<
<
Back
to OSHA Voluntary Protection Program
Site-Based
Participation
Evaluation Report
Company
Name
City,
State
Onsite
Evaluation Date
Month
- Start/End Dates, 20XX
VPP
Evaluation Team
Name,
Title
Name, Title
Name, Title
Name, Title
Name,
Title
EXECUTIVE
SUMMARY
I.
Purpose and Scope of Review
An
onsite review was conducted from <Date>,
at the <Organization>
in <City,
State>.
The purpose of the evaluation was to determine the site's
<eligibility
or continued eligibility>
for site-based participation in the Occupational Safety and Health
Administration's (OSHA) Voluntary Protection Programs (VPP). The
VPP Evaluation Team consisted of:
Name, Title/Special
Government Employee (SGE), Office, City, State
Name,
Title/Special Government Employee (SGE), Office, City, State
Name,
Title/Special Government Employee (SGE), Office, City, State
Name,
Title/Special Government Employee (SGE), Office, City, State
Name,
Title/Special Government Employee (SGE), Office, City, State
II.
Methods of Data Collection
The
information for this report was obtained from the site's VPP
application, documentation reviewed onsite, interviews with
employees and management personnel, annual evaluation reports, and
physical observations of the facility(ies).
III.
Employees at the Worksite
There
are <XXX>
employees working on site. In addition, there are <XXX>
contractor employees onsite performing maintenance, capital
projects, guard services, janitorial services, etc. Employees at
the site are represented by the <insert
union name(s) and local(s)>.
(Employees at the site are not represented by a collective
bargaining agent.) Formal interviews were conducted with <XX>
site employees and <XX>
contract employees. Informal interviews were conducted with <XXX>
site employees and <XXX>
contract employees.
IV.
The Worksite
The
site is properly classified under North American Industrial
Classification System (NAICS) code <XXXXXX>.
Provide
a description of the site, e.g., size, location, operation,
buildings, etc. Describe the site’s processes, productions,
and applications.
Housekeeping at the facility was considered by the VPP Evaluation
Team to be <please
select one: poor, fair, good or excellent>.
V.
Worksite Hazards
The
hazards at the site include, but are not limited to <state
hazards>.
The site <does
or does not>
use chemicals considered to be highly hazardous and in sufficient
quantity to place the site under the Process Safety Management
(PSM) Standard.
VI.
Injury and Illness Rates
The
three year Total Case Incidence Rate (TCIR) and Days
Away/Restricted/Transferred Case Incidence (DART) rate for the
period <20XX-20XX>
are <XX>
and <XX>,
respectively. The site TCIR is <XX%>
<above/below>,
and the DART rate is <XX%>
<above/below>
the 20XX Bureau of Labor Statistics (BLS) industry average for
NAICS code <XXXXXX>
for 20XX.
Team
leader must verify
that a comparison has been conducted against the site’s
injury and illness rates reviewed during the evaluation and the
site’s injury and illness rates reported in its annual self-
evaluation.
Year
|
Hours
|
Total
# of
Cases
|
TCIR
Rate
|
Number
of
Cases
Involving Days
Away from
Work,
Restricted
Activity or Job
Transfer
|
DART
Rate
|
20XX
|
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20XX
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20XX
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Total
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Three-Year
Rate (20XX-20XX)
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BLS
National Average for 20XX (NAICS XXXXXX)
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20XX
YTD
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VII.
OSHA Activity
There
has been no OSHA inspection activity or fatalities at this site
within the past <XX>
years. The site maintains an excellent relationship with its local
OSHA Area and Regional offices.
VIII.
Elements of the VPP Review
The
VPP Evaluation Team has examined each of the required elements of
the site’s safety and health management programs. All VPP
requirements have been met and all OSHA standards are
appropriately covered.
Bullet summary information of
VPP Elements
Management
Leadership and Employee Involvement
Worksite
Analysis
Hazard
Prevention and Control
Safety
and Health Training
<For
Reapproval evaluations>,
discuss significant program or site changes since the last visit.
