Title Page

  • Client / Site

  • Conducted on

  • Prepared by

Workers Compensation

  • Workers Compensation?

Modified RTW

  • Written policy in place?

  • Consistently accommodates MRTW in most or all cases?

  • Modified duty tasks are identified?

  • Written MRTW agreement with the employee?

  • Supervisory/oversight mechanism(s) in place for those on MRTW?

  • Medical provider is aware that the organization provides modified work for employees?

  • Duties are varied/changed every 2 weeks or less?

Designated Medical Provider

  • Organization has established a relationship with a medical provider?

  • Medical provider is an occupational medicine provider?

  • Established and consistent communication from medical provider to the organization?

  • All supervisors are aware of organizations medical provider, their location(s), hours, etc?

  • The organization attempts to limit use of the ER to true emergencies?

Post-Offer Functional Screen

  • Pre-employment physical through medical provider?

  • Post-offer functional screen through medical provider?

  • Written hiring policy in place specifies POFS after conditional job offer?

Drug Testing

  • Post-injury/accident testing?

  • Reasonable suspicion testing?

  • Random testing?

  • Pre-employment testing?

  • Written policy in place?

  • DOT compliant drug testing for those with CDL?

Job Descriptions

  • Written job descriptions present?

  • Job descriptions specify physical demands?

  • Reviewed annually?

  • Medical provider has copies on file for review?

Safety Committee

  • Safety committee in place?

  • Meets regularly, monthly, or quarterly?

  • Goals and mission statement?

  • Includes accident review process, possibly with involved employee?

  • Regular safety walk through/inspection of department?

Claim Reporting and Submission

  • Incident reporting policy in place?

  • Employee injury requires notification of employer within 24 hours or before end of shift?

  • Established claim contact within the organization?

  • Claims contact is utilizing in-sight to report claims?

  • Organization understands the importance of reporting, and reports "incident only" claims?

  • Average lag times are less than 5 days?

Accident Investigation

  • Supervisors trained in WC and accident investigation basics, refreshed annually?

  • Employee completes incident report?

  • Supervisor completes a supervisor's report?

  • Witness report used as applicable?

  • Organization claims contact is notified immediately/ASAP of incidents?

  • Paperwork is submitted to claims contact?

Safety Training

  • Required and best practices safety training is performed at required/recommended intervals?

  • Written training schedule includes topic, method, month/date?

  • Training records are kept for each employee?

  • Blood borne pathogens (for those with exposure)?

  • Lockout/Tagout (for those with exposure)?

  • Hazcom (for those with exposure)

  • PPE (for those with exposure)?

  • Confined space entry (for those with exposure)?

  • Trenching / shoring (for those with exposure)?

  • Ergonomics / spine safety / injury prevention?

Pre-Hire Integrity / Safety Testing

  • Utilization of MIS pre-hire integrity test, post-application, but pre-interview?

  • Utilization of TC SQ or DSG (depending on position) on candidates, pre-interview?

  • SQ / DSQ utilization for existing employees?

Written Safety Programs

  • Blood borne pathogens (for those with exposure)?

  • Hazcom (for those with exposure)?

  • Lockout / Tagout (for those with exposure)?

  • PPE (for those with exposure)?


  • Property?

Property Inspection

  • CBIZ inspection within last 3 years

  • CBIZ deficits addressed and remedied?

Consultant Safety Walkthrough

  • Performed every other year minimally?

  • Safety hazards (GL/WC) identified?

  • Safety hazards remedied by account in timely fashion?

Emergency Action Plan

  • Exists?

  • ServPro plan established, if applicable?

Employment Practice Policy

  • Employment Practice Policy?

Employment Practice Policy

  • Policies are reviewed and updated annually?

  • Policy review by OKGC or formal legal review within the last 2 years?


  • Sexual harassment annually?

  • General harassment?

  • Discrimination?

  • Supervisors: hiring and firing?

  • Supervisors performance evaluation training annually?

  • EEOC laws annually?

Performance Evaluations

  • Annual or more frequent performance reviews are in place?

  • Criteria based on job functions?

  • Performed evaluations are performed?


  • FOIA officer designated?

  • FOIA officer completed annual training via IAG website?

  • Backup FOIA officer designated?


  • All current elected and appointed officials have completed OMA training via the IAG website?

  • Newly elected / appointed officials are required to complete OMA training via the IAG website within 90 days after taking the oath of office or otherwise assuming responsibilities?

Critical Policies

  • Accident reporting?

  • Against concealed firearms?

  • Against violence in the workplace?

  • Anti-harassment and discrimination?

  • At will employment?

  • Attendance?

  • Conflict of interest?

  • Drug testing / drug-free workplace?

  • FMLA

  • Handbook acknowledgment exists?

  • Internet and email?

  • Modified return to work?

  • MVR checks?

  • Performance evaluation?

  • Progressive discipline and corrective action?

  • Reasonable accommodation?

  • Record retention?

  • Safety?

  • Social media?



  • Whistleblower policy?


  • Auto?

MVR Checks

  • Annual MVR check for all employees that drive on organization business?

  • Annual MVR check written policy in place?


  • Defensive driving training annually?

  • Winter driving safety annually?

  • Other job specific driving training (fire/police)?


  • Compliant with all DOT regulations required for CDL holders?

Fleet Maintenance

  • Written fleet maintenance program?

  • Pre-trip visual inspection by user(s)?

  • 360 degree circle of safety?

  • Regular maintenance / inspections for all fleet vehicles, with written records of such?

Law Enforcement Liability

  • Law Enforcement Liability?

LLRMI Portal

  • Access for entire department for training?

  • Access for admin to obtain policies?

  • Access for jail admin for policies?

  • Access for corrections officer for training?


  • Training plan in place for officers?

  • Training documents kept on file for each employee?

Video Monitoring Use

  • Body camera?

  • Dash camera?

  • Building camera within jail?


  • LLRMI policy within 5 years?

  • LLRMI jail policies audit within 5 years?

  • Training documents kept on file for each employee?

  • Critical task jail policies in place - same listing for jails, suicide prevention policy?

  • 10 high risk critical task policies in place and followed?:

  • Suicide Prevention Policy?

  • Safe guards in place for tasers and other response to resistance?

  • Utilization of LLRMI policy review?


  • Department members utilizing LLRMI seminars put on by ICRMT?

  • Department members utilizing LLRMI courses throughout region?


  • Department members utilizing LLRMI webinars?

Safety Grant

  • Grant Application?

  • Grant Reward?

  • What Year?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.