Title Page

  • Client / Site

  • Location
  • Conducted on

  • Prepared by

1 - Management Leadership


  • Management implements and communicates a written, signed policy supporting the safety and health program.

  • Management routinely demonstrates visible commitment to the program.

  • Management defines specific goals and expectations for the program, along with plans for achieving the goals.

  • Management allocates appropriate resources (funds and time) to accomplish goals and manage the program.

  • Management assigns responsibility and accountability for implementing and maintaining the program.

  • Management encourages, recognizes, and rewards worker contributions to workplace safety and health.

2 - Worker Participation


  • Workers are encouraged to participate in the program, have the means to participate, and feel comfortable participating and giving input on safety and health issues.

  • Workers are trained on how to report an injury, illness, hazard, or concern, including good catches/near misses.

  • Workers report injuries, illnesses, hazards, and concerns without fear of reprisal.

  • Reports of injuries, illnesses, hazards, or other concerns are acknowledged promptly.

  • Reports of injuries, illnesses, hazards, or other concerns are resolved promptly, after worker input is sought, and are tracked to completion.

  • Workers have access to information they need to understand safety and health hazards and hazard control measures in the workplace.

  • Workers are assigned roles in or are otherwise involved in all aspects of the program.

  • Workers can participate without encountering language, skill, or education barriers; restrictions on participating during work time; or fear of retaliation or discrimination.

  • Workers have authority to initiate or request a temporary suspension or shutdown of any work activity or operation they believe to be unsafe.

3 - Hazard Identification and Assessment


  • Written materials such as injury/illness logs, Safety Data Sheets, medical reports, workplace inspection results, incident investigation reports, and manufacturers’ literature are reviewed to help identify hazards.

  • The workplace is inspected regularly to identify conditions that pose or could pose a safety or health concern.

  • Inspections cover all areas and activities and include plant and transportation vehicles.

  • Before making changes to operations, workflow, physical plant, equipment, or materials, workers and managers conduct a review to identify any safety or health issues.

  • The workplace is evaluated to identify worker exposure to health hazards. Trends in injury and illness data, reports of hazards, incidents, etc. are analyzed to identify common hazards.

  • Incidents (including close calls/near misses) and employee complaints are investigated to identify any hazards previously unrecognized or inadequately controlled. Investigations focus on identifying the root cause(s) of each incident.

  • Hazards associated with emergencies and non-routine operations are identified in the emergency action plan and operating procedures, respectively.

  • All identified hazards are characterized with respect to the severity of potential, outcomes, likelihood of an event or exposure, and number of workers who might be exposed. This information is identified in operating procedures.

  • Interim controls are adopted while permanent controls are being determined.

  • All serious and recognized hazards are addressed immediately, while prioritizing remaining hazards for further control.

4 - Hazard Prevention and Control


  • Options for controlling hazards are identified using sources such as OSHA, NIOSH, industry best practices, and input from workers.

  • Controls are selected according to the “hierarchy of controls,” emphasizing (in order of priority) elimination, substitution, engineering controls, administrative controls, and PPE.

  • A hazard control plan is used to plan and prioritize controls.

  • Controls are installed as soon as a hazard is identified.

  • Interim controls are used when permanent controls cannot be immediately implemented.

  • Workers are involved in selecting controls.

  • Controls are in place to protect workers during emergencies and non-routine operations.

  • Once installed, controls are monitored to ensure that workers understand their use and application and to verify that they are effective.

  • Implementation of controls is tracked to completion. Controls are inspected and maintained.

5 - Education and Training


  • Managers, supervisors, and workers understand the elements of the safety and health program and how to participate in it.

  • Workers understand the employers’ responsibilities under the program.

  • Each worker understands his or her own role in the program.

  • Workers know whom to contact with concerns or questions, and understand the procedures for reporting injuries, incidents, hazards, and concerns.

  • Workers know that they have a right to participate in the program and report injuries and illnesses without fear of retaliation or discrimination.

  • Workers with assigned roles under the program receive training in how to carry out their roles.

  • Workers are trained to understand how to recognize hazards and effective techniques for their control.

  • Workers can ask questions, receive answers, and provide feedback during and after training.

  • Employers, managers, and supervisors understand their responsibilities under the OSH Act; procedures for responding to workers’ reports of injury, illness, or concern; techniques for identifying and controlling hazards; and fundamentals of incident investigation.

  • Workers receive supplemental training when a change in the workplace could introduce new or increased hazards.

  • Workers receive training in a language and at a literacy level that all of them can understand.

6 - Program Evaluation and Improvement


  • Performance indicators are used to track progress toward program goals.

  • Performance is tracked using both lagging and leading indicators.

  • Performance data are analyzed and shared with workers.

  • Management does an initial review (and subsequent annual reviews) to evaluate the program and ensure that it is fully implemented and functioning as planned.

  • Workers are involved in all program review activities.

  • Program reviews examine key processes to ensure that they are operating as intended.

  • The program is modified as needed to correct shortcomings.

7 - Communication and Coordination


  • Before contractors or staffing agencies bring their workers onsite, they and the host employers determine which among them will implement the various elements of the safety and health program.

  • Before contractors or staffing agencies bring their workers onsite, host employers give them enough information to assess hazards those workers may encounter, to understand the measures taken to control them (e.g., safety and health rules, when PPE is required, whom to contact in an emergency, etc.), and to avoid creating hazards that affect workers on the site.

  • Contractors and staffing agencies inform the host employer about injuries, illnesses, hazards, or concerns reported by their employees, and the results of any tracking or trend analysis that they perform.

  • Contractors and staffing agencies inform the host employer of any hazards arising from their work onsite and the controls in place to address those hazards.

  • Before contractors or staffing agencies bring their workers onsite, the host employer gives them the opportunity to conduct site visits or inspections and to review injury and illness records and other safety and health information.

  • Host employers communicate with contractors and staffing agencies and their workers about non-routine and emergency hazards and emergency procedures.

  • Host employers include any safetyrelated specifications or qualifications in bid documents and contracts.

  • Host employers coordinate with contractors and staffing agencies to ensure that work is planned and scheduled to minimize impacts on safety and health.

  • Staffing agency workers are adequately trained and equipped before arrivingonsite.

  • Host employer, contractor, and staffing agency policies and procedures are aligned to ensure that all workers receive consistent safety and health information.

  • Workers have access to managers with decision-making authority, to resolve any coordination issues or discrepancies.

8 - Completion


  • Recommendations

  • Full Name and Signature of the Inspector

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