INJURY AND ILLNESS PREVENTION PLAN · Web viewOSHA Log records will be maintained for five years...

INJURY AND ILLNESS PREVENTION PLAN

Enter Company Name

You must make this program specific to your operations to be OSHA compliant.Bold Red Text and Form Fields were incorporated to flag areas that require customization.

THIS IS ONLY A TEMPLATEDelete the instructions when modifying this program.

COMPANY STATEMENT OF COMMITMENTOur mission is to provide a safe and healthful work environment for all employees and to prevent injuries and illnesses by establishing a proactive safety culture. At Enter Company Name, safety is considered a priority, equal in importance to both production and quality. Safety is the responsibility of all employees and we must work as a team to prevent injuries.

Your thoughts regarding safety and health issues are important to Enter Company Name. Any employee having a safety or health concern related to his or her employment shall have the opportunity to communicate the concern either verbally or in writing to their immediate supervisor, manager, Safety Coordinator, or safety committee member without fear of retaliation.

Goals of the IIPP include: Developing, implementing, and managing an effective safety program to assure a safe,

healthful, and productive workplace and compliance with applicable state and federal regulations

Developing an incident-free work environment and a place where employees feel valued

Encouraging the responsibility and participation of all employees and management in the organization's safety efforts

Providing ongoing safety training to employees and management so that an understanding of hazards and respective safety requirements are established and supported

Reducing the cost of insurance which can result in greater company profitability

A copy of our Injury and Illness Prevention Program is located here:

For this facility and operation, the following person will lead the development, implementation, and updating of the IIPP and safety programs which are a part of the IIPP:

Name: Title:

Thank you for your efforts towards making safety a priority within this organization.

Signature of Company President Date

*If you have multiple locations, copies of your IIPP and safety programs should be readily available at each location.

Company Name Revision Date of 25

TABLE OF CONTENTSRoles and Responsibilities .........................................................................

4Compliance and Disciplinary Action .........................................................

6Communication .........................................................................................

7Hazard Identification and Assessment .....................................................

7Incident Investigation ...............................................................................

8Hazard Correction and Control ................................................................

9Training and Education .............................................................................

10Recordkeeping Requirements ..................................................................

11Appendix A: Code of Safe Practices.........................................................

12Appendix B: Safety Action Plan ................................................................

16Appendix C: Safety Programs ..................................................................

18Appendix D: Accident Investigation Form ………………………...............

19Appendix E: Accident Investigation Witness Statement Form …............

20Appendix F: Training Sign-In Sheet ..........................................................

23Appendix G: Employee Acknowledgment Form....................................

25


ROLES AND RESPONSIBILITIESEveryone at Enter Company Name is responsible for helping to maintain a safe and healthy work environment for all employees within the organization. All employees will be involved in ensuring the program is a success.

Safety CoordinatorSafety Coordinator is assigned the responsibility and the authority to implement and maintain the IIPP for the organization.

The Safety Coordinator will: Develop and administer the safety and health program Provide support and direction in the training of personnel Develop a process to ensure that new employees are trained on general safety

procedures Monitor the implementation and enforcement of the program Publish and distribute the minutes of safety meetings to appropriate staff Monitor the investigation of accidents and ensure documentation is complete Monitor corrective action necessary to address safety hazards and prevent incident

recurrence Prepare safety and health bulletins, posters, and publicity as needed Maintain the accident and incident report Plan and coordinate inspections, committee meetings, and training sessions Review and update the program as needed

Managers/Supervisors Managers/Supervisors will assist the Safety Coordinator and be responsible for the following:

Handle emergency situations and complete accident investigations. Report all incidents and injuries to Safety Coordinator.

Model and enforce safe work practices for employees and visitors Implement the IIPP in assigned work areas Inspect work areas and report any identified workplace hazards Correct any unsafe conditions brought to managers’ attention by employees Encourage employees to report hazardous conditions, injuries, near misses, and all

incidents Conduct regularly scheduled meetings to address occupational health and safety Encourage employee involvement in safety committees Discipline employees who disregard workplace safety requirements per the

organization’s disciplinary process Train employees in the hazards and respective controls associated with their work area Recommend safety and health improvements to the safety committee or upper-level

management Resolve safety issues discovered through incident reports, the safety committee, or

inspections in a timely manner using Appendix B: Safety Action Plan Correct OSHA-identified hazards by the given deadline

EmployeesEmployees are responsible for working safely and maintaining a safe and healthy workplace. In support of the company’s safety and health effort, employees will:


