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
- 1
- 2
- 3
- 4
- N/A
-
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
