT COMMITMENT (continued) (151 Points) POINTS
POSSIBLE ACTUAL
13. Has senior management for this location submitted reports on the status of the
EIPMS program monthly to corporate safety?
a. Each month 6
b. Bimonthly
c. Sometimes
d. Only when requested

14. At this location has the plant manager assigned roles, responsibilities and authorities
that are specific and clear under the EIPMS?
a. Yes, Formal assignment 4
b. Limited assignment
c. No assignment has been established

15. Did the plant manager appoint a member of management (not the safety manager) to
act as the EIPMS Coordinator?
a. Yes, formal assignment has been done 4
b. Under consideration
c. No assignment has been established

* Who is the plant coordinator:

16. In the established of the steering committee under EIPMS - Did the plant manager
appoint any of the following plant members to the team?

Safety Manager
Human Resources Manager
Maintenance Manager
Engineering 14
Purchasing
QA Manager
Superintendent

17. Has the Plant Manager established monitoring and measurements procedures
for the EIPMS Program?
a. Yes, formal system in place and documented. 10
b. Limited system in place with little documentation
c. No system exists

Points Possible 151

III. EMPLOYEE INVOLVEMENT (56 Points) POINTS
POSSIBLE ACTUAL
1. Which statement best describes the overall level of production employees
participation in the development of EIPMS, and the operation of this locations
plant safety and health program?
a. Employee involvement is accepted, but not solicited or encouraged
b. Employees are often involved and periodically encouraged by management
c. Employees are formally involved and actively encouraged to participate 6
d. Little or no employee involvement

** Number of employees interviewed on involvement: ______

2. In which of the following activities do production employees at this location

routinely participate?
a. Inspection for hazards with recommendations for corrections/controls
b. Analyzing jobs to locate potential hazards 14
c. Developing or revising general rules for safe work
d. Training newly hired employees in safe work procedures and rules
e. Training their co-workers in newly revised safe work procedures
f. Providing programs and presentation for safety meetings
g. Assisting in accident investigations

** Number of employees interviewed: _______

3. Do the employees at this location impact the safety culture through peer interaction
and commitment by watching out for each other?
Not observed during audit
Occasionally
Employees observed influencing others 4

4. Are employees observed following departmental supervisors direction in safety

and health?

Not observed during audit

Occasionally if being observed by supervisor

Without question. Culture is good 4

5. Do the employees know and adhere to the 56 established safety rules and work
procedures for departmental jobs or those jobs which employees may be assigned?

occasionally without question 4

not observed no documentation

6. During this audit did employees use all personal protective equipment required to
perform job duties. This would also include the proper maintenance of equipment.

Equipment was used, but some missing

Equipment was used by all employees at time of audit 4
Maintenance poor Maintenance good
EMPLOYEE INVOLVEMENT (Continued) (56 Points) POINTS
 POSSIBLE ACTUAL
7. Employees at this location report all unsafe conditions immediately to his/her
supervisor for correction.

no documentation occasionally 4

documented practice at location

8. Are all injuries reported immediately to the management or plant health care
professional before departing the plant?

Never takes place

Occasionally takes place

Report are made before departing plant 4

9. Our employees safety culture at this location is made up of the following?

No Yes Safe attitudes and behavior

No Yes Safety policies and procedures
No Yes Safety training and motivation 12
No Yes Safety planning and goals
No Yes Safety responsibility/accountability
No Yes EIPMS knowledge

Number of employees questioned during audit:___________

IV. HAZARD PREVENTION 123 Points POINTS
POSSIBLE ACTUAL
1. Has a comprehensive worksite survey been conducted at location within
the last 12 months to identify existing and potential hazards?
Yes 10
No
Date of last comprehensive inspection: ______

2. How often are routine safety inspections performed at your plant?

A. Annually
B. Every 6 months
C. Bimonthly 10
D. Monthly
E. Weekly Date of last inspection: ________________

3. To what extent has a reliable system been implemented for employees,

without fear of reprisal, to notify plant management of conditions or practices
which appear to pose hazards?
A. Suggestions box only
B. Formal system exists, but input not encouraged. (What is the formal
system used): _________________________________________ 15
______________________________________________________
C. Formal system exists, input actively encouraged by management
D. No system exist for employees to notify management of safety
concerns

4. How quickly does management correct hazardous conditions or practices

revealed by safety inspections or reported by employees?
A. Responses very slow or often not made at all
B. Responses made, but usually after some delay: no follow-up evaluation
C. Responses made quickly with follow-up evaluation 10

5. Which statement best describes the preventive maintenance program at your plant?
A. Limited inspections of knives, tools, machinery; no documentation
B. Formal program but not all items inspected regularly; some documentation
C. All items inspected regularly using formal checklist; full documentation 15
D. No formal preventive maintenance program has been established

