Safety
and Health Program Assessment Worksheet
Blank Form 33
Request
Number
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Visit
Number
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Visit
Date
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Employer
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Site
Location
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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
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Synthesis
Item Score
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0
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1
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2
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3
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With
the total knowledge you now have of this organization (whether
or not such knowledge has been captured by attribute ratings),
use your professional judgment to assign an overall score for
the organization's safety and health system.
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Hazard
Anticipation and Detection
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0
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1
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2
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3
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NA
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NE
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1.
A comprehensive, baseline hazard survey has been conducted
within the past five (5) years.
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Comments:
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2.
Effective safety and health self-inspections are performed
regularly.
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Comments:
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3.
Effective surveillance of established hazard controls is
conducted.
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Comments:
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4.
An effective hazard reporting system exists.
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Comments:
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5.
Change analysis is performed whenever a change in facilities,
equipment, materials, or processes occurs.
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Comments:
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6.
Accidents are investigated for root causes.
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Comments:
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7.
Material Safety Data Sheets are used to reveal potential
hazards associated with chemical products in the workplace.
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Comments:
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8.
Effective job hazard analysis is performed.
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Comments:
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9.
Expert hazard analysis is performed.
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Comments:
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10.
*Incidents are investigated for root causes.
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Comments:
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Hazard
Prevention and Control
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0
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1
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2
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3
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NA
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NE
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11.
Feasible engineering controls are in place.
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Comments:
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12.
Effective safety and health rules and work practices are in
place.
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Comments:
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13.
Applicable OSHA-mandated programs are effectively in place.
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Comments:
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14.
Personal protective equipment is effectively used.
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Comments:
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15.
Housekeeping is properly maintained.
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Comments:
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16.
The organization is properly prepared for emergency
situations.
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Comments:
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17.
The organization has an effective plan for providing competent
emergency medical care to employees and others present at the
site.
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Comments:
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18.
*Effective preventive maintenance is performed.
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Comments:
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19.
An effective procedure for tracking hazard correction is in
place.
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Comments:
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Planning
and Evaluation
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0
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1
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2
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3
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NA
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NE
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20.
Workplace injury/illness data are effectively analyzed.
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Comments:
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21.
Hazard incidence data are effectively analyzed.
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Comments:
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22.
A safety and health goal and supporting objectives exist.
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Comments:
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23.
An action plan designed to accomplish the organizations safety
and health objectives is in place.
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Comments:
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24.
A review of in-place OSHA-mandated programs is conducted at
least annually.
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Comments:
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25.
*A review of the overall safety and health management system
is conducted at least annually.
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Comments:
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Administration
and Supervision
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0
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1
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2
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3
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NA
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NE
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26.
Safety and health program tasks are each specifically assigned
to a person or position for performance or coordination.
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Comments:
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27.
Each assignment of safety and health responsibility is clearly
communicated.
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Comments:
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28.
*An accountability mechanism is included with each assignment
of safety and health responsibility.
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Comments:
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29.
Individuals with assigned safety and health responsibilities
have the necessary knowledge, skills, and timely information
to perform their duties.
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Comments:
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30.
Individuals with assigned safety and health responsibilities
have the authority to perform their duties.
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Comments:
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31.
Individuals with assigned safety and health responsibilities
have the resources to perform their duties.
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Comments:
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32.
Organizational policies promote the performance of safety and
health responsibilities.
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Comments:
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33.
Organizational policies result in correction of
non-performance of safety and health responsibilities.
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Comments:
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Safety
and Health Training
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0
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1
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2
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3
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NA
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NE
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34.
Employees receive appropriate safety and health training.
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Comments:
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35.
New employee orientation includes applicable safety and health
information.
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Comments:
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36.
Supervisors receive appropriate safety and health training.
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Comments:
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37.
*Supervisors receive training that covers the supervisory
aspects of their safety and health responsibilities.
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Comments:
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38.
Safety and health training is provided to managers.
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Comments:
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39.
*Relevant safety and health aspects are integrated into
management training.
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Comments:
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Management
Leadership
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0
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1
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2
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3
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NA
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NE
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40.
Top management policy establishes clear priority for safety
and health.
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Comments:
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41.
Top management considers safety and health to be a line rather
than a staff function.
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Comments:
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42.
*Top management provides competent safety and health staff
support to line managers and supervisors.
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Comments:
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43.
Managers personally follow safety and health rules.
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Comments:
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44.
Managers delegate the authority necessary for personnel to
carry out their assigned safety and health responsibilities
effectively.
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Comments:
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45.
Managers allocate the resources needed to properly support the
organizations safety and health system.
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Comments:
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46.
Managers assure that appropriate safety and health training is
provided.
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Comments:
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47.
Managers support fair and effective policies that promote
safety and health performance.
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Comments:
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48.
Top management is involved in the planning and evaluation of
safety and health performance.
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Comments:
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49.
Top management values employee involvement and participation
in safety and health issues.
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Comments:
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Employee
Participation
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0
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1
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2
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3
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NA
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NE
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50.
There is an effective process to involve employees in safety
and health issues.
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Comments:
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51.
Employees are involved in organizational decision making in
regard to safety and health policy.
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Comments:
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52.
Employees are involved in organizational decision making in
regard to the allocation of safety and health resources.
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Comments:
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53.
Employees are involved in organizational decision making in
regard to safety and health training.
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Comments:
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54.
Employees participate in hazard detection activities.
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Comments:
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55.
Employees participate in hazard prevention and control
activities.
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Comments:
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56.
*Employees participate in the safety and health training of
co-workers.
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Comments:
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57.
Employees participate in safety and health planning
activities.
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Comments:
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58.
Employees participate in the evaluation of safety and health
performance.
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Comments:
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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
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