Obey all safety and health regulations as stated in the company safety programs Keep work areas neat and orderly Attend all required safety training Immediately report all hazardous conditions, injuries, and near misses to management

or a safety committee representative Provide recommendations to the safety coordinator for improving the safety and health

of the work environment Cooperate with workplace inspections and incident investigations

Safety Committee Members Safety committee members have the responsibility to:

Attend and actively participate in all safety committee meetings Solicit safety suggestions from employees Relay safety committee agenda items, findings, and current safety topics to your

department Conduct quarterly walk-through safety inspections for each department using a

checklist or other form of documentation Identify hazards and recommend any needed safety improvements Record in the Safety Action Plan corrective actions to be taken, the person responsible

for implementing the corrective actions, and the targeted completion date. See Appendix B: Safety Action Plan.

Post and distribute reports to management Participate in incident investigations


COMPLIANCE AND DISCIPLINARY PROCEDURES Management is responsible for ensuring all safety and health policies and procedures are clearly communicated and understood by all workers. Managers and supervisors are expected to enforce the rules fairly and uniformly. All employees are responsible for using safe work practices, for following all directives, policies, and procedures and for assisting in maintaining a safe work environment. See Appendix A, Code of Safe Practices.

The following is our system of ensuring that all workers comply with the rules and maintain a safe work environment:

Informing workers of the provisions of our IIPP Evaluating the safety performance of all workers Recognizing employees who exhibit safe work behavior. This recognition is

accomplished by:

If you have a Safety Recognition Program, describe it here. If you do not, delete this bullet.

Providing training to workers whose safety performance is deficient Disciplining workers for failure to comply with safe work practices. The following

outlines our disciplinary process:

This policy is intended to provide rules and guidelines for administering disciplinary action to employees who violate safety rules and procedures or who, by their record or actions, indicate a disregard for safety.

Safety-related disciplinary action would be administered in conjunction with management, the Safety Coordinator, and the Human Resources Department.

Failure to comply with safe work procedures will lead to disciplinary action. This plan is progressive and consists of four tiers.

Verbal Warning Written Warning Suspension Termination

Depending on the seriousness of the violation, an employee may be subject to disciplinary action up to and including dismissal. A copy of the Disciplinary Action Plan is provided by Human Resources during New Hire Orientation and is available upon request.

Other means that we use to ensure employee compliance with safe and healthful work practices include: (Document any other means used or delete this sentence.)


COMMUNICATIONOpen communication about safety must flow both ways, from management down to employees and from employees up through management channels.

Safety communications can include the following: Report of incidents and near-misses by employees to management New hire orientation, including a discussion of safety and health policies and procedures

and a review of the IIPP and Code of Safe Practices (Appendix A) Training programs covering job hazard analysis (JHAs) and safety programs and

applicable State and Federal regulations Open discussion about safety at departmental meetings Employee communication through departmental safety committee representatives to

the central safety committee Posted, distributed, and accessible safety information such as OSHA posters, safety

data sheets (SDSs), and written safety programs Safety suggestion forms which are available for employees to report any hazardous

conditions or issues (anonymously, if needed)

HAZARD IDENTIFICATION AND ASSESSMENTIt is the responsibility of every employee to assist in the identification of hazardous conditions or unsafe actions of employees to prevent losses and injury. Enter Company Name will use Job Hazard Analysis (JHAs) and hazard assessments or inspections to identify and evaluate workplace hazards.

Inspection types:Safety committee inspections: Safety committee members will conduct periodic inspections to identify and evaluate workplace hazards. Safety committee members must also solicit input from employees regarding hazards in their work areas and assess and document them completely.

Management inspections: Department managers will conduct safety observations of employee work practices and periodic hazard assessments. They must perform inspections:

At least When new substances, processes, procedures, or equipment, which presents

potential new hazards, are introduced into our workplace When new, previously unidentified hazards are recognized When occupational injuries and illnesses occur When workplace conditions warrant an inspection (e.g., when any non-routine task

is to be conducted)

Employee inspections: Employees will assist in performing routine safety inspections as directed by management.


Jobsite inspections: Lead personnel on a jobsite will inspect the jobsite on a daily basis prior to beginning work and notify all employees of identified hazards and corrections/procedures to address these hazards.

Job Hazard Analysis (JHAs):JHAs analyze each job step to identify uncontrolled hazards and establish controls to address these hazards. Conducting JHAs helps you to reduce the likelihood of incidents and injuries in the workplace. Involve employees and gain their input throughout the process.

