(Your Company Name Here)
ACCIDENT PREVENTION
PROGRAM
You may follow this example, however it is provided as a sample format only.
Your company’s Accident Prevention Program MUST be customized to your business and the
worker safety and health risks at your company. The safety needs of your company may differ or
require additional safety measures to protect your workers from job related injuries and
illnesses than are contained in this sample. State and federal laws require the employer (not the
workers) to provide a safe and healthy work environment. You must tailor your own Accident
Prevention Program to meet the specific safety needs of your company. This Accident
Prevention Program is only effective in practice if you can prove it is fully implemented daily by
your company and your employees.
Disclaimer: This Sample is provided as a beginning guideline/template for use in developing an
Accident Prevention Program for your company. Nothing contained herein is offered as legal
advice or should be read as an interpretation of state/federal law or the various state/federal
industrial regulations. YOU SHOULD CONSULT AN ATTORNEY OF YOUR CHOICE FOR
SPECIFIC GUIDANCE CONCERNING HOW TO IMPLEMENT AN ACCIDENT PREVENTION
PROGRAM AND WITH ANY QUESTIONS CONCERNING YOUR COMPANY’S
OBLIGATIONS UNDER THE VARIOUS LAWS/REGULATIONS
(SAMPLE)
TABLE OF CONTENTS
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Introduction
Mission Statement
Company Disciplinary Policy
Employee Designations
Employee Responsibilities
Equipment and Job Specific Safety Rules
Personal Protective Equipment
Housekeeping
Fall Protection Guidelines
Site Safety Basics
Fall Protection Work Plan
Emergency Response
Safety Training Program
Safety Inspection Policies and Procedures
Safety Meeting Policies and Procedures
Employee Safety Orientation
Employee Safety Training Record
Substance Abuse Policy
Driving Company Vehicle Safety Policy
Hazard Identification Reporting
Accident Reporting
Supervisor Accident Report
Employee Accident Report
Witness Accident Report
Accident Investigation Guidelines
Accident Investigation Report
Safety Meeting Minutes Template
Job Hazard Analysis Worksheet
Job Site Fall Protection Work Plan Template
Company Safety Recordkeeping and Reporting
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Introduction
This Accident Prevention Program (APP) is specifically designed to provide safety procedures to
employees, subcontractors, and site superintendents. A copy of this APP, applicable Material Safety
Data Sheets (MSDS), and a completed Job Hazard Analysis (JHA) will be maintained at the work site. This
APP should be considered “Job Specific” when these criteria have been met. For each job site with a fall
hazard, a completed Fall Protection Work Plan will be posted before work begins.
Mission Statement
(Your Company Name Here) herein after referred to as “company” places a high value on the safety of
its employees. (Your Company Name Here) is committed to providing a safe workplace for all employees
and has developed this program for workplace injury and illness prevention that requires full
participation by management, supervisors, and employees in identifying and eliminating hazards that
may develop during our work process.
It is the basic safety policy of this company that no task is so important that an employee must violate a
safety requirement contained in this program or take a risk of injury or illness in order to get the job
done.
Employees are required to comply with all company safety requirements contained in this program and
are encouraged to actively participate in identifying ways to make our company a safer place to work.
Supervisors are responsible for the safety of their employees and as a part of their daily duties must
check the workplace for unsafe conditions, watch employees for unsafe actions and take prompt action
to eliminate any hazards.
Management will do its part by devoting the resources necessary to form a safety committee (required
of firms with 11 or more employees on the same shift at the same location WAC 296-800-13020)
composed of management and employee elected employees. We will develop a system for identifying
and correcting hazards. We will plan for foreseeable emergencies. We will provide initial and ongoing
training for employees and supervisors. Violations of this Accident Prevention Plan are subject to the
company’s disciplinary policy to ensure that company safety policies are followed.
Safety is a team effort – Let us all work together to keep this a safe and healthy workplace.
(Your Company Name) Disciplinary Policy
Consult with a qualified attorney to establish a company disciplinary
policy that protects your “at will” states to the maximum extent
possible, and is fair, reasonable, and non-discriminatory
(Your Company Name Here) Employee Designations
1. Competent Person: An employee who is trained and experienced to identify and correct existing and
predictable hazards in the surroundings or working conditions that are unsanitary, hazardous or dangerous
to employees. (Your Company Name Here) designates all crew members as competent persons. The
competent person(s) in our company are: (names here)
2. Qualified Person: An employee (or subcontractor, i.e., professional engineer, scaffold system designer)
who, by possession of a recognized degree, certificate, or professional standing, or who by extensive
knowledge, training and experience, has successfully demonstrated his ability to solve or resolve
problems related to the work. (Your Company Name Here) designates the Safety Director as its qualified
person. The Safety Director will consult with manufacturers and safety consultants as needed. The
qualified person(s) in our company are: (names here)
3. Approved Personnel: Closely monitored employees (such as new hires) who have adequate
experience, supervision and basic training to perform only specified work duties. (Your Company Name
Here) designates approved personnel as those employees who have a completed and signed employee
orientation form on file.
4. Authorized Personnel: Employees above the “approved” status, who are certified by way of advanced
training and experience to perform certain functions, operate specific equipment or enter certain work
areas. (Your Company Name Here) designates authorized personnel as those employees who possess
current and adequate training for the task to be performed unsupervised.
5. Safety Director: An employee who is responsible for the design, selection and maintenance of safety
system equipment; the safety training and evaluation of all employees; and review and implementation of
this accident prevention plan. He performs accident and near-miss investigations and report analysis;
coordinates employee medical and work-related injury and illness recordkeeping; performs regular safety
audits for compliance with the applicable regulatory agency; chairs the safety committee; manages safety
incentive / discipline programs; and regularly reports on safety issues to the CEO and management. The
safety director for our company is: (name here)
6. Safety Committee: A group of volunteer employees who work closely with the Safety Director on all
safety issues. (Your Company Name Here) safety committee members will meet at least quarterly.
