| Challenge Pilot |
| Administrator's Annual Report Instructions |
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| Included in this spreadsheet are: |
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| Tab 1. Administrator's Annual Report - Part A |
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| Tab 2. Summary of Annual Rates - by Participant* |
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| Tab 3. Summary of Hazards Identified and Corrected - by Participant* |
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| Tab 4. Summary of Leading Indicators by Participant* |
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| Tab 5A1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 1 |
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| Tab 5B1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 2 |
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| Tab 5C1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 3 |
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| Tab 5D1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 4 |
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| Tab 5E1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 5 |
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| Tab 5F1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 6 |
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| Tab 5G1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 7 |
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| Tab 5H1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 8 |
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| Tab 5I1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 9 |
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| Tab 5J1-3. Annual Rates/Hazards Identified/Leading Indicators - Participant 10 |
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| * - Worksheet programmed to fill these forms automatically. Do not manually enter data into these worksheets. |
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| To access these documents, please click on the tabs at the bottom of this form. |
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| The Challenge Pilot Administrator must prepare the Administrator's Annual Report each year |
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| along with an OSHA Challenge - Tracking Participant Status (OCTPS) form for each Challenge |
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| Pilot Participant and submit it to: |
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Challenge Pilot Program Coordinator |
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Directorate of Cooperative and State Programs |
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Occupational Safety and Health Administration, Room N3700 |
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U.S. Department of Labor |
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200 Constitution Ave., NW |
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Washington, DC 20210 |
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| You may submit the annual report electronically to: [email protected]. |
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| The Administrator's Annual Report must be submitted by February 15th each year. |
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OMB# 1218 – 0239 Expires xx-xx-xxxx
Public reporting burden for this collection of information is voluntary and is estimated to average 20 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection of information, including suggestions for reducing this burden to the Office of Partnerships and Recognition, Department of Labor, Room N-3700, 200 Constitution Avenue, N.W., Washington, DC 20210
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| Challenge Pilot |
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| Administrator's Annual Report |
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| Administrator Name |
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Report Period |
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CY 2009 |
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| Section 1. Administrator Information Update |
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| (If there were any changes) |
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| Name |
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| Site Address |
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| Section 2. Administrator Contact Information Update |
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| (If there were any changes) |
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| Administrator Contact Name |
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| Administrator Contact Title |
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| Administrator Contact Phone Number |
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| Administrator Contact Fax Number |
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| Administrator Contact E-mail Address |
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| Section 3. Coordinator Contact Information Update |
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| (If there were any changes) |
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| Coordinator Contact Name |
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| Coordinator Contact Title |
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| Coordinator Contact Phone Number |
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| Coordinator Contact Fax Number |
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| Coordinator Contact E-mail Address |
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| Section 4. Candidate Information Update |
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| Please list any Candidates who have dropped out or have been added since the last progress report. You must submit a Candidate Package for all new Candidates. |
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| Challenge Pilot |
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| Administrator's Annual Report |
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| Section 5. Significant Achievements and Milestones |
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| Please describe any significant achievements/milestones accomplished by your |
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| Challenge Pilot Participants during the past year. |
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| Section 6. Roadblocks and Barriers |
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| Please describe any issues that have prevented your Challenge Pilot Participants from making progress. |
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| Section 7. Additional Comments/Suggestions |
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| Please provide any additional comments or suggestions to improve the Challenge Pilot Program. |
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| Form Approved |
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| OMB# 1218 – 0239 Expires 04 -30- 2008 |
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| Public reporting burden for this collection of information is voluntary and is estimated to average 20 |
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| hours per response, including the time for reviewing instruction, searching existing data sources, |
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| gathering and maintaining the data needed, and completing and reviewing the collection of information. |
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| Send comments regarding this burden estimate, or any other aspect of this collection of information |
