Appendix A – Sample Forms
General Safety Rules
Safety Violation Warning Notice
Safety Award Template
Safety Committee Minutes
Safety Meeting/Tailgate Talk Log
Employee Safety Suggestion
Hazard Identification and Correction Form
Hazard, Training and Program Matrix
Job Safety Analysis Worksheet
Inspection Checklist for General Industry
Inspection Checklist for Agricultural Operations
Preventive Maintenance Schedule & Log
Incident Investigation Report
Employee Report of Injury
Witness Incident Report
Incident Investigation Report
Incident Report – Employee Statement
Training Roster
Employee Training Checklist
Corporate Office: Zenith Insurance Company 21255 Califa Street, Woodland Hills, CA 91367
© 2010 Zenith Insurance Company. All Rights Reserved. ® Zenith and TheZenith are registered U.S. service marks
General Safety Rules
(Company Name) strives to provide a safe, healthful work environment. But safety
begins with YOU.
You are responsible for reporting any hazards to your supervisor immediately and
following safe work procedures. Any violation of safety rules will result in disciplinary
action. The following list of safety rules is not complete. Your manager will provide you
with additional information and training as necessary.
1. Report all accidents to your supervisor.
2. Report all unsafe or broken tools or equipment to your supervisor.
3. Don’t take chances.
4. Observe all warning signs, safety bulletins and posters.
5. Avoid ALL horseplay and never distract another worker.
6. Use protective clothing and equipment such as goggles, safety glasses, and guards.
It is mandatory that you use this equipment when required.
7. Report any safety hazard immediately to your supervisor.
8. To lift heavy objects, squat down, keep your back straight and use the leg muscles
when lifting. Do not attempt to lift any object heavier than you can handle.
9. When using sharp-edged tools, cut away from your body.
10. Before starting work, tuck in loose clothing.
11. Keep the floors, aisles and passageways clear of stock, materials, scrap, tools, oil
and equipment. You are responsible for keeping your work area clean and
organized.
12. Do not undertake a job that appears to be unsafe.
13. Report any fire immediately to a manager or supervisor.
14. Do not block access to fire-fighting equipment, fire sprinklers or fire exits.
15. Learn the location of all fire exits and fire extinguishers. In case of fire, turn off all
electrical equipment and walk quietly to the nearest exit. Follow your manager’s
direction.
Safety Violation Warning Notice
Date: ____________
You have been observed violating the following company safety rules or practices:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Your violation may have been unintentional, or you may have not realized that you were
violating a safety rule or a safe practice. We are bringing this to your attention because of
management's sincere concern for your safety. We hope that you share this concern for
yourself and your fellow employees. Production, economy or convenience of either
management or our employee's shall not take precedence over safety in our operation.
Further violations of the above, or frequent violations of any safety rules, or safe practices,
will result in disciplinary action.
IF IN DOUBT, ASK YOUR SUPERVISOR, DON'T TAKE CHANCES!
______________________________________
Supervisor's Signature
I have read and understand the above warning notice. I agree that I will not commit this
violation again, and that I will try to increase the safety with which I work.
______________________________________
Employee's Signature
Presented to:
Name
On DATE
for PURPOSE
Presenter’s Name
Presenter’s Title
Presenter’s Name
Presenter’s Title
Safety Committee Minutes
Date:
Members/Guests Present:
Absent:
Review/Approval of Minutes from (previous meeting date) Meeting:
Old Business: (record discussion concerning previous unresolved matters/recommendations):
Review of Incidents/Accidents: (record discussion regarding causes and committee recommendations for future
prevention):
Current Inspection Results/Recommendations: (assign numbers to current action items, establish person(s)
responsible and completion target dates)
New Business: (record discussion regarding safety education materials, contests, safety events, etc., which are
under consideration or are currently administered by committee)
(Secretary’s signature/date)
Safety Meeting/Tailgate Talk Log
Date
Name of Trainer
Subject(s) Covered
Work Location
____________
Attendees (Please print and sign your name legibly.) Use additional sheets as
necessary.)
Print
Signature
Safety Meeting/Tailgate Talk Log
Page 2
Print
Signature
Employee Safety Suggestion
This form may be used by employees to provide a safety suggestion or report an unsafe
workplace practice.
Description of Unsafe Acts of Conditions
Reasons for Unsafe Acts of Conditions
Suggestion for Improving Safety
Has This Subject Been Reported to Your Supervisor?
Employee Name (Optional)
Yes ____
No ____
Hazard Identification and Correction Form
Date
Hazard (1)
Identified
Dept
Corrective Action
Assigned to: (2)
(1) Hazards Identified, Incorporated from Inspection Checklists, etc.
(2) List who is responsible for corrective action
(3) Date corrective action required and that date which will be diaried and followed up on.
Date Req’d (3)
Date Comp.
Page ___ of ___
(1)
Hazards Identified
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Hazard, Program and Training Matrix
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PROGRAMS
Training for
Department or
Functional Area
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1) NOTE: This matrix is an example of commonly found workplace hazards that require special training. In addition, those noted most always require a specifically written program to support them.
Other hazard, training requirements and programs may exist for your operations. This is an example.
(2) Training Frequency: M=Monthly Q=Quarterly S=Semi Annually A=Annually N=As Needed N/A=Not Applicable (the assumption is that affected employees receive initial training upon hire)
R=Upon re-assignment
Job Safety Analysis Worksheet
Date of Analysis:
Reviewed By:
Company Name:
Job Title:
Analysis Done By:
Step 1: Sequence of Basic Job
Steps
Break the job into a sequence of steps. Each
of the steps should accompany some major
task. That task will consist of a series of
movements. Look at each series of
movements within that basic task.
 New Job Safety Analysis
Department:
Step 2: Potential Hazards
To complete a JSA effectively, you must
identify the hazards or potential hazards
associated with each step. Every possible
source of energy must be identified. It is very
important to look at the entire environment to
determine every conceivable hazard that
might exist. Hazards contribute to accidents
and injuries.
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 Revised Job Safety Analysis
Step 3: Recommended Procedures
Using the Sequence of Basic Job Steps and
Potential Hazards, decide what actions are
necessary to eliminate, control, or minimize
hazards that could lead to accidents, injuries,
damage to the environment, or possible
occupational illness. Each safe job procedure
or action must correspond to the job steps and
identified hazards.
Job Safety Analysis Worksheet
Step 1: Sequence of Basic Job Steps
Step 2: Potential Hazards
Step 3: Recommended Procedures
CONTINUED…
CONTINUED…
CONTINUED…
Job Safety Analysis Worksheet
(Sample - For Reference Purposes Only)
Date of Analysis:
December 20, 2009
Reviewed By: Safety Manager
Company Name: ABC Company
Job Title: Machinist
Analysis Done By: Joe Safety

New Job Safety Analysis  Revised Job Safety Analysis
Department / Task: Finishing / Grinding castings
Step 1: Sequence of Basic Job Steps
Step 2: Potential Hazards
Step 3: Recommended Procedures
Break the job into a sequence of steps. Each of
the steps should accompany some major task.
That task will consist of a series of movements.
Look at each series of movements within that
basic task.
To complete a JSA effectively, you must
identify the hazards or potential hazards
associated with each step. Every possible
source of energy must be identified. It is very
important to look at the entire environment to
determine every conceivable hazard that
might exist. Hazards contribute to accidents
and injuries.
 Struck against edge of box or casting – cut
hand on burr.
 Overexertion from lifting of heavy castings.
 Struck by falling casting on foot.
Using the Sequence of Basic Job Steps and
Potential Hazards, decide what actions are
necessary to eliminate, control, or minimize
hazards that could lead to accidents, injuries,
damage to the environment, or possible
occupational illness. Each safe job procedure
or action must correspond to the job steps
and identified hazards.
1.
Right hand reaches into box, grasps
casting, carries it to wheel.
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Wear gloves to protect against sharp
edges as required when handling raw
stock.
Use proper lifting procedures.
Get help if part is too large for one
person.
Wear steel toe footwear.
Job Safety Analysis Worksheet
(Sample - For Reference Purposes Only)
Step 1: Sequence of Basic Job Steps
Step 2: Potential Hazards
CONTINUED…
CONTINUED…
2.
Left hand grasps left side of casting, right
and left hands push casting against wheel.
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Struck against burr on castings.
Struck against wheel.
Caught on rotating parts.
Flying sparks, dust, chips, or wheel
breakage.
Step 3: Recommended Procedures
CONTINUED…
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3. Left hand places finished casting in box on
side of machine
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Struck against box or castings.
Overexertion from lifting of heavy
castings.
Foot struck by castings.
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Wear gloves to protect against sharp
edges of castings.
Keep hands clear of rotating parts.
Possible use of tool rest.
Do not wear loose clothing.
Do not wear gloves when grinding small
pieces.
Wear eye protection.
Ensure all required guards are in place;
i.e., side guards and tongue guards are
of proper size, tool rests and tongue
guards are properly adjusted.
Wear gloves to protect against sharp
edges of castings .
Use proper lifting techniques.
Provide for moving of finished stock.
Wear foot protection.
Inspection Checklist for General Industry
Note: The purpose of this report is to help you identify and correct unsafe work practices (acts) and conditions before an accident occurs. Begin
each inspection by making safety observations. Then, conduct a thorough inspection utilizing the checklist. Be sure to follow up on all items
needing action.
The items on this checklist should be made specific for your facility. To assist with development, (1) walk through each department with the
supervisor and identify specific hazards that should be addressed, (2) include previously hazards identified elsewhere in the Safety Program,
and/or (3) use OSHA checklists, such as OSHA Small Business Handbook or Cal OSHA Model Injury And Illness Prevention Program For High
Hazard Employers.
Use the space below for general safety observations. Look for unsafe behaviors and note them here. Remember, more than 80% of all accidents
are caused by unsafe acts of personnel. When unsafe acts are observed, the situation should be corrected immediately.
Notes:
Administrative:
OK
Action
Needed
Corrective
Action Taken
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Housekeeping:
A. Walkways clear of obstructions
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B. Employees clean up as they go
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A. Required posters conspicuously
displayed
B. Recordkeeping requirements met
C. Workers trained prior to new or
unfamiliar tasks
Material Handling:
A. Employees trained in proper lifting
methods
B. Equipment provided for heavy or
awkward loads
C. Materials stored to prevent overreaching
Comments
Inspection Checklist for General Industry
Page 2
Floors:
A. Walking and working surfaces kept clear
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Machinery and Equipment:
A. Moving parts guarded
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B. Kept in safe operating condition
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C. Operated and inspected per mfg.
instructions
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Hand Tools:
A. Always inspected before using
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B. Only used for intended purpose
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C. Damaged tools repaired or replaced
promptly
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Stairs:
A. Lighting adequate
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B. Non slip surface
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C. Handrails secure
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Ladders:
A. Proper type for intended use
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B. Maintained in good condition
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C. Proper ladders used instead of chairs,
boxes, etc.
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B. Spilled materials cleaned up
immediately
C. Holes in floor repaired or covered
First Aid:
Inspection Checklist for General Industry
Page 3
A. Fully stocked first aid kit
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B. Emergency telephone numbers posted
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C. At least one person trained in first aid
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B. Communicated to all employees
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C. Employees designated and trained to
implement plan.
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A. Exits clearly marked
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B. Exits accessible
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C. Exit doors unlocked
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A. All equipment either grounded or double
insulated
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B. Extension cords in good repair
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C. At least 30” clearance around control
panels
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Emergency Action Plan:
A. Written; covers fire and other
emergencies
Fire Protection:
A. Fire fighting equipment is serviced and
accessible
B. Employees instructed in use of fire
fighting equipment
C. Employees instructed in fire protection
procedures
Egress:
Electrical:
Inspection Checklist for General Industry
Page 4
Personal Protective Equipment:
A. Proper equipment in use where needed
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B. Properly maintained and stored
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C. Employees trained in proper usage
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Health Hazards:
A. Hazard communication program in
place.
B. Hazardous materials stored and used
properly
C. Warning and identification signs clearly
posted
Use this space to list additional items specific to your operations. Use an additional sheet to continue your list if you run out of
space.
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Inspection Checklist for General Industry
Page 5
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Conducted by:
Date:
Reviewed by:
Date:
Inspection Checklist for Agricultural Operations
GENERAL
1.
2.
3.
4.
5.
6.
All OSHA or workers compensation
notices posted in visible area
There is an established Safety
Program
Employees are instructed in proper
first aid and emergency procedures
Material safety data sheets readily
available
All work areas clean and orderly
Fire extinguishers are readily
available
FIELD
1.
2.
3.
4.
5.
6.
Ladders are free from weak,
damaged rails and loose or broken
rungs
Orchard ladders contain stable third
leg
Cutting, shearing and pruning hand
tools properly sharpened and stored
Grazing, hoeing, and raking tools
are rust free and stored adequately
Seatbelts on tractors with ROPS
fastened correctly and used
PTO guards on tractor or harvesting
implements secure
OK
Action
Needed
Corrective
Action Taken
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OK
Action
Needed
Corrective
Action Taken
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Comments
Comments
Inspection Checklist for Agricultural Operations
Page 2
FIELD
7.
8.
9.
10.
11.
12.
13.
Tractors and harvesting implements
are free from functioning or
mechanical defects
Tractors contain back wheel fenders
Vehicles have working head, signal,
and rear lights
Seatbelts on all vehicles fastened
adequately
Clean potable drinking water
available at all times
Hand washing and toileting stations
are properly maintained and
stocked
Designated areas for shade
14. Irrigation equipment and machines
in good working condition
15. Harvesting equipment and
machines in good working condition
16. Walkways clear from debris or
misplaced equipment
17. Moving parts on agricultural
equipment properly guarded
18. Hazardous substances properly
labeled and identified
19. First aid materials readily available
OK
Action
Needed
Corrective
Action Taken
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Comments
Inspection Checklist for Agricultural Operations
Page 3
PACKING HOUSE
1.
2.
3.
4.
5.
6.
Walkway and floors are free of
trash, debris or misplaced
equipment
Machine guards in place
Packing equipment and tools
maintained, stored properly
First aid kits stocked and easily
accessible
Fire extinguishers easily accessible,
and in working condition
Platforms are stable
7.
Equipment and tools stored in
designated area
8. Signs posted for high voltage or
unsafe entry
9. Ventilation systems in proper
working condition
10. High voltage machines and
equipment grounded
11. Forklifts equipped with horn, brakes
and back up alert
12. No breaks or cracks on pallets
13. Hand and eye washing station in
operating condition
OK
Action
Needed
Corrective
Action Taken
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Comments
Inspection Checklist for Agricultural Operations
Page 4
SHOP
1.
3.
Hazardous materials used, sorted,
labeled, and disposed of properly
Floors clean – no oil, radiator fluid,
etc.
All electrical cords in good condition
4.
Oily rags and paper are removed
5.
Eye protection is available and used
6.
Hand tools are in good condition
7.
Batteries are stored away from
ignition sources
Fire extinguishers are pressurized
2.
8.
9.
10.
11.
12.
13.
Compressed gas bottles are
restrained
Power tools are in good condition
and guarded
Flammable materials are stored in a
steel cabinet
Overhead hoists have hook safety
latches
Employees wear proper boots,
gloves, and other personal
protective equipment
OK
Action
Needed
Corrective
Action Taken
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Conducted By: ________________________
Date: _________________________
Management Review: __________________
Date: _________________________
Comments
Preventive Maintenance Schedule & Log
Company:
Date Rev’d:
By:
Distribution: Orig:
Item/Machine/
Equipment
(1)
(2)
For Year:
Department:
Conducted by:
Copies to:
Frequency (1)
M, Q, S, A, O
Basic Instruction
Maintenance to
Perform
Comments
Frequency: M=Monthly, Q=Quarterly, S=Semi-Annually, A=Annually O=Other, Standard Annual Calendar
(3)
(5)
Initials
If Applicable (4) Include Required Follow Up Notes & Due Dates
Month Names Optional
(4)
Date
Completed.
By: (2)
Preventive Maintenance Schedule & Log
(Sample Only)
For Year:
Department:
Company:
Date Rev’d:
By:
Distribution: Orig:
Item/Machine/
Equipment
Cold water storage
tank
(3)
(4)
Conducted by:
Copies to:
Frequency (1)
M, Q, S, A, O
Q
March, June,
September,
December (5)
Basic Instruction
Exercise & lubricate
gate valves
Maintenance to
Perform
Exercise all cold water
valves; lubricate with
standard company
lubricant & submit
repair orders as needed
Comments (4)
All gate valves checked. All OK
except inlet water valve which
is sticking & needs to be
replaced. Work order
submitted & will confirm
Repair NLT 4-15-10
Frequency: M=Monthly, Q=Quarterly, S=Semi-Annually, A=Annually O=Other, Standard Annual Calendar
(3)
(5)
Initials
If Applicable (4) Include Required Follow Up Notes & Due Dates
Month Names Optional
Date
Completed.
3/15/10
By: (2)
ABC
Incident Investigation Report
The purpose of this report is to help prevent similar incidents from recurring. Make this report as accurate and
thorough as possible. Remember, always follow-up with the appropriate corrective action(s).
Incident:
 Near Miss
 Minor Injury
Incident Date:
 Minor Illness
 Major Injury
Time:
 Major Illness
AM/PM
Injured Employee:
Occupation:
Months on this job:
Incident Description
Where did the incident occur?
Witness(es)
How did the incident occur? (What was the employee doing when injured?)
Describe the injury(s) or damage
Circle Affected
Body Part
What unsafe act(s) or condition(s) contributed to the incident?
Corrective Actions
What do you recommend be done (or have you done) to prevent this type of incident from recurring?
What corrective action(s) has (have) been taken?
Date:
If you suspect that this claim is fraudulent, call Zenith’s Fraud Hotline: 1-866-296-4748
Investigation conducted by:
Date:
Report reviewed by:
Date:
Employee Report of Injury
The purpose of this report is to prevent similar incidents from occurring. It should be completed and signed by the
injured worker.
Incident:
 Near Miss
 Minor Injury
Incident Date:
 Minor Illness
 Major Injury
Time:
 Major Illness
AM/PM
Injured Employee:
Occupation:
Months on this job:
Incident Description
When did you report the incident and to who?
Did you require medical attention?
Yes:
No:
Location of incident (entrance, loading dock, bathroom, etc.)
Witness(es)
Describe in detail how the incident occurred and what you were doing when it occurred?
Circle Affected
Body Part
What body part(s) were affected?
What unsafe act(s) or condition(s) contributed to the incident?
What is at least one thing that can be done to prevent this type of incident from recurring?
Employee Signature:
Date:
Witness Incident Report
The purpose of this report is to prevent similar incidents from occurring. Remember, we are fact finding, not
fault finding. Please make this report as accurate and thorough as possible.
Witness Name:
Time:
Job Title/Occupation:
Incident:
 Near Miss
AM/PM
Work Phone:
 Minor Injury
Incident Date:
 Minor Illness
 Major Injury
Time:
 Major Illness
AM/PM
Injured Employee:
Incident Description
Location of incident (entrance, loading dock, bathroom, etc.)
Describe in detail how the incident occurred and what the employee was doing
when it occurred.
What unsafe act(s) or condition(s) contributed to the incident?
What body part(s) were affected?
What is at least one thing that can be done to prevent this type of incident from
happening again?
Witness Signature:
Date:
Circle Affected
Body Part
Incident Investigation Report
First show concern and respond to the immediate needs of injured employee(s) (emotional, medical, notification of relatives, transportation,
etc.). Once assured, complete your review at the incident scene as soon as possible. Show to all that the purpose of this review is not to
assign blame, rather to ultimately prevent future incidents via a thorough review. Safely secure the scene. Be prepared as necessary to
take photos, measure, sketch, gather evidence, refer to written standards, have witnesses complete written statements, etc. Determine:
who, what, where, when, how, and why?
Conduct interviews individually at the incident scene and in a non-threatening environment. Ask open-ended questions such as “What did
you observe?” and then do not interrupt respondents. To prompt responses, say, “Then what happened?” Wait until respondent has
finished talking and only then ask clarifying questions to fill in information gaps. Always ask their opinion about corrective action.