A bulleted list is acceptable. [For
Star reapproval evaluations recommending One-Year Conditional, add
the following sentence:
Refer to Section XI for discussion of safety and health management
program corrections.]
<Incentive
Programs>
The site utilizes an incentive program which meets the
requirements of Memorandum #5: Further Improvements to the
Voluntary Protection Programs (VPP) dated 6/29/11. OR The site
does not utilize an incentive program.
IX.
Areas of Excellence
All
elements of the site's safety and health management programs met
the high quality expected of VPP participants (or describe the
program requirements that you considered an area of excellence).
NOTE:
Do not characterize the safety and health management programs as
meeting the high quality expected of VPP participants if the team
is recommending One-Year Conditional reapproval.
X.
Recommendation for Participation
The
VPP Evaluation Team recommends <Site
name, City, State>
be approved for participation in the OSHA VPP <Star
or Merit>
Program (add
if relevant
but placed on One-Year Conditional status or
but required to develop an agreed upon Two-Year Rate Reduction
Plan).
XI.
Goals (if applicable)
Merit
Goal(s) (if relevant)
One-Year
Conditional Goal(s) (if relevant)
Two-Year
Rate-Reduction Plan (if relevant)
Site-Based
Participation
Site Worksheet
Company
Name
City,
State
Onsite
Evaluation Date
Month
- Start/End Dates, 20XX
|
How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
A.
Written Safety & Health Management System
|
A1.
Are
all the elements (such as Management Leadership and Employee
Involvement, Worksite Analysis, Hazard Prevention and Control,
and Safety and Health Training) and sub-elements of a basic
safety and health management system part of a signed, written
document? (For Federal Agencies, include 29 CFR 1960.) If not,
please explain.
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A2.
Have all VPP elements and sub-elements been in place at least
1 year? If not, please identify those elements that have not
been in place for at least 1 year.
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A3.
Is the written safety and health management system at least
minimally effective to address the scope and complexity of
worksite hazards? If not, please explain.
MRØ
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A4.
Have
any VPP documentation requirements been waived (as per FRN,
VOL. 74, NO. 6, 01/09/09 page 936, IV, A.4.)? If so, please
explain.
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How
Assessed
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Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
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Interview
|
Observation
|
Doc
Review
|
B.
Management Commitment & Leadership
|
B1.
Does
management overall demonstrate at least minimally effective,
visible leadership with respect to the safety and health
management system (as per FRN, VOL. 74, NO. 6, 01/09/09 page
936, IV. A.5. a-h)? Provide examples.
MRØ
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B2.
How
has the site communicated established policies and
results-oriented goals and objectives for employee safety to
employees?
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B3.
Do
employees understand the goals and objectives for the safety
and health management system?
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B4.
Are
the safety and health management system goals and objectives
meaningful and attainable? Provide examples supporting the
meaningfulness and attainability (or lack there of if answer
is no) of the goal(s). (Attainability can either be
unrealistic/realistic goals or poor/good implementation to
achieve them.)
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B5.
How
does the site measure its progress towards the safety and
health management system goals and objectives? Provide
examples.
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How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
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Interview
|
Observation
|
Doc
Review
|
C.
Planning
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C1.
How
does the site integrate planning for safety and health with
its overall management planning process (for example, budget
development, resource allocation, or training)?
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C2.
Is
safety and health effectively integrated into the site's
overall management planning process? If not, please explain.
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C3.
For site-based construction sites, is safety included in the
planning phase of each project? MRØ
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How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
D.
Authority and Line Accountability
|
D1.
Does
top management accept ultimate responsibility for safety and
health? (Top management acknowledges ultimate responsibility
even if some safety and health functions are delegated to
others.) If not, please explain.
MRØ
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D2.
How
is the assignment of authority and responsibility documented
and communicated (for example, organization charts, job
descriptions, etc.)?
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D3.
Do
the individuals assigned responsibility for safety and health
have the authority to ensure that hazards are corrected or
necessary changes to the safety and health management system
are made? If not, please explain.