Volunteer terms are one year. The safety committee members for our company are: (names here)
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10.
11.
12.
Employee Responsibilities
You are required to follow all safety responsibilities, under your job description, and as outlined
in this safety program.
You shall not perform actions that are unsafe in order to get the job done. If you find a particular
job or task is unsafe, please report it to your immediate supervisor immediately so it can be
evaluated and alternate methods can be developed.
Any safety devices must be kept in place at all times when in use. Do not remove or disable any
safety devices!
No one may operate a piece of equipment unless they have been trained and authorized to do so.
You must use your company provided personal protective equipment whenever this safety
program requires it.
All safety-warning signs must be followed. Comply with all rules on the jobsite.
Working under the influence of or consumption of alcohol or illegal drugs is prohibited. If you
are on any over the counter or prescribed drugs please notify your company safety director prior
to starting work.
Firearms are not permitted on any company property or any company jobsites.
Smoking is only permitted in areas designated by your direct supervisor. Smoking in any
company or jobsite buildings is prohibited.
Horseplay, running, inattention and fighting are prohibited.
Please make sure to use good housekeeping techniques to avoid accidents. Clean up spills
immediately. Return all tools and supplies to their specified location after use. Do not allow
scraps to accumulate where they will become a hazard.
If you are witness to an accident, provide an accurate and truthful explanation of what you have
witnessed.
JOB / EQUIPMENT SPECIFIC SAFETY RULES
These are safety rules required for specific job or equipment use. These are in addition to the General
Safety Rules. You are required to follow these specific safety rules when operating specific equipment
or performing a specific job.
Operating a Tile Saw:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do a safety check of the saw before using and do not use without the proper guards attached and
properly functioning. Guards must be used while in use.
4.
Do not modify in any way.
5.
Check power cord for cracks, cuts, fraying, etc. before using.
6.
Insure that power cord is properly grounded or is of the approved double-insulated type.
7.
Do not use electrical cord for hoisting or lowering to or from roof.
8.
Make sure you are operating it in an area away from endangering others.
9.
Wear company provided earplugs to protect your inner ear from damage.
10.
Wear company provided ANSI stamped eye protection to deflect tile debris from entering the
eyes.
11.
Wear approved and pre-fitted respirator to protect from silica dust.
12.
Hold tile saw with both hands and do not put hands near blade while operating.
13.
If you are using a gas operated tile saw, do not smoke near or while in use.
14.
Make sure to maintenance tile saw per manufacture recommendations. Do not perform
maintenance while plugged in or running.
Operating a Pneumatic Staple and / or Nail Gun:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do not modify in any way.
4.
Do a safety check of the gun before using and check power cord for cracks, cuts, fraying, etc.
before using.
5.
Insure that power cord is properly grounded or is of the approved double-insulated type.
6.
Do not use electrical cord for hoisting or lowering to or from roof.
7.
Make sure you are operating it in an area away from endangering others.
8.
Never point staple guns at yourself or others. Handle it in the same safe manner you would
handle a regular staple gun. Do not rest it on your feet or legs!
9.
Make sure to maintain the staple gun per manufacture recommendations. Do not perform
maintenance while plugged in or running.
10.
Wear earplugs to protect your inner ear from damage. (Voluntary)
11.
Wear company issued ANSI stamped eye protection to deflect any possible ricochets from
entering the eyes.
12.
Disconnect air supply before trying to remove jammed fastener(s).
Operating a Skil Saw:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do not modify in any way.
4.
Do a safety check of the saw before using and do not use without the proper guards attached and
functioning properly. Guards must be used while in use.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Check power cord for cracks, cuts, fraying, etc. before using.
Insure that power cord is properly grounded or is of the approved double-insulated type.
Do not use electrical cord or hoses for hoisting or lowering to or from roof.
Make sure you are operating it in an area away from endangering others.
Make sure to maintain the saw per manufacture recommendations. Do not perform maintenance
while plugged in or running.
Wear earplugs to protect your inner ear from damage. (Voluntary)
Wear company provided ANSI stamped eye protection to deflect any possible ricochets from
entering the eyes.
Keep hands away from blade at all times unless disconnected from power source.
Make sure the material you are cutting is secured.
Never hold material across leg while cutting.
Lifting Safety:
1.
Do not attempt to lift anything unless you have had proper training.
2.
Bend with your knees. Lift with your legs.
3.
Keep your upper back straight. A slight curve in the lower back is good. One key to preventing
back pain is to always maintain a slight arch in your lower back.
4.
Keep the load as close to your body as possible.
5.
Never lift from a bent-forward position.
6.
Avoid turning or twisting your body while holding a heavy object, move your feet to turn.
7.
Never lift a heavy object over your head.
8.
If it is too heavy (optional, more than 50 lbs), GET HELP!
Handling Metal:
1.
Always, wear company issued gloves to protect your hands when handling metal.
2.
Never slide metal through your hands.
3.
Be aware of your surroundings. Be careful not to hit someone while carrying large pieces of
metal.
Utility Knife Safety:
1.
Use only for what the manufacture has designed it for.
2.
Do not modify in any way.
3.
Never cut towards yourself. Always cut away from yourself.
4.
Do not use rusty or dull blades.
5.
Use caution when changing blades.
Operating a Reciprocating Saw:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do not modify in any way.
4.
Do a safety check of the saw before using and check power cord for cracks, cuts, fraying, etc.
before using.
5.
Insure that power cord is properly grounded or is of the approved double-insulated type.
6.
Do not use electrical cord or hoses for hoisting or lowering to or from roof.
7.
