SAFETY ECELLENCE AWARD 2014 TECHNICAL SUPPORT SAFETY SURVEY FORM FINAL EVALUATION SCORING: For each item listed below, decide if the entry meets the criteria as follows: 0 = Below Average 1 = Average 2 = Above Average 3 = Excellent N/A = Not Applicable DATE CONTRACTOR LOCATION CLIENT CONTACT INSPECTION TEAM *1. ACCIDENT PREVENTION PROGRAM A. Management Involvement in safety Programs B. Written Safety Policy C. Safety policy communicated to and understood by all employees D. Safety and Health Manual E. Written procedures for safety activities (JSA, JHA, committee, etc.) F. Written operating procedures/work practices G. Safety handbook for employees H. Annual safety goals set for continuous improvement I. Company safety recognition program in place J. Company safety representative identified K. Safety representative participates in safety problems/activities L. Company representative inspects all jobsites M. Disciplinary action program N. Copy of all federal safety and health regulations available on jobs and/or posted as required O. Jobsite safety activity plan P. Participation in a safety professional association (Safety Council, ABC, TCC, ASSE, HBR, Etc.) *Mandatory OSHA Regulatory Requirements Field/Office verify documentation exits Indicated verification with employees in field 1 Revised 2/14
*2. SAFETY TRAINING EDUCATION A. Written new hire orientation B. Tool box talks/safety meetings C. Specific safety training for all employees (permits, vessel entry, etc.) D. Safety incidents and activities reviewed with all employees *3. HAZARD COMMUNICATION PROGRAM A. Written program in place B. Material Safety Data Sheets available C. Updated MSDS Inventory Sheets D. Hazardous material training conducted and documented (benzene, H2S, Lead Awareness, etc.) E. Labeling system in place F. Part of new employee orientation *4. PROCESS SAFETY MANAGEMENT A. Written program/compliance B. Training verified and documented/records C. Procedures to advise employer of unique hazards D. Management of Change Process 2 Revised 2/14
*5. RESPIRATORY PROTECTION PROGRAM A. Written respiratory protection program B. Respiratory protection training records C. Fit testing conducted D. Maintenance and storage of respiratory protective equipment E. Medical certification F. Breathing Air Quality Management *6. HEARING CONSERVATION PROGRAM A. High noise area and operations identification (Owner or Contractor?) B. Hearing protection and records training C. Noise Monitoring *7. EMERGENCY EVACUATION PLAN A. Written procedure B. Included in orientation C. Posted signal/alarm systems/evacuation routes D. Periodic training E. Emergency assembly area identified F. Annual Drills Conducted G. Emergency Lighting H. Exit Points 3 Revised 2/14
*8. PERSONAL PROTECTIVE EQUIPMENT A. PPE Assessment/Evaluation B. Employee PPE provided by Employer C. Head protection worn by everyone in the designated area and hard hats are in good condition D. Eye/face protection provided and used where operation of machines present potential eye or face injury E. Hearing protection provided where required F. Approved respiratory protection provided and used where required G. Safety harnesses, lifelines and lanyards are provided and used where required H. Dress code and minimum PPE standard I. Safety harness and lanyards meet inspection requirements J. Proper Gloves 9. SUBSTANCE ABUSE CONTROL PROGRAM A. Management policy statement regarding illegal drugs, substances, contraband, and unauthorized items B. Description of how policy will be enforced and how violators will be treated C. Procedures for searches and inspections D. Pre-hire screening procedure E. Employee assistance program F. Random testing (% tested annually) G. Testing for cause H. Post Incident Testing 4 Revised 2/14
*10. WORKSITE EVALUATION PROGRAM A. Written plan/procedure format for conducting safety audits/inspections and frequency of audits B. JSA s, JEP s, STAC s, etc. C. All results documented D. Corrective action implemented and documented E. Problems and remedies communicated throughout company 11. BEHAVIORAL BASED SAFETY A. Written program in place B. Employee participation 1. Tracked 2. Documented 3. Communicated 4. Employee Feedback C. Management involvement and review 12. INCIDENT INVESTIGATIONS A. Initial (within 24-hour) Incident Report B. Near-miss incident investigation report C. Formal Incident investigation format (root cause, corrective action, contributing factors) D. Serious injury, fatality/catastrophe procedure E. Incident communicated throughout company 5 Revised 2/14