MRØ
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D4.
How
are managers, supervisors, and employees held accountable for
meeting their responsibilities for workplace safety and
health? (Are annual performance evaluations for managers and
supervisors require?)
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D5.
Are
adequate resources (equipment, budget, or experts) dedicated
to ensuring workplace safety and health? Provide examples.
MRØ
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D6.Is
access to experts (for example, Certified Industrial
Hygienists, Certified Safety Professionals, Occupational
Nurses, or Engineers), reasonably available, based upon the
nature, conditions, complexity, and hazards of the site? If
so, under what arrangements and how often are they used?
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How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
E.
Contract Employees
|
E1.
Does
the site utilize contractors? Please explain.
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E2.
Were
there contractors/sub-contractors onsite at the time of the
evaluation?
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E3.
When
selecting onsite contractors/sub-contractors, how does the
site evaluate the contractor's safety and health management
system and performance (including rates)?
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E4.
Are
contractors and subcontractors required to maintain an
effective safety and health management system and to comply
with all applicable OSHA and company safety and health rules
and regulations? If not, please explain.
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E5.
Does
the site’s contractor program cover the prompt
correction and control of hazards in the event that the
contractor/sub-contractor fails to correct or control such
hazards? Provide examples. MRØ
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E6.
How
does the site document and communicate oversight,
coordination, and enforcement of safety and health
expectations to contractors?
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E7.
Have
the contract provisions specifying penalties for safety and
health issues been enforced, when appropriate? If not, please
explain.
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E8.
How
does the site monitor the quality of the safety and health
protection of its contract employees?
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E9.
Do
contract provisions for contractors require the periodic
review and analysis of injury and illness data? Provide
examples
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E10.
If
the contractors' injury and illness rates are above the
average for their industries, describe the site's procedures
that ensure that all employees are provided effective
protection on the worksite? If yes, please explain.
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E11.
Based
on your answers to the above items, is the contract oversight
minimally effective for the nature of the site? (Inadequate
oversight is indicated by significant hazards created by the
contractor, employees exposed to hazards, or a lack of host
audits.) If not, please explain.
MRØ
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How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
F.
Employee Involvement
|
F1.
How
were employees selected to be interviewed by the VPP team?
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F2.
How
many employees were interviewed formally? How many were
interviewed informally?
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F3.
Do
employees support the site's participation in the VPP?
MRØ
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F4.
Do
employees feel free to participate in the safety and health
management system without fear of discrimination or reprisal?
If so, please explain.
MRØ
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F5.
Are
employees meaningfully involved in the problem identification
and resolution, or evaluation of the safety and health
management system (beyond hazard reporting). (As per FRN page
936 IV, A.6.) For site-based construction sites, does the
company encourage strong labor-management communication in the
form of supervisor and employee participation in toolbox
safety meetings and training, safety audits, incident
investigations, etc.?
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F6.
Are
employees knowledgeable about the site's safety and health
management system? If not, please explain.
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F7.
Are
employees knowledgeable about the VPP? If not, please explain.
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F8.
Are
the employees knowledgeable about OSHA rights and
responsibilities? If not, please explain.
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F9.
How
were employees informed of the safety and health management
system, VPP and OSHA rights and responsibilities? Please
explain.
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F10.
Did
management verify employee's comprehension of the site's
safety and health management system, VPP and OSHA rights and
responsibilities?
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F11.
Do
employees have access to results of self-inspection, accident
investigation, appropriate medical records, and personal
sampling data upon request? If not, please explain.
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How
Assessed
|
Section
I: Management Leadership & Employee Involvement
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
G.
Safety and Health Management System Evaluation
|
G1.
Briefly
describe the system in place for conducting an annual
evaluation.
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G2.
Does
the annual evaluation cover the aspects of the safety and
health management system, including the elements described in
the Federal
Register?
If not, please explain. MRØ
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G3.
Does
the annual evaluation include written recommendations in a
narrative format? If not, please explain.
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G4.
Is
the annual evaluation an effective tool for assessing the
success of the site's safety and health management system?