Make sure you are operating it in an area away from endangering others.
8.
Make sure to maintain the saw per manufacture recommendations. Do not perform maintenance
while plugged in or running.
9.
Wear company provided earplugs to protect your inner ear from damage.
10.
11.
12.
13.
Wear company provided ANSI stamped eye protection to deflect any possible ricochets from
entering the eyes.
Keep hands away from blade at all times unless disconnected from power source.
Make sure you have on no loose clothing as it may grab onto clothes.
Keep long hair tied up and back as it may grab onto your hair.
Operating Electric Shears:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do not modify in any way.
4.
Do a safety check before using and check power cord for cracks, cuts, fraying, etc. before using.
5.
Insure that power cord is properly grounded or is of the approved double-insulated type.
6.
Do not use electrical cord or hoses for hoisting or lowering to or from roof.
7.
Make sure you are operating it in an area away from endangering others.
8.
Make sure to maintain the shears per manufacture recommendations. Do not perform
maintenance while plugged in or running.
9.
Wear company provided earplugs to protect your inner ear from damage. (Voluntary)
10.
Wear company provided ANSI stamped eye protection to deflect any possible ricochets from
entering the eyes.
11.
Keep hands away from blade at all times unless disconnected from power source.
12.
Always wear gloves when handling metal. (See Handling Metal for specifics.)
Operating a Torch:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only for what the manufacture has designed it for.
3.
Do not modify in any way.
4.
Do not use hoses for hoisting or lowering to or from roof.
5.
Make sure you are operating it in an area away from endangering others.
6.
Make sure to maintain the torch per manufacture recommendations. Do not perform maintenance
while plugged in or running.
7.
Never point flame towards yourself or others.
8.
Never leave burning torch unattended. Always shut off propane when not in use.
9.
Always have a fire extinguisher nearby.
10.
Wear fire retardant clothing or jacket.
Ladder Safety:
1.
Do not attempt to use unless you have been trained to properly use it.
2.
Use only a ladder approved by ALI or ANSI which is properly rated for the worker using the
ladder and only used for what the manufacture has designed it for.
3.
Do not modify ladder in any way.
4.
Set up ladder so that it is at a 4:1 angle (base of the ladder is back ¼ of the height of the top
contact point of the ladder)
5.
Ladder must extend at least 36 inches above the landing surface and must be secured on both rails
to avoid sideways movement.
6.
All ladders to be a minimum Type 1 (250 pound rating). Type 1A (300 Pound rating)
7.
Inspect ladders regularly for any defects or needed repair. If defective, tag the ladder and remove
from service until repaired to meet manufacturer’s specifications or replace the ladder.
8.
Do not use metal ladders near power lines.
9.
When using stepladders, be sure the spreaders are locked into position before using.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Be sure there is no grease and /or oil present on ladder and that the only paint allowed on a ladder
is for numbering purposes.
When ascending or descending the ladder, always face the ladder forward.
Keep all tools in tool belt or other location to keep both hands free for holding the ladder free
during ascent or descent.
Be sure all safety catches are locked and in place on extension ladders.
Keep all tools off steps on ladder.
One person on a ladder at one time.
Do not overreach while using a ladder.
Never jump from one ladder to another and do not move a ladder while it is occupied.
When placing a ladder over a doorway, barricade that doorway to prevent accidental
displacement.
No type of work shall be performed on a ladder over 10 feet from the ground or floor unless a
safety harness is worn and fall arrest fall protection is used.
Anchor Plate:
1.
Installed (recommended by ANSI approved only) for use in areas above a 10 foot fall distance
2.
Plate should be fully intact (no cuts or weak metal).
3.
A minimum of six nails (or amount required by the manufacturer) will be used in temporary
anchors.
Hard Hat:
When working in areas with overhead danger
1.
The employer must provide an American National Standards Institute (ANSI) Z89.1-2009 or
equivalent hard hat to protect workers from objects falling from above.
2.
Always replace a hard hat if it sustains an impact, even if damage is not noticeable. Suspension
systems are offered as replacement parts and should be replaced when damaged or when
excessive wear is noticed. It is not necessary to replace the entire hard hat when deterioration or
tears of the suspension systems are noticed.
Eye Protection:
Working with saws, torches or chemicals or when required by manufacture
1.
Company provided and must have an ANSI stamp on it.
2.
Must be free of scratches that would impair vision. Request a replacement from your supervisor if
scratched.
Respirator:
While running saws or while working with chemicals
1.
The company shall provide and maintain respiratory protection consistent with its written
respiratory program consistent with WAC 296-824
2.
The company shall provide each respirator user with a respirator that is clean, sanitary, and in
good working order. The employer shall ensure that respirators are cleaned and disinfected using the
required procedures. The respirator must be fitted according to WAC 296-824-15005.
PERSONAL PROTECTIVE EQUIPMENT CARE, MAINTENANCE & USE
Personal Protective Equipment (PPE) is required for specific jobs and / or duties. Please refer below to
find out if your job requires PPE.
Proper care and maintenance of your PPE will help keep it in proper working condition to best insure
your safety at all times. It is your responsibility to inspect your PPE for wear and tear. It is also your
responsibility that your PPE is in 100% safe working condition. Please notify the office immediately if
your personal protective gear is damaged so a replacement can be provided.
Harness:
Working in areas above a 10 foot fall distance
1.
Make sure it is free from fraying and loose or cut stitching.
2.
Check all buckles to make sure they buckle and stay buckled.
3.
Make sure your soft stop is not pulled out of its plastic covering.
4.
Make sure that it fits snug to your body but not over tight to where it digs into your skin.
5.
Do not use any harness that fails any of the items above. Request a replacement harness if this
occurs.
Lanyard (Rope):
Working in areas above a 10 foot fall distance
1.