*13. RECORDKEEPING A. First-aid log of all first-aid cases B. OSHA log - Form 300 - Past 3 years posted where required C. OSHA 301 or equivalent for each OSHA 300 log entry *14. MEDICAL / FIRST AID PROGRAM A. First-aid supplies 1. Process to manage 2. Process to monitor supply 3. Resource adequate for number of employees on site B. Qualified personnel (first-aid card minimum)/cpr C. Emergency service set up D. Emergency telephone numbers posted E. Medical personnel available for advice and consultation F. In compliance with blood borne pathogens standard 15. WORK PERMITS A. Safe work/system entry B. Hot Work C. Confined space entry/physical entry D. Lock-out/tag-out program in place 6 Revised 2/14
*16. HOUSEKEEPING A. Work areas, passageways, stairs, office spaces, field trailers, kitchen, break areas kept clean B. Scrap and debris removed at regular intervals C. Waste containers identified *17. FIRE PROTECTION AND PREVENTION VERFIED A. Fire protection program developed B. Fire extinguishers provided C. Fire extinguisher training conducted D. Fire extinguisher inspection conducted E. Alarm or telephone system available for use in emergency F. "No smoking or open flame" signs posted and enforced where needed G. Fire Alarm systems (detectors, pull stations, detection heads, alarm panel 1. Maintenance, Inspected and Tested H. Designated Smoking area identified *18. ENVIRONMENTAL MANAGEMENT A. Written Environmental Policy Statement B. Spill Prevention Plan C. Environmental Risk Assessment D. Communication of Site Environmental Concerns E. Notification to Owner of leak or upset F. Green Initiatives 7 Revised 2/14
19. TOOLS/EQUIPMENT INSPECTIONS A. Inspection Program B. Tool Training in Place C. Portable electric tools D. Tools are maintained in safe condition E. All power operated tools properly guarded F. Abrasive wheels and tools properly equipped and used G. Powder actuated tools H. Wire rope/chain/slings, Lifting equipment (comealongs and chain falls) I. Mobile Equipment (power industrial trucks, man lifts, cranes, fork lifts, JLG s *20. ELECTRICAL SAFETY A. Written assured grounding program/gfci B. Electrical tools grounded or double insulated C. Electrical panels labeled/clear pathways D. State licensed/certification/qualified *21. SIGNS, SIGNALS, AND BARRICADES VERFIED A. Danger" and "Caution" signs available and used to warn against potential hazards or to caution against unsafe practices B. Safety instructions and directional signs posted where required C. Accident prevention tags available and used where required D. Flagmen used where required E. Crane/Signalman Training verified F. Crane and hoist signals posted and used G. Barricades provided where needed 8 Revised 2/14
22. LPG/COMPRESSED GASES/FLAMMABLE LIQUIDS A. Storage Cabinets/Racks (location, spacing, separation, labeling) B. Warning signs/identification C. Transporting/field use D. Fire extinguisher E. Grounding/bonding F. Drip pans 23. LADDERS A. Condition B. Inspection of C. Training on proper placement D. Retractable devices *24. SCAFFOLDS A. Written program in place B. Training - User, Builder, Competent PersonRAINING C. Inspection System/Program D. Fall Protection for Builder E. Records and Documentation 9 Revised 2/14
*25. ECAVATION A. Written Program in place B. Pre-dig procedures (Excavation permit) C. Daily inspections by competent person D. Sloped by classification, A, B, C/or supporting system determined and utilized according to standard E. Trenching requirements, bracing, other safeguards according to standards F. Barricades utilized G. Competent person Identified *26. INDUSTRIAL HYGEINE PROGRAM 1. Written program in place 2. Exposure Assessment 3. Periodically monitoring 4. Employee Communication 5. Biological Monitoring 27. WORKFORCE DEVELOPMENT A. Formal Craft Training B. Craft Written Assessments C. Skills Upgrade Training D. Performance Verification E. Benefits & Improvements F. Incentives and Motivation 10 Revised 2/14
28. BEST PRACTICES & YEAR TO YEAR IMPROVEMENT A. Are Best Practice(s) Fully Implemented at Site B. Year to Year Improvement in Site Statistics C. OSHA Challenge, VPP, OSHA SHARP, OSHA Star 29. FINAL A. Sum of Sub-totals (sum of sub-totals from each page) B. Total (sum of number of items from each page) C. Final Score (A/B) 30. Comments from client and other comments: 31. Do you feel that safety is a high personal priority with management and employees of this company? If so, explain why: 32. Additional comments: 11 Revised 2/14