6. Which statement best describes the use of job safety analysis (JSA's) at this
location?
A. Limited use of JSA program; JSA results seldom used at the workstation
B. JSA's generally used, but usually only after an incident is reported
C. JSA program fully implemented, including documented updates and reviews 15
D. No JSA program has been established

7. Has a complete analysis of your plant's medical, safety, and workers compensations
records been performed to locate evidence of improvement?
A. Yes: Date of review: __________________ 5
B. No review done

8. Has the EIPMS steering committee for this location conducted a full plant review or a
gap analysis that is scored?
Yes No
5
Date of last review:
HAZARD PREVENTION (Continued) (123 Points) POINTS
POSSIBLE ACTUAL
9. Hazard identification is a very large part of the requirements under the EIPMS program
and is to be used on an ongoing basis. Has this location completed its hazard
identification?
a. All jobs are completed and documented
b. 75% of jobs are completed and documented
c. 50% of jobs are completed and documented 20
d. 49% or less completed with no documentation
e. No hazard identification done to date

10. Under hazard identification and assessment of risk have the following issues been
taken into consideration
a. Potential consequences
b. Probability of occurrence
c. Classified risk 8
d. Severity

11. Has this location started to develop a program to control, prevent, or reduce the
injuries to employees?
a. Yes, readily accessible with documentation
b. Yes, with some documentation
c. No program exist 10

Points Possible 123

V. ACCIDENT INVESTIGATION (92 Points) POINTS
POSSIBLE ACTUAL
1. How often are major incidents/accidents (loss time) thoroughly investigated?
A. Always
B. Often 6
C. Sometimes
D. Never

2. How often are minor incidents/accidents (no loss time) thoroughly investigated?
A. Always
B. Often 6
C. Sometimes
D. Never

3. How often are property-damage-only incidents thoroughly investigated?

A. Always
B. Often 6
C. Sometimes, if reported
D. Never

4. How often are near-miss incidents thoroughly investigated?

A. Always
B. Often 6
C. Sometimes, If reported
D. Never

5. Are all accident reports submitted to Plant Management/Human Resources,

Safety Manager, or the Medical Department by the end of the work shift?
A. Always
B. Often 6
C. Sometimes
D. Never

6. Does management at this location conduct accident investigation reviews?

Yes Date of last Review:________________ 5

No

7. Are supervisors at this location held accountable for the investigation of on-the-job
accidents?
Yes 5

No

8. Is a follow-up made to ensure that all causes of accidents are correctly identified and
that corrective action has been taken?

Yes Documented 5

No No documentation

9. Is there an active job safety analysis for each job at this location?
Yes 5
 No

ACCIDENT INVESTIGATION (continued) POINTS SCORE

10. Are lost trends identified and acted upon?

Yes How ________________________________________ 5

____________________________________________
No ____________________________________________

11. Are accident repeaters identified so further training can be scheduled?

Yes Documented 5

No

12. Who of the following management members receive and review all accident reports?
Plant Manager Clinic Manager
Superintendents Other 12
Safety Manager
Human Resources

13. Are accident Reports completed in detail in the following areas?

Injury Type
Incident Type
Unsafe Acts
Unsafe Conditions 20
Immediate Action
Root Causation
Personal Factors
Action Planning
Signature: Supervisor, Superintendent, Safety Mgt., and Plant Mgt
Other

Possible Points 92
VI. SAFETY AND HEALTH TRAINING (118 Points) POINTS
POSSIBLE ACTUAL
1. Do all new employees receive formal general safety and health training as part of their
company orientation?
A. Regularly
B. Sometimes
C. Seldom
D. Never 6

** How is this conducted _________________________________________________

______________________________________________________________________
______________________________________________________________________

2. Do all new employees at this location receive special departmental training done by
his or her charge supervisor?
A. Always
B. Sometimes
C. Seldom
D. Never 6

** Is this training documented? YES _____ NO _____

3. In the past 12 months, what percentage of upper management received at least one
hour of formal safety training?
A. Under 5%
B. Under 10%
C. 10-25%
E. 51-75% 12
F. 76-90%
G. 91-100%

4. In the past 12 months, what percentage of middle management received at least 30

minutes per month of formal safety training?
A. Under 5%
B. Under 10%
C. 10-25%
D. 26-50% 14
E. 51-75%
F. 76-90%
G. 91-100%

5. In the past 12 months, what percentage of line supervisors received at least one hour
per month of formal safety training?
A. Under 5%
B. Under 10%
C. 10-25%
D. 26-50%
E. 51-75% 14
F. 76-90%
G. 91-100%
SAFETY AND HEALTH TRAINING (Continued (118 Points) POINTS
POSSIBLE ACTUAL
6. In the past 12 months, what percentage of line workers received at least 10 minutes
per month of formal safety training?
A. Under 5%
B. Under 10%
C. 10-25%
D. 26-50% 14
E. 51-75%
F. 76-90%
G. 91-100%

