A Workplace Accident and Injury Reduction Program · PDF fileAppendix E Employee Training and Instruction Record 68 Appendix F ... Accident and Injury Reduction Program ... A Workplace

A Workplace Accident and

Injury Reduction Program

For

XYZ Company

Required for all Minnesota Businesses with 25 or More Employees

Incorporates Provisions of Minnesota Statutes Chapter 182.653, Subdivision 8

Americana Safety. All rights reserved.

Minnesota - A Workplace Accident and Injury Reduction Program


Table of Contents

Section Description Page

1 Management Commitment 3

2 Assignment of Responsibilities 4

3 Safety Committees and Meetings 10

4 Hazard Identification and Analysis 13

5 Hazard Prevention and Control 23

6 Accident Investigation and Reporting 33

7 Emergency Planning 40

8 Safety and Health Training 49

9 Company Required Safety Programs 52

10 Company Required Safety Training Courses 53

11 Company Required Safety Forms & Checklists 55

12 Program Review 57

Appendices:

Appendix A List of Training Subjects 61

Appendix B Hazard Assessment Checklists 63

Appendix C Hazard Assessment and Correction Record 64

Appendix D Accident/Exposure Investigation Report 66

Appendix E Employee Training and Instruction Record 68

Appendix F Source of Information – MN OSHA 70

Appendix G Minnesota OSHA Area Offices 71

Appendix H Employee Acknowledgement Form 73



Section 1

Management Commitment

Program Policy Statement

XYZ Company shall comply with all occupational safety and health laws of the State of

Minnesota.

To accomplish this, we must constantly be aware of unsafe acts and conditions in all work areas

that can produce injuries. No employee is required to work at a job they know is not safe or

healthful.

As employees of XYZ Company, your cooperation in detecting hazards and, in turn, controlling

them, is a condition of your employment. Inform your supervisor immediately of any situation

beyond your ability or authority to correct.

Program Requirement

This written program is required for all businesses within the State of Minnesota.

This program incorporates and complies with the provisions of Minnesota Statutes Chapter

182.653, Subdivision 8.

Proper use of this program requires the Program Administrator to carefully review the require-

ments for each of the program sections, appendices and to modify, where necessary, to accu-

rately 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.



Section 2

Assignment of Responsibilities

1. Program Administrator

Written Safety and Health Program administrator, Program Administrator has the authority

and responsibility for implementing the provisions of this program.

DECISION POINT – Enter a name or position title (recommended)

The Program Administrator for XYZ Company is

_______________________________________.

Company Responsibilities

XYZ Company responsibilities shall including the following:

1. Provide support from the top level down to first line supervisors in terms of time, effort,

and money.

2. Resolve scheduling and personnel conflicts.

3. Provide realistic dates for correcting safety and health concerns.

4. Support training for safety committee members.

5. Provide leadership and direction.

6. Participate in safety committee meetings.

7. "Talk up" the positive effects of safety committee activities, on a one-on-one basis or in-

group meetings.

8. Respond to recommendations in a timely manner.

9. Ensure lines of communication are open and non-threatening.



Section 3

Safety Committee and Meetings

DECISION POINT - If a Safety Committee is not established state reason.

1. Safety Committee

XYZ Company has formed a safety committee to help employees and management work togeth-

er to identify safety problems, develop solutions, review incident reports and evaluate the effec-

tiveness of our safety program. The committee is made up of management-designated repre-

sentatives 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 reg-

ular inspections of the workplace

C. Membership



Section 4

Hazard Identification and Analysis

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 “Em-

ployee’s 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 “Employee’s 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 devel-

oping safe work procedures and safety and health training.



Section 5

Hazard Prevention and Control

1. Eliminating Workplace Hazards

XYZ Company is committed to eliminating or controlling workplace hazards that could cause

injury or illness to our employees. We will meet the requirements of state safety standards

where there are specific rules about a hazard or potential hazard in our workplace. When-

ever 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 protec-

tive 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 Manual 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 proce-

dures; and



Section 6

Accident Investigation and Reporting

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 com-

plete 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, docu-

ment 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.

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 possi-

ble after the incident, the condition of equipment and any anything else in the work area

that may be relevant.



Section 7

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 ex-

its, 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 evacua-

tion 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 ex-

perts or special consultants where possible, and on an as needed basis.

Emergency procedures shall be updated whenever changes are made in materials, equip-

ment or building structures.



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 fol-

lowing 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



Section 9

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



Section 10

Company Required

Safety Training Courses


following safety training courses are included in our Injury and Illness Prevention Program:

For convenience, courses listed in the 3 tables below are alpha sorted.