Make sure it is free from fraying and loose or cut stitching.
2.
Make sure your plastic eyeholes are free from cracks.
3.
Make sure your monkey fist is adjusted to 6 loops over your lanyard and that it is on snug.
4.
Do not use any lanyard that fails any of the items above. Request a replacement lanyard if such a
failure occurs.
Carabineer:
Working in areas above a 10 foot fall distance
1.
Make sure it is self-latching.
2.
Make sure it is free of cuts.
3.
Make sure it is not bent or distorted.
4.
Do not use any carabineer that fails any of the items above. Request a replacement carabineer if
such a failure occurs.
HOUSEKEEPING
Almost one in every five work related injuries result from a slip, trip or fall. Falls kill more than 12,000
people every year and thousands more wind up with bumps, bruises, strains and broken bones.
Fortunately, there are some simple things to do in the way of prevention. They include the following:
1.
Maintain a clean, dry work area whenever possible.
2.
Report any fall hazards that need to be corrected, such as carpet tears.
3.
Don’t allow equipment or other obstacles to accumulate in aisles, walkways or work areas.
4.
Make sure there are no cords, wires or hoses running through traffic areas.
5.
When carrying a load make sure you can see over and around it.
6.
Walk cautiously, keeping one hand free to maintain balance.
7.
Use railings when walking up stairs and ladders.
8.
Keep drawers closed when not in use.
9.
Always pay attention and watch where you are going.
10.
Wear proper company provided ANSI approved safety shoes that have impact resistant soles that
protect the feet against hot working surfaces common in roofing. The metal insoles of some
safety shoes protect against punctures.
11.
Stay organized while working!
FALL PROTECTION GUIDELINES
1.
A written fall protection work plan must be completed prior to starting work on any job, posted
on the job site, and implemented at all times. All employees on the site must be familiar with the
location and the contents of the written plan. Submit the fall protection work plan with signatures
to the safety director after completing the job.
2.
Hold a crew fall protection meeting each day before starting work on any job. Have crew
member’s sign that they participated in the jobs site safety meeting. Submit the safety meeting
notes and signatures to the safety director after completing the job.
3.
Inspect all fall protection equipment daily.
4.
Fall protection will be implemented by (your company name here) employees at all times when
working on any roof regardless of height and / or pitch.
5.
Workers making minor roofing repairs must wear fall protection when making any repairs, OR
when dangerous working conditions exist.
6.
For fall arrest, an ANSI approved full body harness must be used. The body harness system must
be rigged to minimize free fall distance to within 6 feet with no possible contact to any lower
level.
7.
When vertical lifelines (drop lines) are used, not more than one employee shall be attached to any
one lifeline.
8.
Vertical lifeline must be run from ladder to any working area(s).
9.
A tie off plate must be secured as specified by the manufacturer of the plate, or with not less than
four 16D nails in truss, and/or an ANSI approved sling must be installed as specified by the
manufacturer if used as part of your fall protection system.
10.
Snap hooks must not be connected to loops made in webbing type lanyards.
11.
Snap hooks must not be connected to each other.
12.
Standard guardrails: top rail must be 42 inches from the walking surface. Mid-rail is centered
between the top rail and the walking surface. Minimum height of toe-board is four inches.
13.
Hard hat sign must be posted and a hard hat must be placed on site.
14.
When removing debris from any roof areas, a designated area must be clearly marked using
caution tape.
15.
When working over bodies of water life preservers must be worn.
SITE SAFETY BASICS
The following is a list of safety basics for job site work. This sheet is for quick reference only. Please see
complete safety program for detail information.
1.
Fill out Fall Protection Plan.
2.
Inspection of all safety gear.
3.
Type 1 ladder (250 lb rating):
Three (3) feet above fascia and secured.
4.
Hang hard hat sign.
5.
Put hard hat next to ladder.
6.
First Aid kit on site.
7.
Caution tape for tile piles or when throwing debris from the roof.
8.
Tie off plate:
Secure with six (6) 16d nails in truss or use fasteners supplied with anchor always
following manufacturer instructions.
9.
Wear harnesses and connect lifeline on all roofs regardless of pitch or height.
10.
Utilize safety line from work area to ladder.
11.
Clothing:
Denim jeans.
T-shirt (minimum 4 inch sleeves).
Wear proper company provided ANSI approved safety shoes that have impact resistant
toes and heat resistant soles that protect the feet against hot work surfaces common in
roofing.
No loose or torn pants or shirts.
12.
Use all safety equipment as needed:
Company provided eye protection at all times on the jobsite.
Company provided earplugs for high-pitched noises (tile / chainsaws). (voluntary)
Company provided chaps when using chainsaws.
Company provided gloves for all lead products and handling chemicals or flammable
materials.
Company provided face masks for cutting concrete tile or high volume of dust.
13.
Fire extinguisher on roof when flame is present.
Fall Protection Work Plan
(See attachment.)
The entire crew will perform a jobsite walk-around safety inspection. After the inspection
document any hazards and have each employee sign and date the fall protection work-plan. A
new fall protection work-plan will be posted each day on the jobsite. Previous forms may be
reused if posted provided employees document any new hazards, sign, and date the previously
posted form before each shift on the jobsite. In the event that a job lasts more than one week, a
new fall protection work plan will be completed, at the beginning of each week the job is in
progress. All previous fall protection work plans will be saved and kept in a folder for review.
What to do in an emergency
In case of fire:
1. Make sure that a fire extinguisher(s) with a minimum 2A rating is available within 100 feet of where
employees work at our job sites.
2. All employees will receive training on how to use a fire extinguisher when they first start to work for
us.
3. If you discover a fire: Tell another person immediately. Call or have them call 911 and tell the site
supervisor.