Please explain.
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G5.
What
evidence demonstrates that the site responded adequately to
the recommendations made in the annual evaluation?
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G6.
Is
the annual evaluation conducted by competent site, corporate
or other trained personnel experienced in performing
evaluations?
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Section
I: Management Leadership & Employee Involvement
|
Merit
Goals: (Include
cross- reference to section, subsection, and question, e.g.,
I.B2)
|
1.
2.
|
90-Day
Items: (Delete
this section for final transmittal to National Office)
|
1.
2.
|
Comments
including Recommendations:
(optional)
|
1.
2.
|
Documents
Referenced, Programs Reviewed:
(optional)
|
1.
2.
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
A.
Baseline Hazard Analysis
|
A1.
Has
the site been at least minimally effective at identifying and
documenting the common safety and health hazards associated
with the site (such as those found in OSHA regulations,
building standards, etc., and for which existing controls are
well known)? If not, please explain.
MRØ
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A2.
What
methods are used in the baseline hazard analysis to identify
health hazards? (Please include examples of instances when
initial screening and full-shift sampling were used. See FRN
page 937, B.2.b)
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A3.
Does
the company rely on historical data to evaluate health hazards
on the worksite? If so, did the company identify any
operations that differed significantly from past experience
and conduct additional analysis such as sampling or monitoring
to ensure employee protection? If so, please describe.
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A4.
Does
the site have a documented sampling strategy used to identify
health hazards and assess employees' exposure (including
duration, route, and frequency of exposure), and the number of
exposed employees? If not, please explain.
MRØ
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A5.
Do
sampling, testing, and analysis follow nationally recognized
procedures? If not, please explain.
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A6.
DDoes
the site compare sampling results to the minimum exposure
limits or are more restrictive exposure limits (PELs, TLVs,
etc.) used? Please explain.
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A7.
Does
the baseline hazard analysis adequately identify hazards
(including health) that need further analysis? If not, please
explain. For site-based construction sites, does the hazard
analysis include studies to identify potential employee
hazards, phase analyses, task analyses, etc.?
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A8.
Does
industrial hygiene sampling data, such as initial screening or
full shift sampling data, indicate that records are being kept
in logical order and include all sampling information (for
example, sampling time, date, employee, job title,
concentrated measures, and calculations)? If not, please
explain the deficiencies and how they are being addressed.
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A9.
For site-based construction sites, are hazard analyses
conducted to address safety and health for each phase of work?
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
B.
Hazard Analysis of Significant Changes
|
B1.
When
purchasing new materials or equipment, or implementing new
processes, what types of analyses are performed to determine
impact on safety and health, and are these analyses adequate?
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B2.
When
implementing/introducing non-routine tasks, materials or
equipment, or modifying processes, what types of analyses are
performed to determine impact on safety and health, and are
these analyses adequate?
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
C.
Hazard Analysis of Routine Activities
|
C1.
Is
there at least a minimally effective hazard analysis system in
place for routine operations and activities?
MRØ
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C2.
Does
hazard identification and analysis address both safety and
health hazards, if appropriate? If not, please explain.
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C3.
WWhat
hazard analysis technique(s) are employed for routine
operations and activities (e.g., job hazard analysis, HAZ-OPS,
fault trees)? Please explain.
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C4.
Are
the results of the hazard analysis of routine activities
adequately documented? If not, please explain.
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C5.
For
site-based construction sites, are hazard analyses conducted
to address safety and health hazards for specialty trade
contractors during each phase of work?
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
D.
Routine Inspections
|
D1.
Does
the site have a minimally effective system for performing
safety and health inspections (i.e., a minimally effective
system identifies hazards associated with normal operations)?
If not, please explain.
MRØ
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D2.
Are
routine safety and health inspections conducted monthly, with
the entire site covered at least quarterly (construction
sites: entire site weekly)?
MRØ
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D3.
For
site-based construction sites, are employees required to
conduct inspections as often as necessary, but not less than
weekly, of their workplace/area and of equipment?
MRØ
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D4.
