(Company Name)

HEALTH AND SAFETY PLAN

INDEX

		I	Safety Policy Statement

		II	Accident/Injury Analysis Component

		III	Safety Program Recordkeeping Component

		IV	Health and Safety Education and Training Component

		V	Safety Inspection Component

		VI	Accident Investigation Component

		VII	Health and Safety Plan Review

		Appendix A		Safety Training Attendance List

		Appendix B		Self- Inspection Form

		Appendix C		Safety Hazard Report

		Appendix D		Vehicle Inspections 

		Appendix E		Accident Investigation Form

		Appendix F		Annual Health and Safety Plan Review

I	Safety Policy Statement

It is the policy of this company to work continually toward improving our Safety Policy, as well as our safety procedures.

It is the company’s intent to provide a safe working environment in all areas, for all employees.  Accident and injuries are prevented by controlling the work environment and the actions of employees.  Therefore, safety will take precedence over expediency or shortcuts.  Every attempt will be made to reduce the possibility of accident occurrence.  Protection of employees, the public, and company property and operation is paramount. Management considers no phase of the operation more important than the health and safety of the employee. 

Employee safety is to be the first consideration in the operation of the business.  Safe practices on the part of the workers must be part of all operations. Employees must understand their personal responsibility for the prevention of injuries on and off the job.  Accident prevention and efficient production go hand-in-hand.  All injuries can and should be prevented!

Management will continue to be guided and motivated by this policy, and with the cooperation of all employees, will actively pursue a safer working environment throughout the company.  

						                                                            
						(Management)

	Assignment of Responsibilities

The                                                        will be the primary person responsible for the implementation and enforcement of the Company Safety Policy.  

In the absence of the                                                , the                                                                              will assume the responsibility for enforcing the program.  

Additionally, the                                                          will be responsible for all documentation and records developed as a result of safety training, meetings, accident investigations and hazard reports required by this plan.  

									

II	Accident/ Injury Analysis Component

The                                                   (management) and                                                         will review all accident investigation reports, hazard reports, incident reports, inspection reports and the OSHA 300 log on a quarterly basis, or as needed, to determine any trends in accidents or hazards that may be developing.  

The                                                                            will recommend corrective actions to be taken to prevent recurrence of similar accidents or hazards.  The
                                                                       will be responsible for implementing corrective actions and for tracking the status of the corrective actions. 

Documentation of these reviews will be retained by the                                          for a period of 12 months.

III	Safety Program Recordkeeping Component

The                                                             will be responsible for maintaining all documentation of training, accident reports, OSHA logs, hazard reports, incident reports and any other documentation incidental to the implementation of this Health and Safety Plan.  Records of all HAZCOM training (if applicable) will be maintained as part of the Hazard Communication training. 

Blank forms for all safety related training and documentation will be available in the                                                              .

	Injury Records:
An injury log will be maintained in the                                               .  Injuries will be recorded on an OSHA 300 log, or equivalent, within 24 hours of being reported.  
	
The summary portion of the OSHA 300 log will posted from February 1st to April 30th  each year in a place where employee notices are normally placed. 

	Injury records will be retained for a period of five (5) calendar years. 

	Inspection Records will be kept in the                                                                 .

	Safety Meetings/ Training Records will be kept in the                                        .

	Accident Investigation Records will be kept in the                                             .

IV	Health and Safety Education and Training Component

The                                                                   will be responsible for identifying the education and training needs of this facility on an annual basis.

Employees will attend monthly safety meetings/training which will conducted by the                                                           . All employees will attend the following training:

•	HAZCOM
•	Safety Equipment
•	Housekeeping
•	First Aid
•	Equipment Guarding
•	Personal Protective Equipment
•	Fire Extinguishers (as applicable)
Forklift Training will be provided to the employees whose job responsibilities include operating forklifts.

Refresher training on these health and safety topics will be given annually, or as needed.

Safety meetings and safety training will be documented and records will be maintained by the                                                                   for a period of 24 months or as required by law or directives.