The JHA process:

Break down jobs into their steps or job tasks Identify existing hazards in each job step and consider what controls will work to resolve

them Set priorities for correcting identified hazards Review and analyze past safety incidents to identify trends

Reports and documentation:All inspectors must:

Complete the Hazard Assessment form/checklist Submit the completed Hazard Assessment form/checklist to. Safety Coordinator who is

accountable for taking follow-up actions, if needed If a condition that is immediately dangerous to life or health (IDLH) is observed, notify

the appropriate personnel and stop work in the area until the hazard has been corrected

INCIDENT INVESTIGATIONAll near misses and incidents must be reported to Safety Coordinator and investigated. Refer to GoSafe for more information and training related to Accident Investigation. The main purpose of the investigation is not to determine who was at fault but to identify the root causes that contribute to injuries so that corrective actions can be taken.

After a serious injury or fatality, any equipment involved in the incident should be removed from service pending investigation. The equipment should be inspected prior to returning to service to ensure that it operates properly and all guards are in place.

Investigation:Management is responsible for overseeing the investigation process following an incident involving an employee in their department. The investigation must be done immediately. An Accident Investigation Form is located in Appendix D.


The investigator must: Identify hazards, root causes, and corrective actions Document investigation results in the Accident Investigation Form and retain these

records Inform management of the results of the investigation so that appropriate action can be

taken

HAZARD CORRECTION AND CONTROLManagement is responsible for implementing a plan to ensure a safe working environment, to correct and control the hazards, and assure that the corrective actions are effective and sufficient.

Hazard Correction and Control includes the following: Document and track all actions taken to correct and control hazards in the Safety Action

Plan Prioritize corrective actions so that safety-related issues are addressed promptly Review the JHA to assure the hazard has been adequately addressed and develop a

new JHA if needed Assure that affected employees are aware of all noted hazards and plans to correct

them

Specific practices used to address hazards can include: Elimination of the hazard, if possible. (For example, this might involve substituting a

hazardous material with a non-hazardous one) Development of engineering controls to limit or prevent exposure Implementation of administrative controls (e.g., policies and procedures, training, etc.).

These are the second line of defense after engineering controls. Provision of Personal Protective Equipment (PPE) for employees. This is a last resort

after engineering and administrative controls Assure that interim controls are in place if hazards cannot be controlled immediately.

Do what it takes to safeguard staff until permanent controls are put in place Stop any unsafe work practices and provide retraining to employees, if needed


TRAINING AND EDUCATIONManagers are responsible for informing employees about all hazards in the workplace. Safety Coordinator will ensure that all education and training sessions are scheduled and completed as necessary but must address both general safety and job specific procedures.

Training related to the IIPP will be conducted by . Employee training will be conducted at least once a .

Training content:Training must cover the following:

Your Safety Program, including the IIPP and any other safety-related programs identified in your hazard assessment. Refer to Appendix C.

Hazards specific to employees’ individual job assignments Controls including, but not limited to, safety procedures and Personal Protective

Equipment (PPE) specific to employees’ individual job assignments

Training frequency:Training must occur:

As soon as possible for new employees, preferably before starting work For employees beginning new job assignments For employees being temporarily relocated to another type of machinery or equipment When the IIPP is first established When a new or previously unrecognized hazard is discovered When new substances, processes, procedures, or equipment are introduced to the

workplace and represent a new hazard Periodically, in the form of refresher training

General requirements:Both employees and management must be trained. Management must be aware of hazards that the employees under their direction may be exposed to.

Training must be conducted in a language and vocabulary that trainees understand.

All training must be documented. One on one training and certifications are maintained in each employee’s file. Group training, such as safety and tailgate meetings, are documented using a sign in sheet like the one in Appendix F.


RECORDKEEPING REQUIREMENTSSafety Coordinator oversees recordkeeping.

Records to be kept: OSHA 301, 300, and 300A forms Hazard assessment and correction forms, which identify the following:

o Hazardso Work practices and actions taken to correct hazards o Safety work orderso Action planso Those who conducted the assessmentso Those responsible for making correctionso The target dates and completion dates for corrections

Employee training and instruction forms for each employee, which include their names or other identifiers, training dates, types of training, and trainer name

Other technical safety programs, such as respiratory protection, have additional recordkeeping requirements (for example, air monitoring records)

Duration: OSHA Log records will be maintained for five years following the end of the calendar

year that the records cover. Inspection records should be maintained for a minimum of five years. Training documentation should be maintained for the duration of employment plus five

years. Any exposure or medical records are to be retained for the duration of an employee’s

employment plus 30 years.