Does
the site incorporate hazards identified through baseline
hazard analysis, accident investigations, annual evaluations,
etc., into routine inspections to prevent reoccurrence?
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D5.
Are
employees conducting inspections adequately trained in hazard
identification? If not, please explain.
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D6.
Is
the routine inspection system written, including documentation
of results indicating what needs to be corrected, by whom, and
by when? If not, please explain.
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D7.
Did
the VPP team find hazards that were not found/noted on the
site's routine inspections? If so, please explain.
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
E.
Hazard Reporting
|
E1.
Is
there a minimally effective means for employees to report
hazards and have them addressed? If not, please explain.
MRØ
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E2.
Does
the hazard reporting system have an anonymous component?
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E3.
Does
the site have a reliable system for employees to notify
appropriate management personnel in writing about safety and
health concerns? Please describe.
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E4.
Do
the employees agree that they have an effective system for
reporting safety and health concerns? If not, please explain.
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
F.
Hazard Tracking
|
F1.
Does
a minimally effective hazard tracking system exist that result
in hazards being controlled? If not, please explain.
MRØ
|
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F2.
Does
the hazard tracking system result in hazards being corrected
and provide feedback to employees for hazards they have
reported? If not, please explain.
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F3.
Does
the hazard tracking system result in timely correction of
hazards with interim protection established when needed?
Please describe.
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F4.
Does
the hazard tracking system address hazards found by employees,
hazard analysis of routine and non-routine activities,
inspections, and accident or incident investigations? If not,
please explain.
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How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
G.
Accident/Incident Investigations
|
G1.
Is
there a minimally effective system for conducting
accident/incident investigations, including near-misses? If
not, please explain.
MRØ
|
|
|
|
|
|
|
G2.
Is
the accident/incident investigation policy and procedures
documented and understood by all? If not, please explain.
|
|
|
|
|
|
|
G3.
Is
there a reporting system for near-misses that include
tracking, etc.? If not, please explain.
|
|
|
|
|
|
|
G4.
Are
those conducting the investigations trained in
accident/incident investigation techniques? Please explain
what techniques are used, e.g., Fault-Tree, Root Cause, etc.
|
|
|
|
|
|
|
G5.
Describe
how investigators discover and document all the contributing
factors that led to an accident/incident or a near-miss.
|
|
|
|
|
|
|
G6.
Were
any uncontrolled hazards discovered during the investigation
previously addressed in any prior hazard analyses (e.g.,
baseline, self-inspection)? If yes, please explain.
|
|
|
|
|
|
|
|
How
Assessed
|
Section
II: Worksite Analysis
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
H.
Trend Analysis
|
H1.
Does
the site have a minimally effective means for identifying and
assessing trends?
MRØ
|
|
|
|
|
|
|
H2.
Have
there been any injury and/or illness trends over the last
three years? If so, please explain.
|
|
|
|
|
|
|
H3.
Did
the team identify trends that should have been identified by
the site? If so, please describe.
|
|
|
|
|
|
|
H4.
If there have been injury and/or illness trends, what adequate
courses of action have been taken? Please explain.
|
|
|
|
|
|
|
H5.
Does
the site assess trends utilizing data from hazard reports
and/or accident/incident investigations to determine the
potential for injuries and illnesses? If not, please explain.
|
|
|
|
|
|
|
H6.
Are
the results of trend analyses shared with employees and
management and utilized to direct resources, prioritize hazard
controls and modify goals to address trends? If not, please
explain.
|
|
|
|
|
|
|
Section
II: Worksite Analysis
|
Merit
Goals: (Include
cross- reference to section, subsection, and question, e.g.,
II.B2)
|
1.
2.
|
90-Day
Items: (Delete
this section for final transmittal to National Office)
|
1.
2.
|
Comments
including Recommendations:
(optional)
|
1.
2.
|
Documents
Referenced, Programs Reviewed:
(optional)
|
1.
2.
|
|
How
Assessed
|
Section
III: Hazard Prevention and Control
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
A.