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

Company Required Safety Training Courses – Sorted A-E

Accident Investigation Construction Safety Management

Accident Prevention Signs & Tags Crane Safety – Refresher

Asbestos Safety Cranes & Derricks in Construction

Bloodborne Pathogens – Initial/Refresher Electrical Safety

Bloodborne Pathogens – Train-the-Trainer Emergency Exit Routes

Chemical Spills Emergency Response Team

Competent Persons Ergonomics – Basic Human Factors

Compressed Gas Cylinder Ergonomics – Advanced Human Factors

Concrete & Masonry Excavation Safety

Confined Space Entry Eye & Face Protection

Table 2



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



Section 11

Company Required

Safety Forms & Checklists


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

For convenience, forms listed below are subject sorted.

DECISION POINT – Review and select those forms that apply or included others not listed

CONFINED SPACE

Confined Space Entry Permit Confined Space – Class A & B Permit Confined Space – Class C Permit List of Authorized Entrants Permit Required Confined Space – Inventory Log

CONSTRUCTION INDUSTRY - SAFETY MANAGEMENT

Construction Industry Inspection Checklist Job Start-Up Checklist Contractors Job Site Checklist Contractor Safety Performance Report Construction Equipment Checklist Forklift Service Checklist Operator Performance Evaluation Checklist Safety Nets Inspection Checklist Body Harness & Lanyard Inspection Report Competent Person Evaluation – Fall Protection

CRANE OPERATIONS

Cranes, Derricks or Material Handling Devices Worksheet Crane Inspection Checklist Crane Pre-Lift Checklist Sling (Chain) Inspection Report Monthly Hoist Rope Inspection Report Monthly Hoist Hook Inspection Report

EMERGENCY ACTION AND RESPONSE Crisis Management Response Team - Contact Log Safety Representatives - Contact Log External Resources – Contact Log Vulnerability Analysis Chart Bomb Threat Checklist Employee Evacuation - Accounting Log Physically Challenged – Employee List Command Post Equipment Inventory Log Press Information Log Post Exercise Evaluation Report



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



Section 12

Program Review

The AWAIR Act requires employers to review the entire program at least annually and document

the findings. Program review is vital, because it serves as a check to see if the organization is

making progress towards its goal of creating a safer, healthier workplace for all employees.

The second reason for conducting a review or audit of the workplace safety and health program

is to determine whether the procedures used in the facility are consistent with those described

in the program and if they are effective. For example, if the audit shows there are injuries and

illnesses occurring from hazards that have not been identified or controlled through the meth-

ods described in the safety and health program, the auditor needs to determine if the methods

are being used in the facility correctly and as described in the program. If the methods are not

being used or are used incorrectly, the auditor needs to determine what barriers are present

that prevent the correct application of the methods (e.g., production demands, supervisor work-

loads or lack of training). If the hazard identification and control techniques are being applied

correctly, then the organization needs to further review the techniques and, perhaps, modify

them or adopt new ones.

The primary focus of the evaluation effort should be whether the organization has made pro-

gress in achieving the AWAIR program’s goals and objectives within the past year and, if so,

whether the progress made actually improved worker safety and health. If an organization has

achieved the goals and objectives described in its safety and health program, it should set new

goals and objectives for the coming year to motivate managers and employees to work to fur-

ther improve safety and health on the job. The organization, its management and its employees

should continually work to improve workplace safety, just as they do to improve quality, cost

effectiveness and other facets of the business.



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 equip-

ment.

5. Safe procedures for cleaning, repairing, servicing and adjusting equipment and machinery.

6. Safe access to working areas.

7. Protection from falls.

8. Electrical hazards, including working around high voltage lines.

9. Crane operations.

10. Trenching and excavation work.

11. Proper use of powered tools.

12. Guarding of belts and pulleys, gears and sprockets, and conveyor nip points.

13. Machine, machine parts, and prime movers guarding.

14. Lock-out/tag-out procedures.

15. Materials handling.

16. Chainsaw and other power tool operation.



17. Tree falling/bucking procedures and precautions, including procedures for recognizing and

working with hazard trees, snags, lodged trees, and unsafe weather conditions.

18. Yarding operations, including skidding, running lines, unstable logs, rigging and communi-

cation.

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 _____________________________________________



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

Documents

A Workplace Accident and Injury Reduction Program · PDF fileAppendix E Employee Training and Instruction Record 68 Appendix F ... Accident and Injury Reduction Program ... A Workplace