Form 33 Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet

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	Score
Hazard Anticipation and Detection Score
Hazard Prevention and Control Score
Planning and Evaluation Score
Administration and Supervision Score
Safety and Health Training Score
Management Leadership Score
Employee Participation Score
Total Score
Average Score

Hazard Anticipation and Detection	Score
1. A Comprehensive, baseline hazard survey has been conducted within the past five (5) years
Comments:
2. Effective safety and health self inspection are performed regularly.
Comments:
3. Effective surveillance of establishment 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:
10. *Incidents are investigated for root causes.
Comments:

Hazard Prevention and Control	Score
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	Score
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.
Comments:
25. *A review of the overall safety and health management system is conducted at least annually.
Comments:

Administration and Supervision	Score
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	Score
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:
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	Score
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	Score
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 co-workers.
Comments:
57. Employees participate in safety and health planning activities.
Comments:
58. Employees participate in the evaluation of safety and health performance.
Comments:

Paperwork Reduction Act Notice

OMB Number: 1218-0110

Expiration Date: March 31, 2015

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 On-site 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. 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 Revised Form 33 information. In accordance with 29 CFR 1908.6(h)(1) and (2), Consultants must preserve their confidentiality of information obtained as the result of a consultative visit which contains or must reveal a trade of secret of the employer. It is estimated that Consultants average 45 minutes to complete 12-18 entries on the form (for a general consultation visit) and Consultants average 5 hours to complete all 58 entries on the form (for a comprehensive consultation visit or SHARP evaluation), 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 the Office of Small Business Assistance, Occupational Safety and Health Administration, Room N-3660, 200 Constitution Avenue, NW, Washington, DC 20210.

Revised Form 33, October, 2000