Hazard Prevention and Control
|
A1.
Does
the site select at least minimally effective controls to
prevent exposing employees to hazards?
MRØ
|
|
|
|
|
|
|
A2.
When
the site selects hazard controls, does it follow the preferred
hierarchy (engineering controls, administrative controls, work
practice controls [e.g., lockout/tagout, bloodborne pathogens,
and confined space programs], and personal protective
equipment) to eliminate or control hazards? Please provide
examples, such as how exposures to health hazards were
controlled.
|
|
|
|
|
|
|
A3.
Describe
any administrative controls used at the site to limit employee
exposure to hazards (for example, job rotation).
|
|
|
|
|
|
|
A4.
Do
the work practice controls and administrative controls
adequately address those hazards not covered by engineering
controls? If not, please explain.
|
|
|
|
|
|
|
A5.
Are
the work practice controls (e.g., lockout/tagout, bloodborne
pathogens, and confined space programs) recommended by hazard
analyses implemented at the site? If not, please explain.
|
|
|
|
|
|
|
A6.
Are
follow-up studies (where appropriate) conducted to ensure that
hazard controls were adequate? If not, please explain.
|
|
|
|
|
|
|
A7.
Are
hazard controls documented and addressed in appropriate
procedures, safety and health rules, inspections, training,
etc.? Provide examples.
|
|
|
|
|
|
|
Disciplinary
System
|
A8.
Are
there written employee safety procedures including a
disciplinary system? Describe the disciplinary system?
|
|
|
|
|
|
|
A9.
Has
the disciplinary system been clearly communicated and enforced
equally for both management and employees, when appropriate?
If not, please explain.
|
|
|
|
|
|
|
Emergency
Procedures
|
A10.
Does
the site have minimally effective written procedures for
emergencies?
MRØ
|
|
|
|
|
|
|
A11.
Did
the site explain the frequency and types of emergency drills
held (including at least an evacuation drill annually)?
|
|
|
|
|
|
|
A12.
Is
the emergency response plan updated as changes occur in the
work areas e.g., evacuation routes or auditory systems?
|
|
|
|
|
|
|
A13.
Did
the site describe the system used to verify all employees'
participation in at least one evacuation drill each year?
|
|
|
|
|
|
|
Preventative/Predictive
Maintenance
|
A14.
Does
the site have a written preventative/predictive maintenance
system? If not, please explain
|
|
|
|
|
|
|
A15.
Did
the hazard identification and analysis (including
manufacturers' recommendations) identify hazards that could
result if equipment is not maintained properly? If not, please
explain.
|
|
|
|
|
|
|
A16.
Does
the preventive maintenance system detect hazardous failures
before they occur? If not, please explain. Is the preventive
maintenance system adequate?
|
|
|
|
|
|
|
Personal
Protective Equipment (PPE)
|
A17.
How
does the site select Personal Protective Equipment (PPE)?
|
|
|
|
|
|
|
A18.
Did
the site describe the PPE used at the site?
|
|
|
|
|
|
|
A19.
Where
PPE is required, do employees understand that it is required,
why it is required, its limitations, how to use it, and how to
maintain it? If not, please explain.
|
|
|
|
|
|
|
A20.
Did
the team observe employees using, storing, and maintaining PPE
properly? If not, please explain.
|
|
|
|
|
|
|
Process
Safety Management (PSM)
|
A21.
Is
the site covered by the Process Safety Management standard (29
CFR 1910.119)? If yes, please answer questions A22-A25 below.
Additionally, please complete either the onsite evaluation
supplement A or B, and the onsite evaluation supplement C. If
not, skip to section B.
MRØ
|
|
|
|
|
|
|
A22.
Which
chemicals that trigger the Process Safety Management (PSM)
standard are present?
MRØ
|
|
|
|
|
|
|
A23.
Which
process(es) were followed from beginning to end and used to
verify answers to the questions asked in the PSM application
supplement, the PSM Questionnaire, and/or the Dynamic
Inspection Priority Lists?
MRØ
|
|
|
|
|
|
|
A24.
