Form FORM-33 Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet
Blank Form 33
Request Number

Visit Number

Visit Date

Employer
Site Location
Legend: 0 = No; 1 = No, Needs major improvement; 2 = Yes, Needs minor improvement; 3 = Yes; NA =
Not Applicable; NE = Not Evaluated
* = Stretch Items Attribute of Excellence

Synthesis Item Score
0

1

2

3

0

1

2

3

With the total knowledge you now have of this organization (whether or
not such knowledge has been captured by attribute ratings), use your
professional judgment to assign an overall score for the organization's
safety and health system.

Hazard Anticipation and Detection
1. A comprehensive, baseline hazard survey has been conducted within
the past five (5) years.
Comments:
2. Effective safety and health self-inspections are performed regularly.
Comments:
3. Effective surveillance of established hazard controls is conducted.
Comments:
4. An effective hazard reporting system exists.
Comments:
5. Change analysis is performed whenever a change in facilities,
equipment, materials, or processes occurs.
Comments:
6. Accidents are investigated for root causes.
Comments:
7. Material Safety Data Sheets are used to reveal potential hazards
associated with chemical products in the workplace.
Comments:
8. Effective job hazard analysis is performed.
Comments:
9. Expert hazard analysis is performed.

NA

NE

Comments:
10. *Incidents are investigated for root causes.
Comments:

Hazard Prevention and Control
0

1

2

3

NA

NE

0

1

2

3

NA

NE

11. Feasible engineering controls are in place.
Comments:
12. Effective safety and health rules and work practices are in place.
Comments:
13. Applicable OSHA-mandated programs are effectively in place.
Comments:
14. Personal protective equipment is effectively used.
Comments:
15. Housekeeping is properly maintained.
Comments:
16. The organization is properly prepared for emergency situations.
Comments:
17. The organization has an effective plan for providing competent
emergency medical care to employees and others present at the site.
Comments:
18. *Effective preventive maintenance is performed.
Comments:
19. An effective procedure for tracking hazard correction is in place.
Comments:

Planning and Evaluation
20. Workplace injury/illness data are effectively analyzed.
Comments:
21. Hazard incidence data are effectively analyzed.
Comments:
22. A safety and health goal and supporting objectives exist.
Comments:
23. An action plan designed to accomplish the organizations safety and
health objectives is in place.
Comments:

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24. A review of in-place OSHA-mandated programs is conducted at least
annually.
Comments:
25. *A review of the overall safety and health management system is
conducted at least annually.
Comments:

Administration and Supervision
0

1

2

3

NA

NE

0

1

2

3

NA

NE

26. Safety and health program tasks are each specifically assigned to a
person or position for performance or coordination.
Comments:
27. Each assignment of safety and health responsibility is clearly
communicated.
Comments:
28. *An accountability mechanism is included with each assignment of
safety and health responsibility.
Comments:
29. Individuals with assigned safety and health responsibilities have the
necessary knowledge, skills, and timely information to perform their
duties.
Comments:
30. Individuals with assigned safety and health responsibilities have the
authority to perform their duties.
Comments:
31. Individuals with assigned safety and health responsibilities have the
resources to perform their duties.
Comments:
32. Organizational policies promote the performance of safety and
health responsibilities.
Comments:
33. Organizational policies result in correction of non-performance of
safety and health responsibilities.
Comments:

Safety and Health Training
34. Employees receive appropriate safety and health training.
Comments:
35. New employee orientation includes applicable safety and health
information.
Comments:

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36. Supervisors receive appropriate safety and health training.
Comments:
37. *Supervisors receive training that covers the supervisory aspects of
their safety and health responsibilities.
Comments:
38. Safety and health training is provided to managers.
Comments:
39. *Relevant safety and health aspects are integrated into
management training.
Comments:

Management Leadership
0

1

2

3

NA

NE

40. Top management policy establishes clear priority for safety and
health.
Comments:
41. Top management considers safety and health to be a line rather
than a staff function.
Comments:
42. *Top management provides competent safety and health staff
support to line managers and supervisors.
Comments:
43. Managers personally follow safety and health rules.
Comments:
44. Managers delegate the authority necessary for personnel to carry
out their assigned safety and health responsibilities effectively.
Comments:
45. Managers allocate the resources needed to properly support the
organizations safety and health system.
Comments:
46. Managers assure that appropriate safety and health training is
provided.
Comments:
47. Managers support fair and effective policies that promote safety and
health performance.
Comments:
48. Top management is involved in the planning and evaluation of safety
and health performance.
Comments:
49. Top management values employee involvement and participation in
safety and health issues.

4

Comments:

Employee Participation
0

1

2

3

NA

NE

50. There is an effective process to involve employees in safety and
health issues.
Comments:
51. Employees are involved in organizational decision making in regard
to safety and health policy.
Comments:
52. Employees are involved in organizational decision making in regard
to the allocation of safety and health resources.
Comments:
53. Employees are involved in organizational decision making in regard
to safety and health training.
Comments:
54. Employees participate in hazard detection activities.
Comments:
55. Employees participate in hazard prevention and control activities.
Comments:
56. *Employees participate in the safety and health training of coworkers.
Comments:
57. Employees participate in safety and health planning activities.
Comments:
58. Employees participate in the evaluation of safety and health
performance.
Comments:
OMB Number: 1218-0110
Expiration Date: 08/31/08

Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. OSHA does not mandate that State Onsite Consultants (Consultants) use Form 33;
Consultants voluntarily use Form 33. However, when the Consultation Project Manager recommends an
applicant for the OSHA Safety and Health Achievement Recognition Program (SHARP), which exempts the
employer from an OSHA enforcement inspection as long as the applicant remains a SHARP site, managers
must provide Form 33 information. In accordance with 29 CFR 1908.6(h)(1) and (2),Consultants must
preserve the confidentiality of information obtained as the result of a consultative visit which contains or might
reveal a trade secret of the employer. It is estimated that Consultants average between 10 and 30 minutes to
complete the form,. The Form serves as a comprehensive evaluation tool. The information obtained from the
form is used to evaluate an employer’s safety and health management system. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden, to the Directorate of Cooperative and State Programs, OSHA, U.S. Department of Labor, Room N3700, 200 Constitution Ave. NW., Washington DC 20210.

Revised Form 33, October, 2000

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