Documentation method:Documents can be found in .


Appendix A – Code of Safe Practices

Employees are responsible for working safely and maintaining a safe and healthy workplace. Failure to follow safety & health guidelines could result in disciplinary action.

THIS IS NOT AN ALL-INCLUSIVE LIST OF ALL OF THE RULES THAT SHOULD APPLY TO YOUR WORKPLACE. You should add and delete rules to address your specific exposures and operations.

Safe behaviors: Never work under the influence of drugs or alcohol. We are a drug-free work

environment. Anyone known to be under the influence of drugs or intoxicating substances that impair their ability to safely perform the assigned duties shall not be allowed on the job while in that condition. Report the use of prescription drugs that might cause drowsiness or might impair your ability to do your job safely to management at the start of every shift.

Do not work when you are impaired with fatigue, illness, or another potential cause for incident or injury.

Do not engage in horseplay or any activities that may have an adverse influence on the safety or well-being of other employees.

Do not run in the workplace. Walking or climbing on equipment is prohibited. Never access an area with moving parts or place any body part in a hazard zone of

machinery or equipment (e.g., a point of operation), unless trained and authorized. Never stand on, under or near any suspended load (e.g., on a crane or lift). Do not smoke in any area of our facility. Do not enter confined spaces, i.e., manholes, underground vaults, chambers, tanks,

silos, or other similar places that receive little ventilation, unless they have been determined safe to enter per the Confined Space Entry Program.

Reporting: Report all incidents and near misses to management, even if they do not result in an

injury. Report unsafe working conditions, unsafe practices, or defective tools and equipment to

management immediately. Red tag and remove defective tools and equipment from service immediately, so nobody else will use them.

Ergonomics: Ensure your workspace is properly designed to avoid injury. Notify your supervisor of pain and discomfort immediately so that an ergonomic

evaluation can be completed. Lift with your legs, not your back. Do not move items that are too heavy, large or bulky without assistance or the use of a

lifting aid.

Housekeeping: Keep all exits, emergency equipment and electrical panels unblocked. Maintain clear walkways and aisles at all times. Tape down all cords or insert in rubber anti-trip protectors to prevent trips. Keep your work area clean. Don’t stack materials on top of lockers or file cabinets. Wipe up spills promptly.



PPE: Use personal protective equipment (PPE) at all times as required. Maintain your company provided PPE including cleaning it, as needed. Inspect your PPE regularly for wear or defects. Wear the company approved footwear for your job. Wear safety glasses any time you may be exposed to particles or flying objects.

Machine safety, electrical safety, and equipment care: When working around machinery, do not wear loose clothing, have loose hair or jewelry,

as these can get caught in the machinery and pull you in. Do not handle or tamper with any utilities associated with electrical equipment,

machinery, or air or water lines in a manner not within the scope of your duties. Do not remove guards or other protective devices. Never operate machinery without guards or safeguards in place. If guards or protective

devices are not properly in place or firmly adjusted, report deficiencies promptly to management.

are the only people authorized and trained to perform work involving lockout/tagout.

o Do not try to repair or de-jam any equipment without authorization. o If you are authorized to make repairs, make sure that all equipment is

deactivated, locked and tagged out. Do not use compressed air to clean your clothing. Do not use defective or improper tools or machinery. It must be immediately removed

from service and repaired or replaced. The following rules pertain to electrical equipment:

o Keep electrical panels closed. o Assure that electrical panels are clearly marked to indicate equipment/circuits

controlled by specific breakers.o Keep the ground intact.o Consider all electrical equipment being assembled or tested “live.” o Use ground fault circuit interrupters in wet areas.

When working with electrical hand tools, make sure the ground is intact and that all insulation is sound.

Ladder safety: Utilize the proper type and size of ladder for the job. For extension ladders, maintain the 4:1 rule (vertical rise to horizontal slope), and

secure the top of the ladder. Do not utilize the top two rungs on a stepladder. Assure that ladders are sturdy and in good condition. Immediately red tag and remove

from service if this is not the case. Prior to climbing, ensure that the ladder is stable and cannot shift. Use three points of contact when climbing. Do not carry items (except on a tool belt). Only one person may climb the ladder at a time.

Welding: Welding and any hot work requires the authorization of the person responsible for

cutting or welding operations, or the issuance of a hot work permit, prior to starting. Unless welding, stay away from welding and grinding areas.