Verify
that contractor employees who perform maintenance, repair,
turnaround, major renovation or specialty work on or adjacent
to a covered process have received adequate training and
demonstrate appropriate knowledge of hazards associated with
PSM, such as non-routine tasks, process hazards, hot work,
emergency evacuation procedures, etc.? Please explain.
MRØ
|
|
|
|
|
|
|
A25.
Is
the PSM program adequate in that it addresses the elements of
the PSM standard and the PSM directive? Please explain.
MRØ
|
|
|
|
|
|
|
|
How
Assessed
|
Section
III: Hazard Prevention and Control
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
B.
Occupational Health Care Program
|
B1.
Describe
the occupational health care program (including availability
of physician services, first aid, and CPR/AED) and special
programs such as audiograms or other medical tests used.
|
|
|
|
|
|
|
B2.
How
are licensed occupational health professionals used in the
site's hazard identification and analysis, early recognition
and treatment of illness and injury, and the system for
limiting the severity of harm that might result from workplace
illness or injury? Is this use appropriate?
|
|
|
|
|
|
|
B3.
Is
the occupational health program adequate for the size and
location of the site, as well as the nature of hazards found
here? If not, please explain.
|
|
|
|
|
|
|
C.
Recordkeeping
|
C1.
Are
OSHA required recordkeeping forms being maintained properly in
terms of accuracy, form completion, etc.? If not, please
explain.
MRØ
|
|
|
|
|
|
|
C2.
Is
the recordkeeper knowledgeable of 29 CFR 1904, OSHA's
recordkeeping standard?
MRØ
|
|
|
|
|
|
|
C3.
What
records were reviewed to determine compliance with the
recordkeeping standard?
|
|
|
|
|
|
|
C4.
Do
the injury and illness rates accurately reflect work performed
by contractors/sub-contractors at the site evaluated? Please
explain.
MRØ
|
|
|
|
|
|
|
C5.
Was
there any evidence of recordable injuries/illnesses not being
reported due to management pressure, production concerns,
incentive programs, etc.? If yes, please explain.
|
|
|
|
|
|
|
Section
III: Hazard Prevention and Control
|
Merit
Goals: (Include
cross- reference to section, subsection, and question, e.g.,
I.B2)
|
1.
2.
|
90-Day
Items: (Delete
this section for final transmittal to National Office)
|
1.
2.
|
Comments
including Recommendations:
(optional)
|
1.
2.
|
Documents
Referenced, Programs Reviewed:
(optional)
|
1.
2.
|
|
How
Assessed
|
Section
IV: Safety and Health Training
|
Yes
or
No
|
|
Interview
|
Observation
|
Doc
Review
|
A.
Safety and Health Training
|
A1.
What
are the safety and health training requirements for managers,
supervisors, employees, and contractors? Please explain.
|
|
|
|
|
|
|
A2.
Is
the training delivered by qualified instructors?
|
|
|
|
|
|
|
A3.
Does
the training provided to managers, supervisors, and
non-supervisory employees (including contract employees)
adequately address safety and health hazards?
MRØ
|
|
|
|
|
|
|
A4.
Does
the company/site operate an effective safety and health
orientation program for all employees including new hires?
Please explain.
|
|
|
|
|
|
|
A5.
How
are the safety and health training needs for employees
determined? Please explain.
|
|
|
|
|
|
|
A6.
Does
the site provide minimally effective training to educate
supervisors and employees (including contract employees)
regarding the known hazards of the site and their controls? If
not, please explain.
MRØ
|
|
|
|
|
|
|
A7.
Are
managers, supervisors, and non-supervisory employees
(including contract employees) taught the safe work procedures
to follow in order to protect themselves from hazards during
initial job training and subsequent reinforcement training?
|
|
|
|
|
|
|
A8.
Who
is trained in hazard identification and analysis?
|
|
|
|
|
|
|
A9.
Is
training in hazard identification and analysis adequate for
the conditions and hazards of the site? If not, please
explain.
|
|
|
|
|
|
|
A10.