4. If the fire is small and there is minimal smoke, you may try to put it out with a fire extinguisher.
5. If the fire grows or there is thick smoke, do not continue to fight the fire. Tell other employees in the
area to evacuate.
6. Our designated assembly point is outside the building in front of an adjacent building so that we don't
block the arrival of fire trucks.
7. The site supervisor will check that all employees have safely evacuated.
In case of earthquake
The west coast of the United States is subject to earthquakes. There will be no advance warning. The
shock will be your only warning.
If you are inside a building:
Drop down under a work bench or other cover, if available and hold on until the shaking stops.
Otherwise get in a doorway or corner away from windows or any heavy objects in the room that
could fall on you.
1. Evacuate quickly after the shaking stops since there may be after shocks.
2. Check for coworkers who may be injured or trapped as you evacuate.
3. Move to the designated assembly point
4. Don't move in the direction of overhead power lines.
5. Don't touch downed power lines or objects they touch.
If you are outside: move to an open area away from power lines, poles, trees, walls or
chimneys. If you are in a vehicle pull to the side of the road and stop. Don't park under bridges,
overpasses or overhead wires.
SAFETY TRAINING PROGRAM
The following is a list of required safety training programs for specific individuals who are employed
with (your company name here).Training is required prior to performing specified jobs or duties.
Management will verify whether or not you have successfully completed your safety training. You must
have authorization from Management prior to performing specified jobs or duties. Failure to obtain
authorization could result in disciplinary action. These training courses are put in place for your safety.
Safety Training Course:
New Hire Orientation
Safe Lifting Training
Fire Extinguisher Safety
Fall Protection Training
Electrical Equipment Grounding Training
First Aid
Respirator training
Ladder safety
Tile saw operator
Staple gun operator
Nail gun operator
Skil saw operator
Torch operator
Electric shear operator
Who Must Attend:
All employees prior to start
All employees prior to start
All employees prior to start
All employees who will be exposed to fall hazard
All employees operating electrical tools
All employees within 90 days of start date.
All employees using respirator
All employees using ladders
All employees using tile saw
All employees using staple gun
All employees using nail gun
All employees using skil saw
All employees using torch
All employees using electric shears
SAFETY INSPECTION POLICIES & PROCEDURES
Every job site and / or work area will be inspected for safety compliance on a regular basis.
All inspections will be conducted unannounced / random basis.
Authorized person conducting safety inspection is to meet directly with job site and / or work area
supervisor/ superintendent immediately prior to continuing inspection.
Competent persons are required to walk through job site and / or work area while inspection is conducted.
This will help to quickly solve any hazards noted during inspection.
Management appointed Safety Inspectors will perform random safety inspections. If possible each crew
will be inspected at least once each week. These inspections may be visual, after-the-fact, or may involve
a walk-around inspection with the competent person.
Any necessary disciplinary action against the competent persons / or crew or office member is to be
issued within three (3) days of the inspection.
SAFETY MEETING POLICIES & PROCEDURES
Field Safety Meetings:
Field safety meeting will be held every Friday at 6:30 am. All field personnel are required to attend.
Safety minutes will be taken at the meeting and every attending field employee will be required to sign
the Safety Meeting Minutes sheet. An employee who consistently misses these safety meetings will be
suspended or terminated.
Job Site Safety Meetings:
A job site-specific safety meeting will be held on the job site at the beginning of the job. At times it may
be necessary to have more than one job site-specific safety meeting. This will be at the discretion of the
Competent Persons and / or Management. All field personnel working on that job site are required to
attend the safety meeting and must also sign off on the Fall Protection Work Plan. Document potential
hazards found on the jobsite.
Office Safety Meetings:
An office specific safety meeting will be held once each year. All office personnel are required to attend.
Safety minutes will be taken at the meeting and every attending office employee will be required to sign
the Safety Meeting Minutes sheet.
Failure to attend these required meetings could result in disciplinary action and / or termination.
(your company name here) EMPLOYEE SAFETY ORIENTATION
Instructions: Each employee is required to receive a safety orientation before beginning work. This checklist
documents that each item was covered in the orientation. Initial each box to indicate that the item was covered.
Employee Name:________________________________________________________________

Informed of elements of our written safety program outlining our company’s efforts. In some
cases (your company name here) policy exceeds WISHA standards. Our goal is to protect
employees to the best of our ability.

Given a copy of, and has read, company safety book. A copy of safety guidelines is also available
in each crew vehicle and maintained by each competent person.

Given required personal protective equipment and has been trained how to properly use it, care
for it and inspect it. PPE issued:_______________________________________
_______________________________________________________________________

Told to report injuries immediately, who to report them to, and the reporting process.

Told to report all hazards immediately to his / her supervisor and shown process.

All injuries and safety hazards will also be reported immediately to the Safety Director:
________________________________________________________________________

Told / shown the location of First Aid Kit and where to find list of those competent in first aid.
First aid kits and fire extinguishers are available in each crew vehicle.

Told / shown location of all MSDS and SDS, there purpose and how to read them.

Trained in Fall Protection according to the Fall Protection Work Plan WISHA Program
Requirements.

Trained in Assured Equipment Groundings per WISHA Program Requirements.

Trained in emergency procedures. (Fire, Earthquake, Evacuation.)
Note to Employee: DO NOT SIGN unless ALL items are covered and ALL questions are satisfactorily answered.
The signature below document that the appropriate elements have been discussed to the satisfaction of both parties,
and that both Management and Employees accept responsibility for maintaining a safe and healthful work
environment.
Employee Signature:___________________________________Date:___________________
Competent Person/s:___________________________________ Date:__________________
Safety Director:_______________________________________Date:___________________
(your company name and address here)
Required Training Employee Certification Record
This is a record of Training Certification for:
Employee Name:
1.