	Documentation will include:

1)		Date of training,
2)		Name of trainer, 
3)		Subject(s) covered, and
4)		Attendance roster with employees’ signatures. 
	(see Appendix A) 

	All required  training will be per OSHA or other directing guidelines. 

Specialized training (such as Forklift and HAZCOM training) will be provided and documented before employees are required to perform tasks that could potentially expose them to health and safety concerns.  

New employee orientation will include all of the above -mentioned health and safety training topics.  New employees will receive HAZCOM training before being allowed to work with potentially hazardous chemicals.  Refresher training will be given annually and/or as needed when new hazardous materials are introduced into the workplace.   Material Safety Data Sheets (MSDS), as required by the Hazard Communication Standard, are available to all employees.

V	Safety Inspection Component

The                                                            will be responsible for conducting and documenting                              (weekly or monthly) safety inspections within the facility.  Items to be checked are listed on the Self-Inspection Form  (see Appendix B). Records of these inspections will be kept by the                                                         .

Employees are responsible for inspecting their work stations for potential hazards. (see Appendix C)  Potential and/or real hazards will be reported in writing to the                                                   .  The                                            will recommend corrective actions to be taken.  Hand and power tools will be inspected daily to identify any hazardous conditions prior to beginning work.  

The                                                 will be responsible for conducting daily and weekly inspections of the workplace and for correcting any identified hazards. 

Reports will be filed in a log and maintained in the                                                   until all discrepancies are corrected or at least 12 months, whichever is longer. 

	Documentation will include:

1)		Date of inspection, 
1)	

1)		Name of inspector,
1)	

1)		Discrepancies found,
1)	

1)		Person responsible for corrections, and 
1)	

1)		Estimated date of corrections. 
	
	Documentation of these inspections will be kept by the                                            	for a period of 12 months.

(If applicable, any vehicles being operated will be inspected thoroughly by the driver before use.) (see Appendix D)

VI	Accident Investigation Component

An accident can be defined as any occurrence that interrupts or interferes with the orderly progress of the job and usually occurs suddenly and unexpectedly.  Some accidents involve human injury.  Accidents arise from a combination of unsafe acts and unsafe conditions.

The intent of an accident investigation should be to determine what basic condition or act caused the accident so corrective measures can be taken to prevent reoccurrence and not to identify the guilty party.  

Accidents should be investigated as soon as possible and at least within the first 24 hours of the occurrence.  The sooner the information is gathered, the more accurate the facts will be.  

	Accident Investigation Procedures:

1)	Investigations are required on all accidents, including those “near misses” not producing injuries.  “Near misses” will be documented on an accident report and forwarded to the                                                                  and                                                             for review.  “Near misses” are reviewed to determine if a recurring hazard exists. Therefore, they must be thoroughly investigated and reported.  Accidents that do not produce injury have probably produced other job hindrances, such as delays, damaged material, damaged equipment, etc.

2)	All accidents are to be investigated and documented by the                                                                     (management) and                                             of the employee involved.  Investigations will be conducted as soon as possible, but no later than 24 hours after the accident. 

3)	Accident reports will be forwarded to the                                               and                                                for review.  All incident reports, hazard reports, accident investigation reports and inspection checklists will be reviewed by company management to determine if trends are occurring. 

4)	The steps for a thorough and effective investigation include:

1.	Interview the employee(s) involved,  if possible,  to evaluate the situation and potential liability.
2.	Have the involved employee(s) step through the sequence of events of the accident.
3.	Locate, interview and get statements from any witnesses.
4.	Gather facts about the investigation (who, what, where, how,  why).
5.	Evaluate any evidence found at the scene and reconstruct events.

6.	Take pictures or  draw diagrams of the accident scene. Don’t rely on memory - accident scenes change.
7.	Do not disturb the accident scene until you are satisfied with the investigation. 
8.	Before leaving the scene of the accident,  warn, protect and/or repair any exposure areas to prevent another accident from occurring.
9.	Re-interview the involved employee(s) or witnesses, if necessary.
10.	Prepare a written detailed report before leaving for the day.
11.	Recommend corrective actions.
12.	Follow-up on the recommendations to ensure the corrective actions have been implemented.
13.	Double check the corrective action(s) to ensure they are effective. 

