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.
Comments:

NA

NE

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:
24. A review of in-place OSHA-mandated programs is conducted at least
annually.

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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:
36. Supervisors receive appropriate safety and health training.
Comments:

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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.
Comments:

Employee Participation

4

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: 10/31/2011

Persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number. OSHA requires that all State Onsite Consultants (Consultants) use the Revised Form 33 if they
collect information in the course of their visit which would allow them to fill out a portion of the form. See
Chapter 4, II. of the Consultation Policies and Procedures Manual (CPPM). 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 complete all the Revised 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, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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
Office of the Chief Information Officer, U.S. Department of Labor, Room N-1301 200 Constitution Avenue, NW
Washington, DC 20210.

Revised Form 33, October, 2000

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