Assure that welding curtains are used to protect employees working in adjacent areas or walking by.

Forklift and powered industrial truck safety: Do not use a forklift or powered industrial truck unless you are properly certified and

authorized to do so. When in the shop, assume that forklift/pallet jack operators do not see you. For certified operators:

o Only one person at a time is permitted on the equipment. o Keep loads low, and keep weights within limits. o Wear seat belts during operation.

Chemical use: Only use chemicals if you have been trained on their safe use and you have completed

Hazard Communication Training. Always add acid to water; never add water to acid. Always wash hands with soap and water after handling any chemicals. Do not use any chemical unless the container is clearly and correctly labeled. Do not taste or sniff chemicals, solvents, or any processing solution. Use all chemicals under proper ventilation. Always check ventilation gauges, if present,

to be sure of proper function prior to operating/charging. Tightly close all chemical containers after use and return them to the proper storage

cabinet (i.e., acid, base, peroxide, or flammable). Assure that chemical products are stored with compatible chemicals (e.g. avoid storing

acids near bases or flammables near oxidizers). Do not store chemical containers on floors; they should be stored in spill containment

receptacles that can contain the full capacity of any spill. Use proper procedures and labeled waste containers for disposal of all chemicals. Eating, drinking, or smoking is not permitted in any chemical use/storage area.


Appendix B - Safety Action Plan

Purpose: Manage and provide accountability for follow-up of all safety-related corrective actions.

1. List conditions that require attention or correction. Explain why you are taking the action to help with prioritizing.

Example Action Items include those which pertain to safety committee tasks, hazard identification findings, behavioral-based safety observations, incident trend analysis, safety training development, reviews of written safety policy and program documentation.

2. A three tier priority system is recommended – High, Medium, Low, or 1, 2, 3. Limiting the number of high priority items keeps your organization focused on next steps. Reprioritize as action items are completed or added.

Action Item1 Responsible Individual(s)

Targeted Completion Date

Actual Completion Date

Priority2


Appendix B - Safety Action Plan

Action Item1 Responsible Individual(s)

Targeted Completion Date

Actual Completion Date

Priority2


Appendix C – Safety Programs

Instructions: Conduct a hazard assessment to discover which safety programs your facility needs. The following is a list of commonly required programs and should be converted into a list of your existing safety programs. Remember, your IIPP cannot be used in lieu of creating specific safety programs for hazards to which employees may be exposed. This list is not all inclusive. Delete any programs that do not apply to your operations and add any programs that are needed but not listed. Items listed in black generally apply to all workplaces.

Bloodborne Pathogens Chemical/Substance-Specific Written Programs (e.g., lead, asbestos, silica) Confined Space Entry Driving Safety Policy for Non-Commercial Drivers Electrical Safety Emergency Action Plan Ergonomics Policy Fall Protection Policy Fire Prevention Plan Fleet Safety Policy Forklift/Powered Industrial Truck Operation Policy Hazard Communication/GHS HAZWOPER Heat Illness Prevention Plan Hot Work (including welding, cutting, and brazing) Incident Investigation Plan Lockout/Tagout Policy Medical Services (including first aid/CPR/AED) Noise and Hearing Conservation Program Personal Protective Equipment (PPE) Program Respiratory Protection Program Safety Committee Program Spill Prevention and Response Plan Substance Abuse Policy Workplace Violence Prevention Program


Appendix D – Accident Investigation Form

Instructions: Obtain statements from the injured employee and any witnesses to describe what happened, what caused the incident, and what the contributing factors to the incident were. To do this, reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. Provide copies of the completed form and all Witness Statements to the designated Safety Coordinator.Injured Employee DataEmployee Name Date of Incident Time of Incident

a.m. p.m.Near Miss On Site First Aid Only Medical Treatment

Required OSHA Reportable (8 hour limit)

Incident Description:Describe the injury. Specify the affected body part(s) and injury type (or indicate no injury occurred if it was a near miss):

List persons involved and witnesses, if any: What equipment or tools were involved?

Where did the incident happen? Provide a full description of the surroundings of the location and any environmental factors:

What events led up to the incident? Describe the sequence in order and when each took place:

How did the incident occur?

Why did the incident occur? Try to identify the root cause by asking why. Use the worksheet on the next page to help with your analysis.

Additional InformationProvide any additional information important to the investigation (pictures taken, evidence collected).

Initial Investigator:Incident Investigator Name Date of Investigation Time of Investigation

a.m. p.m.