7. Has a safety and health training program been developed for supervisors?
A. Program is limited in scope and documentation, not all supervisors trained
B. Comprehensive program, all supervisors trained, incomplete documentation
C. Comprehensive, well-documented program, includes special problem
sessions 6
D. No safety and health training program has been dev eloped for supervisors

8. Has an on-the-job and/or refresher training program been established at this location
for plant hourly employees?
A. Written program, but no follow-up or documentation
B. Written program, used by location supervisors that make use of training
C. Formal written program for OTJ procedures, full documentation and
follow-up on 6
D. No on-the-job/refresher training program has been established

9. Which of the following methods are used to assess employee comprehension

upon completion of training session?
A. Oral review with questions
B. Formal written test sometimes
C. Formal written test after all training 8
D. Observation studies

10. Has an inventory been made of job procedures to determine those with high risk
potential requiring special training?
Yes No 5

11. Has training been conducted at this location in the following subjects:

Date of last training

Forklift Training
Lifting/Material handling
Employee Fire Fighting
Confined Space 22
Hazard Communication
Accident Investigation
Lockout/Tagout
First Aid/CPR
Personal Protective Equipment
Emergency Evacuations
Other
SAFETY AND HEALTH TRAINING (Continued) POINTS
POSSIBLE ACTUAL
12. For each category of specialized training given at your facility, can you indicate
the name of the person giving training? 5
Yes NO N/A

Points Possible 118

VII. OCCUPATIONAL ILLNESS ANALYSIS (65 POINTS) POINTS
POSSIBLE ACTUAL
1. Has the location identified any of the following potential health hazards?
Noise
Chemicals/Solvents
Respiratory Exposure
Non-ionizing 14
Ionizing Radiation
Heat Stress
Other (specify)

2. Does your plant perform periodic industrial hygiene test for these hazards?
Yes No
5

3. Have steps been taken to address exposures identified as needing attention by the
industrial hygiene test?
Yes No
5

If yes, please describe.

4. Does your plant maintain a records of industrial hygiene test for known
employee exposures?
Yes No
5

5. Are any employees or group of employees given health examinations due to potential
exposures to any suspected or confirmed health hazards such as hearing or
respiratory?
Yes No
5

If yes, what type of examination? Is their record documented? Are the employees
advised of the results of such examinations?

6. What types of personal protective equipment are required at your plant?

Date of Last Training

Safety Shoes
Safety Glasses
Face Shields
Hearing Protection 16
Gloves
Specialized Clothing
Respirators
Other (specify)

7. Are training programs in place for the above-checked personal protective equipment?
Yes No
5
OCCUPATIONAL ILLNESS ANALYSIS (Continued) POINTS
POSSIBLE ACTUAL
8. Is a disciplinary system used to enforce the use of personal protective equipment?
Yes No 10

Points Possible 65
VIII. OSHA STANDARDS (29
(166 Points) POINTS
POSSIBLE ACTUAL
1. Have lockout/tagout procedures been established at this location?
A. Verbal program, attempts at lockout/tagout inadequate or inefficient
B. Written program, but performance not consistent or reliable
C. Written program, fully tested and evaluated; DATE OF: ___________ 6
D. No lockout/tagout procedures have been established

2. Is point of operation guarding provided on all machines whose operation exposes

employees to injury?
A. Always 4
B. Often, some guards available, but not in place
C. Sometimes, all equipment not guarded properly

3. To what extent has a program been established for the proper handling, labeling and
storage of hazardous materials (chemicals) at your location?
A. Many items incorrectly labeled; storage/control poor; limited training
B. Proper labels applied, training for all employees, but no documentation
C. All procedures followed with complete training and documentation 6
D. No program or training in hazardous materials handling/labeling/ storage

4. Does a material safety data sheet (MSDS) exist for all hazardous chemicals at
your location?
A. Yes, MSDSs readily accessible on-site for all employees to review
B. Yes, MSDSs readily accessible with copies provided at employees request
C. Yes, MSDSs readily accessible, with copies and help in understanding 6
provided MSDS sheet
D. No, MSDSs do not exist for all chemicals

5. Which of the following are included in your plant's written, site-specific hazard 10
communication program?
A. Labels/warnings (NFPA) put on by location
B. Employee training
C. List of Chemicals at location
D. Are pipes with chemicals in them labeled
E. Does this location have outside contractors MSDSs

6. Has a specific, written program been written and established for this location
to train employees in the proper use and maintenance of personal protective
equipment (PPE)
A. Yes, but program not fully implemented; PPE not properly used/maintained
B. Yes, program is place and PPE properly used/maintained,
documentation poor.
C. Yes, program in place and well documented, including training and 6
employees fitted for equipment
D. No written program regarding PPE used has been established
XIII. OSHA STANDARDS (29
(166 Points) (Continued) POINTS
POSSIBLE ACTUAL
7. Hazard Communication Standard - Have the following elements been completed? 10
Yes No
Chemical Inventory
Material Safety Data Sheets (MSDS's)
Employee Training
Program Documentation
Labeling

