Safety Groups – Five Steps Worksheet
Company Name:
Element Name:
_______________________________________________________________
___________________________________Date:_______________________
Step 1 - Set Standard
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I have a written standard for the above element
The standard is current (date of standard_______________________________________)
The standard is signed / approved by senior management (name on the
document_____________________ title______________________________________)
The standard describes exactly how the element will be implemented in the workplace
The standard clearly describes the specific responsibilities of everyone in the workplace (e.g.,
management, supervisors, workers, JHSC, Safety Group contact, etc.)
It outlines exactly how the standard will be communicated
It outlines exactly what health and safety training is necessary to meet the standard
It outlines exactly how the standard will be evaluated at the end of the year
The requirements of the standard are realistic
The standard meets minimum legislative requirements.
Step 2 - Communication
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The standard has been communicated to
o All those responsible for implementing the standard
o All those who will be affected by the standard.
Name
Means of Communication
(e.g., bulletin boards, emails,
memos, meetings, etc.)
1 of 2
Date of Communication
Step 3 – Training
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The training requirements outlined in the standard have been fulfilled
Training records are available showing the following information
Name of Person Trained
Job Title
Training Content
Date of Training
Step 4 – Evaluation:
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Proposed date of evaluation of the standard: ________________________________________
Means of evaluation (e.g., quizzes, surveys, workplace inspection observations, accident statistical
review, etc.): _________________________________________________________________
Persons responsible for conducting the evaluation: ___________________________________
Actual date of evaluation: _______________________________________________________
Summary of the evaluation results/findings (be specific):
Evaluation Results/Findings:
Step 5 – Acknowledge Success/ Make Improvements:
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The standard was successfully implemented.
o Who will formally acknowledge / recognize this success? _________________________
o How will success be formally acknowledged? __________________________________
o Date of acknowledgement: _________________________________________________
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Improvements recommended as a result of the above evaluation:
Recommended Improvements (be specific)
2 of 2
Date Completed
Signature