Select all CONDITIONS that contributed to the incident. Close Clearance/Congestion Floors/Work Surfaces Poor Housekeeping

Hazardous Placement Inadequate Ventilation Equipment Failure

Inadequate Warning System Inadequate Illumination Hazardous Materials

Improper Material Storage Inadequate Guards/Barrier Defective Tools/Equipment/Vehicle

Inadequate/Improper PPE Equipment/Workstation Design Illness or health condition

Unexpected Movement Protruding Object Exposure to Extreme Enviro. Conditions

Other

Select all ACTIONS or INACTIONS that contributed to the incident. Failure to Make Secure Use of Defective Equipment Failure to Use PPE

Improper Lifting Improper Technique Improper Loading

Improper Use of Equipment Unauthorized Actions Operating At Improper Speed

Violation of Job Procedure Unsafe Position or Posture Used Wrong Tool/Equipment

Horseplay/Distracting/Teasing Coworker’s Actions Under Influence Drugs/Alcohol

Removed Safety/Control Devices Running/Rushing/Acting In Haste Failure to Warn/Signal

Servicing Equipment In Motion or Energized Lack of Communication Between Workers Other

Select all UNDERLYING OR ROOT CAUSES that apply. What caused or influenced the conditions or behaviors?

Lack of Proper Procedures Inadequate Job Instructions Lack of Job Planning

Failure to Train or Train Properly Inadequate Supervision Inadequate Enforcement of Policy

Inadequate Maintenance Standards Unsafe Design or Construction Inspection overlooked or not required

Failure to Meet Maintenance Standards Inadequate Purchasing Standards Complacency

Failure to Staff Appropriately Improper Extension of Service Life Intentional Act

Other

CHECK ALL ACTIONS NECESSARY TO CORRECT THE DIRECT AND ROOT CAUSESWhat corrective actions have been taken or are needed to prevent a recurrence?

Procedure Revision Improve Housekeeping Procedures Repair/Replace Equipment

Reinstruction/Retraining Improve Storage/Arrangement Rotation of Employee

Eliminate Congestion Improve/Change Work Method Identify/Improve PPE

Create or Revise Maintenance Standard Install/Adjust Guards/Devices Improve Enforcement

Improve Design/Construction Job Reassignment Use Other Materials/Supplies

Improve Illumination Mandatory Pre-Job Instructions Improve Ventilation

Refer to Human Resources Other



Recommend corrective actions or preventive measures to be taken.Action Item Person Responsible Target Date

Date Complete

Initial after reviewing investigation.

Initials Review Date Comments

Supervisor

Safety Representative

Management


Appendix E –Accident Investigation Witness Statement Form

Instructions: This form should be completed by anyone who observed an incident that caused or could have caused a work-related incident. Statements will be used to identify the primary causes of the incident so that corrective actions can be taken to prevent future, similar incidents from occurring. The completed form should be provided to the incident investigator.Incident DescriptionDate of Incident: Location of Incident:

Describe what you saw or heard:

In your opinion, was anyone injured? If yes, please indicate who was injured and describe the injury that occurred:

What acts, failure to act, or conditions contributed to the incident?

Additional comments and information:

VerificationI verify that the statements listed above are my own and accurately describe what I observed or heard.Name: Phone number or email address:

Signature: Date:


Appendix F –Training Sign-In Sheet

Training Sign-In SheetTopic:

Trainer: Date:

Name Signature


Appendix G –Code of Safe Practices

Acknowledgement of the Code of Safe Practices

I, ________________________ (print your name), hereby acknowledge that I have received, read and understand the "Code of Safe Practices" for Enter Company Name.

I agree to conform to all practices, safety rules, and regulations relating to safe work performance.

I understand that my failure to follow these safety procedures will result in disciplinary action up to and including discharge.

I further understand that:A) It is my responsibility to report all unsafe conditions or violations of the Code of Safe

Practices to my supervisor or Safety Coordinator in order to minimize the potential of injury to my fellow workers.

B) I am encouraged to inform my immediate supervisor or Safety Coordinator of any hazards on the job without fear of reprisal. If at any time I feel that this report is being held against me, I should notify Safety Coordinator or management.

____________________________________________________________

(Signature of Supervisor) (Date)

_____________________________________________________________

(Signature of Supervisor) (Date)


INJURY AND ILLNESS PREVENTION PLAN · Web viewOSHA Log records will be maintained for five years...

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Transcript of INJURY AND ILLNESS PREVENTION PLAN · Web viewOSHA Log records will be maintained for five years...