8. Lockout/Tagout Standard - Have the following elements been completed? 8

Yes No
Written program for isolating energy
Use of lockout/tagout devices
Periodic inspections
Training

9. Confined Space Standard - Have the following elements been completed? 10

Yes No
Identification of confined spaces and inventory
Permit/nonpermit
Periodic inspections
Atmospheric testing
PPE and emergency response plan

10. Bloodborne Pathogens - Have the following elements been completed? 10

Yes No
Exposure Control Plan
Communication Hazards to Employees
Preventive Measures
Methods of Control
Exposure Incident Plan

11. Hearing Conservation - Have the elements been completed? 6

Yes No
Monitoring of the plants noise levels, and recordkeeping

Administrative controls or PPE

Audiometric testing of employees

12. Machine Guarding - Have the following elements been completed? 6

Yes No
Are guards in place?

Are processes for machine guarding properly documented?

Is training being conducted that covers the machine guarding?

XIII. OSHA STANDARDS (29
(166 Points) (Continued) POINTS
POSSIBLE ACTUAL
13. Ergonomics - Have the following elements been completed? 10
Yes No
Policy Statement
Ergonomic Committee
Medical Management
Ergonomic Analysis of Risk Factors
Education and Training

14. Laboratory Standard - Have the following elements been completed? 6

Yes No
Policy/SOP been established at this location

Training of lab employees over safe operations of lab

Hazard Assessment

15. Process Safety Management - Have the following elements been completed? 18
Yes No
Materials identified
Formal Program
Process Hazard Analysis
Operating procedures
Emergency Plans
Training
Contractor Awareness
Pre-start-up Safety Reviews
Work Permit System

16. Personal Protective Equipment - Have the following elements been completed? 4
Yes No
Hazard Assessment

Training

17.Respiratory Protection - Have the following elements been completed? 14

Yes No
Identification of substance as hazardous exposures
Respiratory selection
Health evaluation and surveillance
Employee training
Fit testing
Respiratory cleaning, maintenance and storage
Respiratory program Evaluation
XIII. OSHA STANDARDS (29
(166 Points) POINTS
POSSIBLE ACTUAL
18. Electrical Safety - Related Work Practices - Have the following elements been 6
completed?
Yes No
Training
Use of Personal Equipment
Protective Tools

19. HAZWOPER (Hazardous Waste Operations) - have the following elements been 8
completed?

Yes No
A written program
Employee training
Communication
Documentation

20. Has this location developed the following programs/policies?

Asbestos

Fall Protection

Hazard Assessment

Posting Requirements 12

Power Industrial Trucks

Emergency Action plan

Points Possible 166

IX. MEDICAL PROGRAM (167 Points) POINTS
POSSIBLE ACTUAL
1. Which of the following elements are contained in your facility's bloodborne pathogen
(BBP) /written exposure control plan and training program?
A. Exposure determination
B. Personal protective equipment
C. Exposure control plan/determination
D. Universal precautions/work practice controls
E. Hepatitis B vaccination program
F. Employee training and education
G. Post-exposure evaluation/follow-up procedure 26
H. Housekeeping and laundry practices
I. Biohazard signs, labels and bags
J. Modes of transmission training
K. No BBP training is conducted
L. Regulated waste disposal
M. No exposure control plan in place

2. To what extent have ergonomic considerations been applied to the design of

employee workstations at this location/
A. Limited
B. Person/machine interaction analyzed, but further design needed
C. Human engineering principles are fully utilized in task improvement 6
D. Ergonomic considerations have not been applied to task design

3. In addition to engineering/design improvement, which of the following administrative 12

practices have been employed as part of your locations plant ergonomics program?
A. Job enlargement
B. Job rotation
C. Work/rest schedules
D. Work method evaluations
E. Workload reduction
F. Exercise/conditioning program

4. Has a complete analysis of your locations medical and workers compensation

records been performed to locate evidence of cumulative trauma disorders?
A. Yes 5
B. No

5. Are appropriate medical records, i.e. OSHA form 101 and 300, completed and
reviewed for each incident?
A. Yes 5
B. No

6. Employees with exposure to bloodborne pathogens been offered hepatitis B shots?

Yes No N/A 5

7. Have post exposure evaluations been provided and documented?

Yes No N/A 5

8. Are all employees who may be required to wear a respirator been given a physical as
required under 1910.(f)(3)(i)(B). (every twelve months)

Yes No N/A 5
MEDICAL PROGRAM (167 Points) (Continued) POINTS
POSSIBLE ACTUAL
9. Are prospective employees given a post-offer health examination?