Does
management have a thorough understanding of the hazards of the
site? Provide examples that demonstrate their understanding.
|
|
|
|
|
|
|
A11.
Do
managers, supervisors, and non-supervisory employees
(including contract employees) and visitors on the site
understand what to do in emergency situations? Please explain.
|
|
|
|
|
|
|
Section
IV: Safety and Health Training
|
Merit
Goals: (Include
cross- reference to section, subsection, and question, e.g.,
I.B2)
|
1.
2.
|
90-Day
Items: (Delete
this section for final transmittal to National Office)
|
1.
2.
|
Comments
including Recommendations:
(optional)
|
1.
2.
|
Documents
Referenced, Programs Reviewed:
(optional)
|
1.
2.
|
VPP
Participant and Onsite Evaluation Team Data Sheet
VPP
Participant Information:
|
Company
Name:
|
Site
Address:
|
Mailing
Address:
|
Site
Manager Name:
|
Site
Manager Phone:
|
Site
Manager E-mail Address:
|
VPP
Contact Name: if
same as Site Manager, state “same as above”
|
VPP
Contact Phone:
|
VPP
Contact E-mail Address:
|
Small
Employer (<250 employees onsite AND <500 employees
corporate-wide: Yes_____ No_______
|
NAICS
Code:
|
No.
of site employees:
|
No.
of site contract employees:
|
Union
Information
|
Union
Name & Local No.:
|
|
Site
Representative:
|
|
Mailing
Address:
|
|
Telephone
Number:
|
|
Union
Information
|
Union
Name & Local No.:
|
|
Site
Representative:
|
|
Mailing
Address:
|
|
Telephone
Number:
|
|
Onsite
Evaluation Team Information:
|
Evaluation
Start Date:
|
Evaluation
End Date:
|
Type
of Visit:
Initial Approval: ____________ Reevaluation:
___________
|
Participation:
Site-based:
__________________
Mobile Workforce: ___________
Corporate: __________________
|
MAO
Requested: Yes_____ No_______
If Yes, Date:
|
MAO
Rec’d Before Onsite:
Yes_____ No_______
|
Date
MAO Rec’d:
|
90/30
Day Items: Yes_____ No_______
|
Date
90/30 Day Items Completed:
|
TCIR/DART
3-Year Rate Change: Yes_____ No______
(Onsite vs. Annual
Submission)
|
If
Yes, Explain:
|
Team
Leader (TL):
Back-Up Team Leader:
Team Member
2:
Team Member 3:
Team Member 4:
Team Member 5:
|
Team
Leader:
Back-Up Team Leader:
Team Member 2/or
indicate if SGE:
Team Member 3/or indicate if SGE:
Team
Member 4/or indicate if SGE:
Team Member 5/or indicate if
SGE:
|
PARTICIPANT
AREAS OF EXCELLENCE/BEST PRACTICES CHECKLIST
Ergo
Program
|
Confined
Space Program
|
LO/TO
Program
|
PSM
|
Hazard
Analysis
|
Contractor
Program
|
Medical
Program
|
Self-Inspections
|
Accountability
|
Industrial
Hygiene
|
Employee
Involvement
|
Tracking
of Hazards
|
Pre-Job
Analysis
|
Other:
|
|
|
|
|
STRATEGIC
PLAN
|
High
Hazard Industries
|
Landscaping
– 078
|
Oil/Gas
– 138
|
Fruits/Vegetables
203
|
Concrete/Gypsum/Plaster
– 327
|
Blast
Furnace/Steel Production – 331
|
Ship/Boat
Building/Repair – 373
|
|
Wholesale
Storage – 422
|
|
|
|
|
Hazards
|
Ergo
|
Lead
|
Silica
|
Amputations
– Construction
|
Amputations
– General Industry
|
|
VPP
CORPORATE TRACKING
|
Application
Review
|
Onsite
Prep
|
Onsite
|
Report
Writing
|
Total
|
Team
Hours Spent (Est)
|
|
|
|
|
|
|
|
|