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| including suggestions for reducing this burden to the Division of Voluntary Programs, |
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| Department of Labor, Room N-3700, 200 Constitution Avenue, N.W., Washington, DC 20210. |
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| Challenge Pilot |
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| Summary of Annual Rates by Participant |
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| Administrator |
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Year |
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2009 |
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| Participant |
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Current Yr. |
Baseline |
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Current Yr. |
Baseline |
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| Name |
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TCIR |
TCIR |
CHANGE |
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DART |
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CHANGE |
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| Challenge Pilot |
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| Summary of Leading Indicators by Participant |
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| Administrator |
[Insert Administrator Name Here] |
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Year |
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| Management Leadership |
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2009 |
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Mgt. Participated in |
Mgt. Participated in |
S&H Discussed at |
Mgt. Participated in |
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2010 |
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S&H Mtgs. |
Self-Inspections |
Mgt. Meetings |
S&H Mtgs. |
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2011 |
| Name |
% of Planned |
% of Planned |
% of Planned |
% of Planned |
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2012 |
| [Insert Participant Name Here] |
#DIV/0! |
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2013 |
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| Challenge Pilot |
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| Summary of Leading Indicators by Participant |
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| Administrator |
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Year |
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| Employee Involvement |
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Employees Participated |
Employees Participated |
Employees Participated |
# Employees |
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| Participant |
in S&H Mtgs. |
in Self-Inspections |
in Training |
Involved in S&H |
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| Name |
% of Planned |
% of Planned |
% of Planned |
% of Planned |
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#DIV/0! |
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| Challenge Pilot |
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| Summary of Leading Indicators by Participant |
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| Administrator |
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| Worksite Analysis |
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# of Employee Reports &/or |
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| Participant |
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Safety Suggestions Turned In |
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| Name |
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% of Planned |
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|
|
|
|
| [Insert Participant Name Here] |
|
|
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| [Insert Participant Name Here] |
|
|
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| [Insert Participant Name Here] |
|
|
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| [Insert Participant Name Here] |
|
|
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| [Insert Participant Name Here] |
|
|
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average Response Time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
|
|
|
|
Hazards Identified and Corrected |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
|
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
| Type of |
# of Hazards |
# of Employees |
# of Hazards |
# of Employees |
# of |
|
|
|
| Hazard |
Identified |
Affected |
Controlled |
Affected |
Near-Misses |
|
|
|
| Machine Guarding |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Emergency Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Lock-out/Tag-Out Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Electrical Safety |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Walking/Working Surfaces |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Ergonomics |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Process Safety Management |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| Industrial Hygiene/Health Exposure |
0 |
0 |
0 |
0 |
0 |
|
|
|
| PPE |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate/Deficient Training |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Program Issue/Hazard |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Inadequate Procedures |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Work Practices |
0 |
0 |
0 |
0 |
0 |
|
|
|
| Miscellaneous |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
| TOTAL |
0 |
0 |
0 |
0 |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Source Used to |
# of Hazards |
|
Additional Comments |
|
|
|
| Identify Hazard |
Identified |
|
|
|
|
|
| Facility Audit |
0 |
|
|
|
|
| Accident/Near-Miss Investigation |
0 |
|
|
|
|
| Employee Suggestion |
0 |
|
|
|
|
| Safety Committee/Team/Line Meeting |
0 |
|
|
|
|
| Observation |
0 |
|
|
|
|
| TOTAL |
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
| Challenge Pilot |
|
| Leading Indicators |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participant |
|
Administrator |
|
Year |
|
| [Insert Participant Name Here] |
|
[Insert Administrator Name Here] |
|
2009 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
# |
# |
Per Cent |
|
|
|
|
Planned |
Actual |
of Planned |
|
|
|
|
|
|
|
|
| Management Leadership |
|
|
|
|
|
|
| Management participated in safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in self-inspections |
0 |
0 |
#DIV/0! |
|
| Safety and health discussed at management meetings |
0 |
0 |
#DIV/0! |
|
| Management participated in safety and health training |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Employee Involvement |
|
|
|
|
|
|
| Employees participated in or conducted safety and health meetings |
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted self-inspections |
|
|
0 |
0 |
#DIV/0! |
|
| Employees participated in or conducted training |
0 |
0 |
#DIV/0! |
|
| Number of employees involved in safety and health activities |
* |
0 |
#VALUE! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Worksite Analysis |
|
|
|
|
|
|
| Number of employee reports of hazards and/or safety suggestions turned in** |
0 |
0 |
#DIV/0! |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Hazard Prevention and Control |
|
|
|
|
|
|
| Timeliness of corrective action |
Goal -- Average response time |
|
|
|
|
| Actual -- Average response time |
|
|
|
|
| Result -- Difference between Actual and Goal |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| * -- Enter the total number of employees here - the goal is 100% employee involvement. |
|
|
|
|
|
|
| ** -- Difficult to predict or have a goal for this |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|