Yes No
5

10. Do you have medical staff at your location?

Yes No
RN 8
LPN
EMT
OTHER

Which Shifts?
1st 2nd 3rd

11. Have any supervisors/employees received certified First Aid/CPR training?

Yes No
Is it current 5

If yes, how many?

12. a. Have first aid facilities been established by a medical doctor and/or hospital/clinic?
Yes No None
5

13. b. Have standing orders been provided and issued to the PAs,RN,LPNs or ENTs?
Yes No
Are they up-dated each year? 5

14. Is access to first aid supplies controlled and a first aid log maintained?
Yes No
Log not being used 5

15. Are first aid supplies updated as to their shelf life?

Yes No
5

16. Are the services of a medical doctor retained?

Yes No
5

17. a. Are annual health examinations given to any employees or employee groups?

Yes No N/A 5

b. If yes, are procedures established to ensure that all employees subject to the
physician actually get one?

Yes No N/A 5
MEDICAL PROGRAM (167 Points) POINTS
POSSIBLE ACTUAL
18. Are training programs in place for employees who are exposed to noise at or above
85 decibels?

Yes No N/A 5

19. Is the training for Hearing Conservation repeated annually for each employee?

Yes No N/A 5

20. Access to information and training materials under the Hearing Conservation
Program is posted and made available to employees and their representatives?

Yes No N/A 5

21. Audiometric (baseline) are given to each employee within the first six (6) months
of employment. If a mobile van test is used the test must be conducted within the
first year of employment.

Yes No N/A 5

22. At this location are employees tested annually after the baseline has been
established?
Yes No N/A 5

23. Is the clinic/first aid station clean and kept in a sanitary condition?
YES NO N/A 5

If so is their a written schedule for cleaning along with method of decontamination?

YES NO N/A 5

24. Are Biohazard signs and labels in use that are fluorescent orange or red?

YES NO 5

25. Do health care employees have food in the clinic/first aid station?

YES NO 5

Possible Points 167

X. EMERGENCY PREPAREDNESS 191 Points POINTS
POSSIBLE ACTUAL
1. Has a formal fire safety inspection program been implemented at this location?
A. Procedure outlined but not followed regularly; no documentation
B. Procedure followed but frequency and documentation need improvement
C. Regularly scheduled inspections using checklist; accurate documentation 15
D. No formal fire inspection program has been established

2. Which of the following apply to the emergency evacuation/exit routes from your
location?
A. All are 28" wide or more
B. All are free of obstruction
C. All are clearly marked
D. Access to all exits is not through any room's) subject to being locked
E. All exit doors open in an emergency, even if locked to prevent entrance
F. All exit doors are out-swinging if more than 50 employees use the exit route 16
G. All doors are marked "Exit"/"Not An Exit", are properly identified unless
obvious
H. Exit signs with arrows used where direction of travel is not immediately
apparent

3. Which of the following are included in your plant's written emergency action plan?
A. Emergency escape procedures
B. Emergency escape routes assignments
C. Procedures for employees who stay behind to control critical operations
D. A system to account for all employees
E. Assigned duties for employees responsible for medical care. 12
F. Established procedures for employees to report emergencies
G. No written emergency action plan has been established

4. Do all employees with specific functions within the emergency action plan receive
A. Yes, function-specific training conducted but not documented
B. Yes, function-specific training conducted but fully documented
C. Yes, function-specific training/periodic retraining conducted/documented 6
D. No function-specific training is conducted

5. Which of the following employee groups have received general training in the
emergency response procedures?
A. Senior plant management
B. Middle management
C. Line supervisors
D. Engineering
E. Maintenance 16
F. Medical personnel
G. Production employees
H. Contractors

6. Has a testing/evaluation program for the emergency response procedures been

established at this location?
A. Yes, but most procedures rarely tested and some not tested at all
B. Yes, but only limited testing program with no follow-up on evaluation
C. Yes, including fully monitored testing/evaluation program 6
D. No testing/evaluation program has been established
EMERGENCY PREPAREDNESS (191 Point (Continued) POINTS
POSSIBLE ACTUAL
7. Does your plant have an emergency evacuation plan?
Yes No
5

8. Does your plant have a written communication procedure for emergencies?

Yes No
5

9. Has the emergency team or other employees been trained in the use of fire
extinguishers and evacuation?
Yes No
5
Dates of training:

10. Do you conduct fire drills?

Yes No
5

Dates of last drill

11. Does your local fire department conduct or assist in fire drills? 5
Yes No

12. Does your local fire department conduct periodic inspections? 5

Yes No

13. Have you posted evacuation routes for all employees to observe?
Yes No 20

14. Does your plant have an emergency plan?

Yes No
30

If yes, does it cover the following:

Fire
Explosions
Tornado
Plant Re-entry
Shutdown of Utilities
Other (Please specify)

15. Has each department supervisor in the plant been provided with the emergency plan
instructions?
Yes No
 5

EMERGENCY PREPAREDNESS (191 Point (Continued) POINTS

POSSIBLE ACTUAL
16. Has the plant been provided with emergency lighting?
Yes No 5

17. Is someone responsible for maintaining the emergency lights?

Yes No
5

18. Are the emergency lights properly positioned to direct light at aisles, routes and exits
Yes No
5

19. Does this plant include a system to account for employees, contractors and visitors
in an emergency evacuation?

Yes No N/A 5

20. Is a written inventory of emergency equipment such as rescue equipment, personal

protective equipment, and medical supplies available?

