Voluntary Protection Program, Special Government Employee

VPP PSM SUPPLEMENT C

for

Company Name

City, State

Evaluation Date

Month x, 20xx

Report Date

Month x, 20xx

Evaluation Team

Name, Team Leader

Name, Backup Team Leader

Name, Safety Specialist

Name, Hygienist

Name, SGE

Instructions: Please use the form below to provide answers to the PSM Dynamic Inspection Priority list questions. Questions are located: http://intranet.osha.gov/compliance/dep_psm.html under the heading “Refinery NEP Dynamic Inspection Priority Item (IPI) - Primary and Secondary Lists.” Please be sure to use the list that corresponds with the VPP onsite evaluation dates.

Question numbers should always start with either a “P” for Primary or “S” for Secondary, followed by the question number (e.g. P-2, S-4). Please select the 10 questions from the primary and secondary lists that are most appropriate to the site. If there are not 10 questions from the active list that apply to the site, please complete as many as are applicable and indicate in the following questions space that there are “no additional applicable questions.”

			How Assessed
Dynamic Inspection Priority List Questions		Yes or No	Interview	Observation	Doc Review
List Effective Date: mm/dd/yyyy	List Type: Refinery
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:
Question x-x:

VPP PSM Supplement C 2 of 2