Name of Injured Employee
Job Title
If other than HQ, Branch/Jobsite Location of Injury
Task Performed when Injured
Date & Time Injury Occurred
Date and Time Reported to Supervisor
Injured Employee’s
Department
Injured Employees Experience in
Was Task (Check One)
How Long Employed?
Job Task (Check One)
Routine Infrequent
New
Novice
Competent
New Experience
Expert Unauthorized
When Did Injury Occur In Shift
Occurred on Company Premises?
Exact Location Where Injury Occurred
(Check One) Early Mid
Near Break
Late,
Yes
No
Overtime
When was On-Scene
Observation of
Incident Site made by
Supervisor?
Photos/Sketches Attached?
Yes
No
Was Post-Incident Drug Testing
Administered?
Yes
No
Any Witnesses? If “Yes,”
attach Statements
Yes
No
Evidence Secured?
Yes
No
Who is the management person responsible for
coordination of return to work and for maintaining
regular contact with concern for injured worker?
Additional Comments:
If Drug Test Performed, Where, Date,
Time
Have the injured worker and medical provider been
informed that transitional work will be offered for
immediate return to work within medical restrictions?
Yes
No
Nature of Injury and Body Parts Affected: (e.g., cut left thumb, broken right arm, strained lower back, etc.)
Severity of Injury/Illness
“Near-Miss” Incident (no injury)
First-Aid (in house treatment only)
Minor Medical (initial doctor treatment, then release)
Serious (partial disability, continuing medical care)
Catastrophic (critical condition, severe disability, fatality)
Work Status Following Initial Medical Treatment
Full Duty Returned to work on next shift
Transitional’ Duty Returned to work on next shift
Lost Time (did not return to work on next shift)
Mechanism of Injury
Slip/Trip/Fall onto same level
Chemical, Heat/Cold, Blade)
Fall from above level (ledge, platform, ladder, stairs)
Caught In/On/Between (pinched, snagged, grabbed)
blood)
Overexertion (strain from force, exhaustion)
Respiratory Exposure
Struck-Against (hit on, bumped into)
Contact With (Electrical,
Struck By (hit by something)
Repetitive Motion Condition
Airborne Material in Eye
Bio-hazard Exposure (needle stick,
Vehicle Incident Other:______________________________________
Describe in Detail How the Incident Occurred
Comment on equipment/tools, materials, people, vehicles, or environmental factors (such as noise, lighting, heat, cold etc.) that may have
contributed.
Protective Gear Used by Injured Employee (when incident occurred)
Comment on equipment/tools, materials, people, vehicles, or environmental factors (such as noise, lighting, heat, cold etc.) that may have
contributed.
Immediate Causes of Incident (identify both behavior(s) and condition(s). Check as many as applicable.
Behaviors/Work Practices
Physical Conditions
Using Improper Equipment (wrong type/damaged)
Abuse or Misuse of Equipment
Removing Safety Devices or making them inoperable
Failing to Use PPE or Seatbelts
Improper Placement/Arrangement (unstable)
Improper Handling Technique (help, grip, reach, posture)
Failure to Use Handling Equipment (carts, lifts, etc.)
Improper Body Position or Overreach (in harms way)
Working on Equipment in Motion
Performing at Unsafe Speed or Pace
Not Authorized or Qualified to Perform
Failure to Isolate/Secure/Lockout
Horseplay
Inadequate Ventilation
Other/Comments:
Inadequate Guards/Barriers/Safety Devices
Inadequate or Improper Protective Equipment
Defective/Worn Tools or Equipment in Service
Congested/Restricted Area/No Separation
Fire or Explosion Hazard
Working Surface Unsafe (slippery, sloped)
Poor Housekeeping/Disorder/Traffic Flow
Noise/Vibration
Temperature Extremes
Visibility Inadequate (dark, glare, obscured)
Heavy Work Uncontrolled
Production Pace Unsafe
Emergency Systems/Provisions Inadequate
Root Causes of Incident (identify both personal factor(s) and management practice factor(s). Check as many as
applicable.