Yes No N/A 5

21. Dose this location have a HAZMAT trailer that is used on all three shifts
Yes No N/A 5

If yes, do we have a company vehicle to move the trailer in an emergency?

Yes No N/A 5

Points Possible 191

XI. ACCIDENT RECORDING SYSTEM (55 POINTS) POINTS
POSSIBLE ACTUAL
1. Is the required OSHA injury recording system being completed every 5 days? 5
Yes No
Date of last up-date:

2. Is the required OSHA 300 log posted from February 1st through April 30th? 5
Yes No

3. Is someone in charge of the workers' compensation/claims program? 5

Yes No

4. Have proper claims management techniques been implemented? 10

Yes No

5. Are frequency and severity rates computed for your plant monthly? 10
Yes No
Date of last report:

6. Does top management receive periodic analysis reports? 10

Yes No
Date of last report:

7. Has a formal workers compensation report been developed and distributed each 10
month to:

a. Senior Management
b. Middle Management
c. Supervisors
d. Departmental Postings
e. All of the above
f. No formal report has been established

Points Possible 55
XII. SAFETY COMMITTEE (92 POINTS) POINTS
POSSIBLE ACTUAL
1. Do you presently have any active safety committees at your plant? 10
Yes No

If no please indicate if there has been and why it was disbanded:

2. What types of safety committees are presently active at your plant?

Executive Safety Committee

Departmental Safety Committee
Plant Safety Central Committee 12
Management/Employee Safety Committee
EIPMS Committee
Other (explain briefly)

3. Are minutes taken and distributed for each safety committee meeting?
Yes No 10
Date of last meeting?

4. Can employees volunteer to serve on the safety committee?

Yes No
5

5. Are safety committee members rotated on/off on a regular basis?

Yes No
5

6. Can you list some of the accomplishments of the safety committee for the past year?
Yes No
10

7. Are goals established for the safety committee?

Yes No
15

8. Has training been conducted with safety committee?

Yes No
15

9. Has management endorsed the safety committees work, and gives recognition to
employees? 10
YES NO

Points Possible 92
XIII. SAFETY COMMUNICATION (35 Points) POINTS
POSSIBLE ACTUAL
1. Are safety awards or other forms of incentives given to deserving employees for
safety achievements?
Yes No
10

2. Do you have an in-plant newspaper or newsletter that has safety and health articles?
Yes No
5

3. Do you have a safety suggestion system?

Yes No
5

4. Do you use any of the following in your safety communication program?

Yes No

Employee-of-the Month Program

Bulletin Board Safety Displays 10
Contests
Posters
Other (please specify)

5. Are you a member of the National Safety Council or any other safety organizations?
Yes No
5

If yes, please specify.

Points Possible 35
XIV. EMPLOYEE ORIENTATION (80 Points) POINTS
POSSIBLE ACTUAL
1. Is there a formal safety orientation program for new employees?
Yes No
15

2. Is a specific individual responsible for new employee safety orientation?

Yes No
Who: __________________________________________ 10

3. a. Is there a published booklet listing established safety rules and regulations?

Yes No
10

b. Is this booklet reviewed with all new employees (including office and shop)
during orientation?
Yes No
10

4. Do supervisory personnel have department checklists concerning particular department

hazards which must be pointed out to the new employee upon her/his arrival?
Yes No
10

5. Is the new employee evaluated periodically on her/his safety performance?

Yes No
5

If yes, please indicate how:

6. Are current employees trained immediately once new equipment or processes are 10
introduced into the department?
YES NO

7. Are supervisors currently using the four phases of safety training?

Prepare employee Present the job 10
Involve the employee Conduct follow-up

Points Possible 80
XV. PLANT HAZARD EVALUATION (93 Points) POINTS
POSSIBLE ACTUAL
1. Are formal plant safety inspections being performed?
Yes No
10

2. How often is the plant formally inspected for hazardous conditions and practices?
Monthly (20 pts.), Quarterly (15 pts.), Semi-annually (10 pts.), or Annually (5 pts.)
Yes No
20

3. Are supervisors, the safety committee or other responsible groups required to

perform routine plant safety inspections?
Yes No
How often: 10

4. Is there a follow-up system to ensure that identified hazardous conditions have been
corrected?
Yes No
10

5. Have supervisory personnel been trained in hazard recognition?

Yes No
10

Date of last training:

6. Are employees encouraged to report hazards and make safety suggestions?

Yes No
5

7. Are there any special safety inspections for the following?

Yes No
Boilers

Fire 8

Sprinklers

Other (specify)

8. Are outside contractors working on the premises required to abide by established

plant safety rules?
Yes No
10

9. Is there a method to inform outside contractors of specific hazards on the premises?

Yes No
10
Points Possible 93
XVI. DEPARTMENT SUPERVISION (150 Points) POINTS
POSSIBLE ACTUAL
1. Do supervisory personnel receive formal safety/loss control training monthly? 10
Yes No

If yes, indicate the subjects covered and date

2. Do supervisory personnel conduct the job training of all new employees?

Yes No
20

3. Do supervisory personnel use an employee contact program or five-minute safety

talks to communicate safety to employees?
Yes No 10

4. Are supervisory personnel required to make periodic hazard identification inspections

of their department?
Yes No
10

5. a. Is a written report made of their inspection findings?

Yes No
5

b. Is the inspection followed up routinely?

Yes No
5

6. Are staff supervisors evaluated and held accountable for their department safety
performance?
Yes No
10

7. Have supervisory personnel been trained in how to investigate accidents and make
meaningful reports?
Yes No
Date of Last Training 10

8. Do any management members receive and review all accident reports?

Yes No
10

9. Is there a method to inform outside contractors of specific hazards on the premises?

Yes No
20
DEPARTMENT SUPERVISION (Continued) POINTS
POSSIBLE ACTUAL
10. Are supervisors require to make safety contacts with departmental employees?
Yes Occasionally 10

Routinely None noted

If the supervisor is required to make contact with employees. Has he explained and
reinforced his expectations for safety performance
5
Yes No

11. Supervisors indoctrinate new employees to the safety and health issues in his
department?
Not done Occasionally 10
Routinely Documented

This practice is just as critical for transferring employees into his department. Has
he established documented training on transfer employees?

None Occasionally 5

12. Have supervisors defined safe behaviors they wish to see in their departments?
YES NO 10

Points Possible 150

XVII. PHYSICAL PLANT AUDIT/COMPLIANCE N/A Complies Does Not
MEANS OF EGRESS Comply
1. Dose this location provide sufficient exits for prompt escape
in case of emergency?

2. Inspection of all components of means of egress, including

doors, stairs, ramps, passages, and signs, to verify they are
reliable is completed each day by supervisors?

3. No locks or fastening devices that would prevent free escape

from the inside of the plant are used on emergency doors?

4. Exits are arranged to prevent them from being blocked at any

time.

5. All exits routes are clearly visible and marked so occupants

can fine the escape route?

6. All doors, passageways, and stairways that is not an exit or

has exit access that could be mistaken for an exit are
marked with NOT AN EXIT SIGN?

Possible score this section 30 Score

Fire Extinguishers N/A Complies Dose Not

Sprinkler System/Alarms and Warnings Comply
1. Only approved portable fire extinguishers will be used, and
must be mounted and identified so they can be readily
located without injury at ACME CO locations.

2. Do procedures for the inspection, maintenance, and testing

of all portable fire extinguishers exist?

3. Are records kept on the monthly fire extinguisher checks?

The annual maintenance check?

Fire extinguishers records on hydrostatic test?

4. Are supervisors at this location receiving proper training

annually on how to use the fire extinguisher?

5. Materials are keep 18 inches below the sprinkler head?

6. Has this location established an employee alarm system?

7. Will the alarm alert disabled employees?

Fire Extinguishers N/A Complies Dose Not

Sprinkler System/Alarms and Warnings (continued) Comply
8. Can alarms be heard, seen, or otherwise perceived by
everyone in the workplace?

9. How often is the reliability and adequacy of the alarms tested

10. Have all employees been trained in how to report an

emergency and how to sound the emergency alarm ?

11. Are emergency telephone numbers posted by each phone

in the production area with direction/location of emergency?

12. Are approved safety cans or acceptable containers used for

handling and dispensing flammable liquids?

13. Have all flammable liquids that are kept inside buildings
stored in proper storage cabinets?

14. Do you have an enforced NO SMOKING rule and if so are

NO SMOKING signs posted?

Possible score this section 70 Score

Electrical N/A Complies Dose Not

Comply
1. Is all equipment that uses electricity free from recognized
hazards likely to cause death or serious physical harm to
our employees?

2. Have power cords been spliced in the plant?

3. Are electrical parts arcing?

4. Have each disconnecting means and circuits for motors and

appliances been legibly marked to indicate its purpose?

5. Do power rooms have sufficient access and working space

free from equipment storage and work shops for maintenance

6. Is the workspace in front of electrical equipment 36 inches

wide?