2.
The employee named above was instructed during the “New Hire” company safety
orientation, about our Accident Prevention program; both verbally and in written form (Copy
Available).
Specific training about fall hazards, fall protection and fall restraint is attained by these three
methods.
A. Verbal / Visual demonstrations
B. Training videos
C. On the job training and/or prior training and experience
3.
(your company name here) has provided this employee with a comprehensive, continual
training program and believes this employee to be competent. This employee acknowledges
the Safety Training programs provided by (your company name here)
Employee Signature
Date
Instructors Signature
Date
SUBSTANCE ABUSE POLICY
Here at (your company name here) we are striving to provide a safe work environment. Therefore, we
have implemented the following substance abuse policy.
If we have reason to believe you are involved with substance abuse use at work you will be required to
take a mandatory substance abuse test. The following is a list of, but is not limited to, potential reasons
for substance abuse testing:
1.
2.
3.
4.
5.
6.
7.
Late on a consistent basis.
Repeated unexcused absences.
Job site accident or injury.
Substance abuse paraphernalia found in company vehicle.
Report from coworker, builder / contractor or homeowner of use at work.
Any behavior consistent with substance abuse use.
Accident in company vehicle.
If you have been required to take a test and refuse to do so you will be automatically terminated.
If you have been required to take a test and fail the test you will be suspended without pay until you have
successfully completed the following:
Substance Abuse Treatment:
You must successfully complete an accredited 28 day substance abuse treatment program followed by a
mandatory substance abuse test before returning to work.
Upon successful completion you will have the opportunity to return to the company with the same status
and benefits you had before the incident occurred. Failure to successfully complete the substance abuse
treatment program or failure to pass a second substance abuse test will result in termination.
DRIVING SAFETY POLICY FOR COMPANY DRIVERS
In order to drive company vehicles you must authorize the company to order a driving abstract from the
Department of Licensing. You driving record must be satisfactory to the company and the company
insurer. In the event you are approved to drive, we have stated below grounds for termination of your
driving privilege and / or employment. Driving a company vehicle is a privilege. OSHA reports that
driving accidents are one of the most common causes of injuries to workers.
1.
2.
3.
4.
5.
6.
7.
8.
Alcohol or drugs, including paraphernalia, found in vehicles.
Use of drugs or alcohol while driving company vehicles
Unauthorized personal use of company vehicles.
Poor driving record / abstract.
Moving violations
Accidents where the employee is negligent.
Negligent or reckless driving.
Failure to have vehicle serviced according to maintenance schedule provided by vehicle
manufacturer..
9. Failure to report vehicle safety issues to management.
10. Vehicle Backing Safety: All drivers must use a spotter or complete a 360 degree walk around of their
vehicle before backing up.
11. Park in designated parking areas only, if available.
To insure proper safety while driving company vehicles please follow these guidelines.
Inspect your tires at the beginning of each use for low or flat tires.
Make sure you signals are in good working condition prior to each use.
Make sure your brakes lights are in good working condition prior to each use.
Wear your safety belt and make sure passengers do the same.
Adjust mirrors to make sure you can properly see out of them.
Make sure materials are securely fastened to prevent any shifting and / or movement.
Drive defensively and make an effort to avoid accidents even when other drivers commit errors.
Drive at legal and safe speeds for existing conditions and never take unnecessary risks
Never tailgate- follow the two second rule.
Use a hands free device when using cell phones, or pull off the road to a safe area and place your calls, or
to take notes.
Our goal is to reduce/eliminate all vehicle accidents and assure every vehicle (your workplace while
driving) is reliable and does not expose you to unnecessary hazards.
HAZARD IDENTIFICATION & REPORTING
Hazard Reporting:
1.
All employees of (your company name here), are responsible for reporting any and all hazards in
the office or on the job site immediately to the Safety Director. A Hazard Report Form is
provided to document that the hazard was reported.
2.
The person who takes final action must indicate on the form what action was taken to eliminate
or control the hazard.
3.
A copy of the form will be given to the individual who filed the report within 24 hours of the
time the report was received (excluding weekends and holidays). It will be reviewed against any
previously reported hazards similar to the existing new hazard. This will aid in finding solutions
to preventing hazards from occurring again and will be used in re-training employees. It will also
be used in rewriting any safety policy specific to the hazard.
4.
The original for will be kept in the Hazard Identification Log binder.
Hazard Record Keeping and Review:
All reported hazards are to be kept in a Hazard Identification Log binder. The hazards will be filed,
separated by type (fall hazards, equipment hazards, vehicle hazards, material hazards, etc.) then filed by
date within each section.
Hazard reports will be reviewed by management within 24 hours (excluding weekends and holidays). It
will be reviewed against any previously reported hazards similar to the existing new hazard. This will aid
in finding solutions to preventing hazards from occurring again and will be used in re-training employees.
It will also be used in rewriting any safety policy specific to the hazard.
Depending on the severity of the hazard it may be necessary to secure specific hazardous job site and / or
work area until management deems the subject area safe.
(your company name here) HAZARD REPORT RECORD
Name:_________________________________________________Date:___________________
Contact Phone:__________________________________________
Please fill this form out completely and turn in to Management. Your report will be kept confidential.
Management will contact you within 24 hours to report the resolution (excluding weekends and holidays).
Hazard and Location:
Recommended Solution:
Please retain a copy of this form for your records. A copy, with a solution, will be returned to you within
24 hours of being reported (excluding weekends and holidays).
↓ OFFICE USE ONLY ↓
Solution:
(your company name here)
Representative:
Date of Resolution:
ACCIDENT REPORTING
In the event you suffer a job related work injury, you are required to notify your direct supervisor and
Management immediately or prior to continuing onto a doctor. Your supervisor will help evaluate your
injury or suspected injury and assist you in securing appropriate medical assistance.