5)	Once the investigation is completed, it must be directed to the appropriate person for review.  The review committee will consist of the following:

1.	Immediate supervisor of employee involved,

2.	                                                 or                                               ,and 
3.	Others, as deemed necessary by the                                                                                         . 

6)	Each person in the review process is responsible for assuring thorough investigations and following up on corrective action(s) to make sure it is (they are) effective 

7)		Written accident investigation reports will be filed in a log in the                                                              where it is available for review.  The accident investigation process is documented by the                                                                         and will be retained for a period of 24 months or as required by law or directives.  (see Appendix E)

VII	Health and Safety Plan Review

The                                         (management) and                                                  will review the Health and Safety Plan during the first month of each calendar year.

This review will be to determine if all areas of exposure are addressed in the Health and Safety Plan.  Any new hazards identified during the review will be included in the Health and Safety Plan and employees will receive immediate training when required. 

Annual reviews will be documented showing date of review and any new areas of exposure identified.  Documentation will be maintained by the                                                                                  . (see Appendix F)

Appendix A

SAFETY TRAINING ATTENDANCE LIST

The undersigned have received the following training:

Location:                                                                                                                                                                                                                               
Training Conducted By:                                                                                                                                       

Date:                                                                                                                                                                      

Training Topic:                                                                                                                                                     

Employee Name :                                

[Print]                                                                             [Signature]                                                                     

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

Appendix B			             SELF-INSPECTION FORM

Date of Inspection:                                                                                                                                                   
Location or Departments Inspected:                                                                                                                          
Signature:                                                                                                                                                                
										Yes		No	Date Corrected
1.	Housekeeping - Is the work area clean and orderly?				G		 G	________

2.	Floors - Are floors in good condition - smooth, clear surfaces,
without holes, cracks, or humps?						G		 G	________

3.	Aisles - Are aisles and passageways clear, dry, and free of 
tripping hazards?								G		 G	________

4.	Stairways - Are stairs in good condition, with handrails, and 
adequate lighting?								G		 G	________

5.	Storage - Are materials, products, or supplies properly and safely
 	stored to a workable height?						G		 G	________

6.	Ladders - Are ladders provided where needed, of standard 
construction, and in good physical condition?					G		 G	________

7.	Machines & Equipment - Are machines and equipment in safe
operating condition?  Are the necessary guards provided and used?		G		 G	_________

8.	Hand Tools - Are the right tools for the job being used?  Are
they in good condition?							G		 G	_________

9.	Electrical - Are all required grounds provided on power tools and
extension cords?  Is equipment in good operating condition?			G		 G	_________

10.	Lighting - Is adequate lighting provided in all work areas?			G		 G	_________

11.	Eye Protection - Are all employee provided with suitable eye
protection when around operations that produce flying particles?			G		 G	_________

12.	First Aid - Are first aid supplies provided if needed?				G		G	_________

13.	Fire Extinguishers - Are fire extinguishers easily accessible,
unblocked, and properly serviced?						G		 G	_________

14.	Entrances - Are entrances kept dry or provided with nonskid mats?		G		 G	_________

15.	Exits - Are emergency exits marked, clear, and easily accessible?
Are exit doors unlocked and do they swing toward the outside?			G		 G	_________

16.	Exterior (sidewalks, parking lots, etc.) - Are sidewalks and parking					
lots smooth and free of cracks, holes, and tripping hazards?			G		 G	_________

17.	Training - Are all employees trained in proper lifting techniques
and material handling?							G		 G	_________

18.	Signs - Are safety instructions and warning signs posted
where needed?								G		 G	_________

Deficiencies:___________________________________________________________________________________________

______________________________________________________________________________________________________    

Appendix C
SAFETY HAZARD REPORT

NAME:                                                                                                                                                                          

DATE:                                                                                                                                                                           

DAY OF WEEK:                                                           TIME:                                                                                       

LOCATION:                                                                                                                                                                   

HAZARD DESCRIPTION:

                                                                                                                                                                                    

                                                                                                                                                                                    

                                                                                                                                                                                    

                                                                                                                                                                                    

RECOMMENDATION:

                                                                                                                                                                                    

                                                                                                                                                                                    

                                                                                                                                                                                    

DATE CORRECTION IS MADE:

						

Appendix D
VEHICLE INSPECTIONS

Name of Inspector/Driver:                                                                                                                                     

Beginning Date of Week of Inspections:                                                                                                             

Vehicle #                                                                                                                                                                

 Satisfactory

  X     Needs Servicing

N/A   Not Applicable

Tires:		                       	      Mon.           Tues.              Wed.           Thurs.            Fri.              Sat.            Sun.
Correct air pressure  								
Tire free of wear, high and low spots, damage								
Rims free of damage								
All lugs present and tight								
Properly matched tires								

Lights:
Turn on lights - use low 
beams								
Check high beams, left
and right turn signals,
brake lights, and parking lights.								

Brakes:
Parking brake: apply parking brake with vehicle moving slowly.  Vehicle should stop. 								
Service brake: push brake pedal firmly with 
vehicle going about 5 miles per hour.  Vehicle 
should stop with no pulling to one side or delayed stopping action. 								
Test steering with vehicle moving.  Steering should be smooth and consistent with no play in the steering wheel.  								

					

Emergency Equipment:	   	     Mon.             Tues.             Wed.            Thurs.           Fri.                Sat.             Sun.
Flags, jack, flares or other warning devices, flashlight, fire extinguisher, wheel blocks, etc. Check to see that supplies are in good working order. 								
Spare tire properly inflated.								

Inside of Vehicle:
Check mirrors, windshield wipers, panel gauges, horn.  Adjust seat for comfort.  Adjust side mirrors. 								
Make sure cargo is properly secured. 									

Under Hood:	
Fluid levels: oil, water, brake fluid, window fluid, 
battery fluid.								
Condition of belts.  Look for loose
or frayed belts. 									
Hoses: check for loose or 
disconnected hoses.									
Check under vehicle for leaking fluids. 								

Corrective Actions:                                                                                                                                  

                                                                                                                                                                  			

                                                                                                                                                                  			

                                                                                                                                                                  			

                                                                                                                                                                  

_____________                                                                                                                                        

					

Appendix E
ACCIDENT INVESTIGATION FORM

Employer’s Name:                                                                               Date of this report:                                           

Injured Employee:                                                                                                      Age:                                          

Department/Job Title:                                                                                                                                                  

Date and time of injury:                                                                                                             AM/PM?                                               
Where injury happened:                                                                                                                                              

Nature of Injury/Property Damage:                                                                                                                                                        
                                                                                                                                                                                                           
Object or equipment that inflicted the injury, if applicable?                                                                                                            
Describe the incident (What happened?):                                                                                                                                      

                                                                                                                                                                                   

Contributing factors?                                                                                                                                                       

Witnesses:                                                                                                                                                                                           
What action(s) are being taken, and by whom, to prevent recurrence of this type of injury in the future?                       

                                                                                                                                                                                     

Was the report to supervisor or first aid delayed?                  Why?                                                                             
                    
Was medical treatment required?                 Who administered the medical treatment?                                               

Where was medical treatment administered?                                                                                                                            
What is the severity potential for lost time?   High/Major                 Medium/Serious                  Low/Minor                    

Probable Recurrence Rate:  Frequent                    Occasional                   Rare                                  

Supervisor's signature:                                                                                      Date:                                                 

Investigated by:                                                                                                Date:                                                        

Reviewed by:                                                                                                    Date:                                                  

Appendix F

ANNUAL HEALTH AND SAFETY PLAN REVIEW

Date of Review:                                                                                                                                                        

New Exposures Identified:                                                                                                                                      

                                                                                                                                                                                  

                                                                                                                                                                                  

                                                                                                                                                                                  

Action Taken:                                                                                                                                                           

                                                                                                                                                                                  

                                                                                                                                                                                  

                                                                                                                                                                                  

Reviewed By: