Information

  • Conducted on

  • Address
  • Policy Name

  • Policy Number

  • Contact Name and Phone Number

  • Safety Consultant

Risk Management Assessment

  • 1. Management commitment

  • 1a. Direct commitment and participation by the highest-level of upper management

  • 1b. Involved in developing goals and measuring results of a safety program

  • 1c. Based on results, holds supervisors accountable for those they supervise

  • 2. Safety Coordinator/ Committee

  • 2a. Competent safety person-education and authority

  • 2b. Safety committee that meets regularly, with documentation

  • 2c. Employees are involved in making recommendations for improvement to the safety program

  • 2d. Monitors employees and enforces safety program

  • 3. Safety program

  • 3a. A Job Hazard Analysis (JHA) has been performed to develop a safety program, and addressed OSHA required programs and PPE

  • 3b. Basic safety program that meets the criteria for effective Cost Containment Certification and is effectively implemented and reviewed annually

  • 3c. Safety rules and policies are enforced, documented and reviewed by:<br>- Safety coordinator - Direct supervisor - Upper management

  • 4. Training

  • 4a. New-hire orientation is conducted and documented

  • 4b. Routine safety training is conducted and documented:<br>- Weekly - Monthly -Quarterly

  • 4c. Training for required OSHA programs is conducted and documented

  • 4d. Employees demonstrate competency with regard to the safety training.

  • 5. Claims Management

  • 5a. Formal claims management procedures developed and implemented.

  • 5b. Written designation do medical providers:<br>- Employee notification letter - Letter to injured employee

  • 5c. Formal return to work program-developed and implemented

  • 6. Accident Investigation

  • 6a. Formal accident investigation that identifies root cause:<br>- Employee accident report - Management accident investigation form

  • 6b. Direct supervisor participates in the investigation, corrective actions and follows up, including additional training

  • 6c. Injury trends are identified using loss history reports

  • 7. Business of operation

  • 7a. Radius of operations
  • 7b. Hours of business

  • 7c. Number of shifts

  • 7d. Number of employees

  • 7e. Classification of employees

  • 7f. Basic hiring practices

  • 7g. Do you have a wellness program? If not, would you be interested in one?

  • General comments

  • Safety consultant name and Signature

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.