As soon as practically possible or prior to going back to work, you are required to complete an accident
report documenting the circumstances surrounding the incident. This report is to be turned into
Management. You may obtain this report from your direct supervisor or Management.
If you have any questions in regards to your injury, please direct them to Management. This includes, but
is not limited to, the following:
1.
2.
3.
4.
Initial injury and work status.
Pay questions.
Light duty options and schedule.
Return to work status.
It is your responsibility to keep in constant contact with Management in regards to your injury and
return to work status.
(your company name here) SUPERVISOR’S REPORT OF ACCIDENT
Injured Employee’s Name:
Age:
Job Position / Title:
Department:
Date and time of accident:
Location:
Date and time of accident reported:
To whom:
Name(s) of Witness(s):
What part of the body was injured? (Include left or right):
Did injured employee seek medical attention?
Task being performed when accident occurred:
Describe exactly how the accident occurred:
What caused the accident to occur?
Could anything be done to prevent accidents of the type? If so, what?
What has been done to prevent this type of accident from happening again?
Does further corrective action need to be taken? If yes, what are your recommendations?
Signature of Supervisor:
Date:
Sex:
(your company name here) EMPLOYEE’S REPORT OF ACCIDENT
Employee’s Name:
Age:
Job Position / Title:
Shift Hours:
Social Security #:
Days Off:
Date and time of accident:
Supervisor:
Location:
Task being performed when accident occurred:
Date and time accident reported:
To whom:
Name(s) of witness(s):
Describe how the accident occurred:
What part of the body was injured? (Include left or right):
Describe the injuries in detail:
Date and time you first sought medical attention:
Name of doctor and / or hospital:
Could anything be done to prevent accidents of this type? If so, what?
Signature of Employee:
Date:
Sex:
(your company name here) WITNESS REPORT OF ACCIDENT
Injured Employee’s Name:
Age:
Job Position / Title:
Department:
Date and time of accident:
Location:
Date and time accident reported:
To whom:
Name(s) of witness(s):
What part of the body was injured? (Include left or right):
Did injured employee seek medical attention?
Task being performed when accident occurred:
Describe exactly how the accident occurred:
What caused the accident to occur?
Could anything be done to prevent accidents of this type? If so, what?
What has been done to prevent this type of accident from happening again?
Does further corrective action need to be taken? If yes, what are your recommendations?
Signature of Witness:
Date:
Sex:
ACCIDENT INVESTIGATION GUIDELINES
Interview the injured worker and witness as soon as possible to determine the following:
1.
Circumstances prior to and surrounding the incident. What contributed to the cause?
2.
What physical hazards existed at the time of the accident? (Unprotected openings,
surfaces, protruding nails, etc.)
3.
used?
Were defective tools, equipment or materials provided to workers or were they
4.
Was personal protective equipment not provided? Was PPE defective, not used or used
improperly?
5.
Did unsafe work practices contribute to the incident, including improper lifting or
handling of materials?
6.
What safety rules or safety training might have prevented the accident?
7.
What unsafe conditions or unsafe actions were caused by third party? (Other contractors,
coworkers, etc.)
slippery
improperly
If possible, interview injured worker and witnesses at the scene of the accident and conduct a walk
through or re-enactment. (Be careful not to repeat the act that caused the injury.)
Privacy is important during interviews. Interview the witnesses one at a time. Talk with anyone who has
the knowledge of the accident, even if they did not actually witness the mishap. Express sincere
appreciation to anyone who helped with the investigation.
Record names, phone numbers and statements of witnesses. Consider taking signed, dated statements if
facts are unclear or an element of controversy exists.
If a third party or defective product contributed to the accident, save any evidence.
In major accidents, use sketches, diagrams and photos to document details. Take measurements when
appropriate.
Define corrective action that should be taken to prevent reoccurrence. Who will be responsible for this
action and when must it be completed? Every investigation should include an action plan.
Share accident information with supervisor on job site.
(your company name here) ACCIDENT INVESTIGATION REPORT
Injured Employee’s
Name:
Social Security #:
Date and time of
accident:
Location:
Part of body injured? (Include left or
right):
Name(s) of witness(s):
What specific job or task was being performed at the time of the
accident?
What occurred? Describe in sequence (1) Employee’s location & position (2) How he / she was
doing task (3) What occurred to trigger the accident (4) The type of accident & contact agent (5)
Background
information:
What tool(s) caused or contributed to the
accident?
What is the condition of the
tool(s)?
What did the employee do or fail to do that caused or contributed to the
accident?
What else may have contributed to the accident? (Poorly maintained tool, weather, misuse, working
too fast, ignored hazard,
etc.):
What action has (X) or will (√) be taken to prevent reoccurrence? (Mark all that apply)
__1.
__2.
__3.
__4.
__5.
Re-instruction of person(s) involved
Reprimand of person(s) involved
Preventive instruction of others
Job reassignment of employee
Improved inspection procedure
__12.
__13.
__14.
__15.
__16.
Improve storage
Eliminate congestion
Better temperature control
Use of safety materials
Improved illumination
__6.
__7.
__8.
__9.
__10.
__11.
Improved cleanup procedure
Better design / construction
Job safety analysis
Safety guard / device installed
PPE required
Tool / equipment repair / replace
__17.
__18.
__19.
__20.
__21.
Improved ventilation
Standardized job procedure
Reduction of noise
Reduction of vibration
Correction of other than above
Describe details of corrective action taken or planned:
Person responsible for planned corrective action:
Signature & Title of Investigator:
Date Completed:
SAFETY MEETING MINUTES
DATE:
TIME:
TOPICS:
SPEAKER(S):
TOPICS / MINUTES:
Please sign your name in the space below to verify that you understand the minutes that were discussed
and will comply with any new or reviewed current safety regulations discussed.