Possible Personal Factors
Possible Management Practice Lacking
Knowledge Insufficient
Skill Insufficient
Experience Insufficient
Motivation Lacking
Fatigue (mental or physical
Personal Issues
Other: ____________________________
Leadership/Supervision/Enforcement
Engineering/Design/Capacity/Containment
Process/Work Methods
Maintenance/Inspection program
Staffing/Manpower/Hiring Practices
Tools/Equipment Provided
Hazardous Materials Alternatives/Controls
Training/Development
Hazard Identification/Evaluation
Other/Comments:
Preventive Measures to be Considered. Check as many as applicable.
 General Enforcement
Improvement
 Housekeeping/Disposal
Improvement
 Repair/Replace
Equipment
 P.P.E. improvement
 Training or Re-Training
of Employees
 Substitute Safer Alternative
Material
 Congestion/Traffic
Improvement
 Individual Corrective
Counseling
 Guards/Safety Devices
Improved
 Supply/Purchasing
Improvement
 Formal Procedure
Development/ Revision
 Engineering/Process
Improvements
 Inspection/Maintenance
Improvement
 Ventilation improvement
 Staffing/Hiring Stds /
Development
 Visibility / Illumination
Improved
 Noise/Vibration
Improvement
 Discontinue/Eliminate
Task
 Rotation of Employees
 Storage / Arrangement
Improvement
 Emergency
Systems/Provisions
 Remove / Eliminate
Hazard
 Employee Awareness/
Communication
 Provide Employee Incentive
 Safety Efforts
Effectiveness
 Conduct Hazard
Analysis
 Job Re-Assignment of
Employee(s)
 Remove Employee
Disincentive
 Work Method
improvement
 Workstation Re-Design
 Temperature
improvement
 Warning System
Provided
Other/Comments:
Specific Corrective
Action(s) Taken
Person(s)
Responsible
Report Completed by (Supervisor):
Target Date
Date Completed
Date:
Routed for Review to:
Manager:
Executive:
Safety Committee:
Comments:
Comments:
Comments:
Incident Report – Employee Statement
Note: The purpose of this form is to assist management with determining the facts surrounding an
incident, and to prevent future similar incidents in consideration of all contributing factors.
Event:
Approximate Date/Time of Event:
Name of Employee Providing This Statement:
Date/Time of Statement:
Please be as detailed as possible and take whatever time is necessary to thoroughly contribute to this
incident review. Use additional pages as needed. You will be assisted with any writing difficulties as
needed.
WHEN precisely did these events occur? (During break, during an installation or delivery, during
overtime etc.)
WHEN
WHO all was involved? (Any injured parties, other witnesses, a vendor or contractor, or anyone that can
provide important information?)
WHO
WHERE exactly did the events occur?
WHERE
WHAT happened? Explain in detail all you know about the incident
WHAT
HOW did the event occur?
HOW
WHY in your opinion did the event occur?
WHY
RECOMMENDATIONS: HOW in your opinion could the incident have been prevented and WHAT is
needed to be done to prevent future incidents?
RECOMMEND
My signature below acknowledges that I have been completely truthful with all I know about this
incident at this time. I will immediately forward additional information to management as it may
further appear to me.
Signature of Employee : _______________________________
Date: ______________
Training Roster
Name of Trainer
Date
Name of Training
Location of Training
Training Aids Used
____________
Attendees (Please print and sign your name legibly.) Use additional sheets as necessary.)
Print
Signature
Training Roster
Page 2
Print
Signature
Employee Training Checklist
Employee Name:
All of the rules indicated below were explained to me, I fully understand them, and agree to
abide by them while working for (Company Name). (Note: Have the employee and supervisor
sign his/her initials in the blank next to the safety rules covered with them.)
(Note: The following are examples of common training topics. It should be tailored for your
company with your specific training needs. It may be adapted from your Training Matrix.)
Employee
Initials
General Safety Rules
Reporting Injuries and Illnesses
Equipment and Vehicle Safety
Ladder Safety
Electrical Safety
Hazard Communication
Fire Prevention
Back Safety
Machine and Tool Safety
Personal Protective Equipment
Heat Illness Prevention
Supervisor
Initials
Date