7. Are power rooms, vaults, or similar enclosure accessible

only to qualified persons?
8. Do electrical breaker boxes have exposed live parts that
employees could come in contact with?

Electrical (continued) N/A Complies Dose Not

Comply
9. Is proper illumination provided for all working spaces around
electrical equipment?

10. Are all electrical cords strung so they do not

hang on pies, nails, hooks, etc?

11. Do switches show evidence of overheating?

12. Is there evidence that electrical cords are cut or fraying?

Possible score this section 60 Score

Ergonomics N/A Complies Dose Not

Comply
1. Has employee capabilities and limitations been considered
in material handling designs?

2. Doses material handling designs promote the use of hoists,

scissor lifts, and carts?

3. Has constant lifting been eliminated or minimized?

4. Has adequate attention been given to lighting, heat, cold,

noise, and vibration?

5. Are employees using PPE that fits.

6. Are employees using gloves that fit and in the right number?
7. Is this location doing a job rotation?

8. Have operations been designed to avoid crawling, stooping,

or overreaching?
Possible score this section 40 Score

Walking/Working Surface N/A Complies Dose Not

Comply
1. Are pedestrian aisles clear from obstructions?

2. In aisles, are employees and vehicles adequately separated?

3. Is the walking surface slip-resistant and in good repair?

4. Do all drains have covers and are they level?

5. Are floors designed to stay dry, as will as elevated work-

stations?

6. All elevated workstations are designed with hand rails. Mid

rails and toe boards?

7. All areas of the plant have adequate entrance and egress

paths?

8. Are stairways in good condition and standard railing provided

for every flight having four or more risers?

9. Are convex mirrors at blind corners in use?

Possible score this section 45 Score

Machine and Equipment Guarding N/A Complies Dose Not

Comply
1. Are all machines or operations that expose operators and
other employees to rotating parts, pinch points, flying chips
or meat, adequately guarded?

2. Are mechanical power transmission belts guarded

3. Have all exposed shafting less than 7 feet from the floor been
guarded?

4. If compressed air is used for cleaning, has it been reduce to

30 psi or less?

5. Are power saws, and band saws used for cutting meat
provided with safety guards, and are they properly adjusted?
6. Have grinding wheels been inspected, tool rest set to within
1/8 inch or less of the wheel?

7. Is our maintenance department management team inspecting

our maintenance employees tools for tool conditions like
burred ends, and cracked handles?

Machine and Equipment Guarding (continued) N/A Complies Dose Not

Comply
8. Are compressed gas cylinders inspected regularly for signs
of defects, rusting, and leakage?

10. Have gas cylinders been handled properly, and placed into
storage as to protect the valves from damage?

11. Do jacks and forklifts get inspected at the start of each shift?

12. Do forklifts have the following safety equipment:

a). Seat belts
b). Horn
c). Backup alarm
d). Overhead guard
e). Load backrest

13. If this location has fixed ladders, are they adequate, and are
they in good condition, no rust, equipped with side rails or
cages or special safety climbing devices.

14. Are portable wood, metal or fiberglass ladders adequate for

their purpose, and in good condition? (look at footing)

Possible score this section 60 Score

General Safety And Health N/A Complies Dose Not

Comply
1. Are waste receptacles provided, and are they emptied
regularly?

2. Are washing facilities provided and kept clean?

3. Do toilet facilities meet OSHA requirements, and are they

sanitary?

4. When lunches are eaten on the plant property, are they

eaten in areas where there is no exposure to toxic materials
and not in toilet facility areas?

5. Have all areas at this locations been provided with adequate

 lighting?

6. Is provided ventilation equipment that is used for the removal

of air contaminants operating properly?

7. Is all PPE maintained in a sanitary condition and readily

available for use?

Possible score this section 35 Score

Shipping/Loading dock safety N/A Complies Dose Not

Comply
1. If wheel chocks are used at this location, are dock workers
rather than truckers responsible for placement of chocks?

2. Are ckocks of suitable design and construction?

3. Are we using two chocks for each position?

4. If chocks are in use, are the trailers chocked on both sides?

5. Are vehicle restraints used? If so have employees been

trained in how to use them?

6. Are there warning signs and light used both inside and out
that tells both employees and truckers that the trailer is
secured and when it is not?

7. Do dock restraints need repair or replacement?

8. Are dock levelers working properly?

9. If dock plates are in use, are the plates length, capacity, and
curbed sides adequate?

Shipping/Loading (continued) N/A Complies Dose Not

Comply
10. Are all dock door rails protected by bumper post, and are all
doors in good repair?

11. Do seals and shelters need repair?

12. Are dock lights adequate inside trailers?

13. Are the following in use?

a.) Driver candidate screening for jacks and forklifts
b.) Driver training and licensing
c.) Periodic driver retraining
 d.) Written vehicle safety rules

14. Is pedestrian traffic restricted in dock areas?

Possible score this section 70 Score