Supervisor:_______________________________
Date:_______________________________
Job Hazard Analysis and Worksheet
This job hazard analysis should be used along with the (your company name here) accident prevention
program book and provided Material Safety Data Sheets. Other hazards may be documented on the Fall
Protection Worksheet posted at each jobsite. All safety documentation will remain available at the jobsite.
Site:____________________________
Date:________________
Address:___________________________________________________________________
Job # ________ Description:______________________________________________
Safety Director: (253) 405-8872 Emergency/Fire: 911
Fire Extinguishers and First Aid Kits are located in each crew vehicle.
Job Description
Hazard
Solution
Smoking
Smoking is prohibited except in designated areas. No
General Rule
smoking in company vehicles or buildings.
Transportation
Personnel are not to be transported in the beds of
General Rule
trucks.
Eye Injury
Safety glasses required at all times
General Safety
Head Injury
Hard hats required when working below.
General Safety
Foot Injury
Leather uppers or leather boots
General Safety
Falls from elevation's
Use proper fall protection / fall arrest system
Removal of
existing roof
material
Objects falling from above Block area with barricades and safety tape
Power tool hazard
Use GFI on all power tools used in wet environment
Inspect tools and electrical cords for damage
Cuts and or punctures
Bend or remove all nails from lumber and or
construction debris
Dust Inhalation
Use proper dust mask or respirator
Ventilate area with exhaust fans.
Trip Hazards
Keep work area clear of debris, tools and material.
Run all electrical cords over head or against walls.
Possible back injury
Use proper lifting technique.
Cuts and punctures
Use caution when using razor knifes to cut shingles or
felt.
Possible Drowning
Wear flotation devices when working over bodies of
water.
Job Hazard Analysis and Worksheet
Site:____________________________
Date:_______________
Address:___________________________________________________________________
Job # ________ Description:______________________________________________
Safety Director: (253) 405-8872 Emergency/Fire: 911
Fire Extinguishers and First Aid Kits are located in each crew vehicle.
Job Description
Hazard
Solution
Falls from elevation's
Use proper fall protection / fall
Installation of new roof material
arrest system
Objects falling from
Block area with barricades and
above
safety tape
Working from manlift
Use proper fall protection
Proper training
Use on level solid substrate
Power tool hazard
Use GFI on all power tools used
in wet environment
Inspect tools and electrical cords
for damage
Ventilate area with exhaust fans.
Eye Injury
Use eye protection when using
pneumatic nailers.
Trip Hazards
Keep work area clear of debris,
tools and material.
Run all electrical cords over head
or against walls.
Possible back injury
Use proper lifting technique.
Cuts and punctures
Use caution when using razor
knifes to cut shingles.
.
Job Hazard Analysis and Worksheet
Supervisor:_____________________________________
Supervisor Signature:_____________________________
Job Description:__________________________
Employees Trained/date:
JOB SITE FALL PROTECTION WORK PLAN
Company Name _________________________________________________________
Date __________
Site
Address
_________________________________________________________________
___________________________________________________________________________
(If additional space is needed, use the back of this sheet)
Identify all fall hazards 10’ or more above the ground or lower level (check all that apply) and fall
hazards of 4’ or more but less than 10’ (check all that apply) as well as other fall hazards like floor
openings, wall openings, etc.
10 or more
4’ or more
__ Open-sided walking/working surfaces (i.e. roofs, open-sided floors)
_________
_________
__ Open-sided ramps, runways, platforms
_________
_________
__ Wall openings
_________
_________
__ Skylight openings
_________
_________
__ Floor openings
__ Trenches
__ Surfaces that do not meet the definition of a walking/working surface (i.e. top plate)
**Walking/working surface = any area whose dimensions are 45 inches or greater in all
directions, through which workers pass or conduct work.
Methods of fall protection to be used: LSO = Low Slopes Only (low slopes = 4 x 12 or less)
__Guardrail system (LSO)
__ Warning line (LSO)
Personal fall arrest system
Vertical life line & rope grab
__ Personal fall restraint system
Safety Watch System (LSO)
__ Warning line w/safety monitor (LSO)
system
__ Catch platform
__ Positioning device system__ Appropriate anchors for
__ Covers
__ Safety net
_ Horizontal life lines
Name of safety watch or monitor, if used:
Other methods of fall protection selected:
__ Boom lift
__ Scaffold w/guardrail
__ forklift w/man basket
__ Scissor lift
__Other:
______________________________________________________________
Describe procedures for assembly, maintenance, inspection, disassembly of fall protection system to be
used.
_________________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Describe procedures for handling, storage, and securing tools, equipment, and materials.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Describe methods of overhead protection for workers who may be in, or pass through work area.
__________________________________________________________________________
_________________________________________________________________________
Describe methods to be implemented for prompt, safe removal of injured worker(s).
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Employees who received fall protection training on the above site specific fall protection work plan.
Name (print)
Date__________________
Name (print)
Date__________________
Name (print)
Date__________________
Name (print)
Date__________________
Name (print)
Date__________________
Name & title of person who provided training: ___________________________________________
Workers attending job site fall protection safety meeting:
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
Name (print)
Sign ________________________
__________ (insert your company name here) Safety Recordkeeping and Reporting
__________ (insert your company name here) will maintain required safety records as follows:
1. Complete a OSHA form 301 or equivalent within 7 (seven) days for every accident
2. Report any accident that results in hospitalization of fatality within 8 hours of an incident, or
within 8 hours of learning about an incident to the department of Labor and Industries at 1800-423-7233.
3. Keep an OSHA 300 form current and up to date within 7 (seven) days following an accident.
4. Post an OSHA 300 A form during the months of February through April of each year