(INSERT COMPANY NAME)

EMPLOYEE SAFETY
&
INJURY PREVENTION PROGRAM

prepared by

AmTrust North America

Loss Control Department

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

TABLE OF CONTENTS
Page
1. Management Safety Policy Statement ..............................................................1
2. Safety Authority and Accountability ...................................................................2
3. Safety Committee..............................................................................................3
4. Injury and Accident Analysis And Review .........................................................6
5. Employee Involvement .....................................................................................7
Safety Meetings..........................................................................................8
Reporting of Hazards and Unsafe Conditions ............................................8
6. Employee Safety Orientation and Training Program .........................................8
Safety Orientation Training .........................................................................9
Regular, Refresher and Ongoing Safety Training.......................................9
7. Safety Surveys and Inspections ......................................................................10
Comprehensive Safety Surveys ...............................................................10
Safety Inspections ....................................................................................10
Informal Daily Inspections ........................................................................10
8. Hazard Correction and Control........................................................................11
9. Injury Reporting and Investigation ...................................................................12
10. Safety Disciplinary Policy ..............................................................................13
11. Safety Record Keeping .................................................................................14
12. Hiring Practices and Injury Prevention ..........................................................16
13. Injury Prevention Plan Review and Revision.................................................17
14. General Safety Rules ....................................................................................18
15. Documentation Forms Section ......................................................................21
Employee Acknowledgment Form .................................................. .........22
Report of Hazards and/or Unsafe Conditions ...........................................23
Safety Self-Inspection Checklist ...............................................................24
Safety Meeting Attendance Form .............................................................25
Safety Training Acknowledgment Form....................................................26
Injury Prevention Plan Review and Revision Form...................................27
Supervisors Accident Investigation Form.................................................28
Breakdown of Unsafe Acts and Conditions ..............................................29

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

MANAGEMENT SAFETY POLICY STATEMENT

The Executives And Management of (INSERT COMPANY NAME)are committed
to providing a safe and healthful work environment for all employees and others
that may work, visit, or enter our grounds, facilities and business.
It is the policy of (INSERT COMPANY NAME) to manage and conduct our
business in a manner that offers maximum protection to each employee and any
other person that may be affected by our operations.
It is our absolute conviction that we have the responsibility to provide a safe and
healthful work environment for our entire staff.
(INSERT COMPANY NAME)will make every effort to provide a working
environment that is free from any recognizable or potential hazards.
(INSERT COMPANY NAME)recognizes that the success of our safety and
health program is contingent and dependent upon support from the executive
levels of management as well as involvement of all employees of (INSERT
COMPANY NAME)
The management of this company is committed to allocating and providing the
resources needed to promote and effectively implement the safety and injury
prevention program.
This company will establish avenues to solicit and receive comments,
information, and assistance from employees where safety is concerned and will
act appropriately upon the information received.
This company is responsible and will make every effort to comply with all safety
and health regulations established by federal, state, and other local regulatory
agencies.
Management and all supervisors of this company will lead by example, reflecting
the established commitment to safety and health within this company.

_____________________________________________
Signed

_____________________
Date

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY AUTHORITY AND ACCOUNTABILITY

The Management of (INSERT COMPANY NAME)accept the responsibility for providing
resources and guidance for the development and implementation of this written
employee Safety and Injury Prevention Plan and to the overall employee safety and
health program.
The Safety Director is responsible and will be held accountable for the overall
implementation of this plan. The Safety Director has the authority to delegate any and
all portions of the plan to subordinates, but will ultimately be responsible for the ongoing
implementation, compliance and performance of the plan. Furthermore, the Safety
Director has the authority to approve or carry out disciplinary actions against those
employees that choose to violate, current or future established safety policies,
procedures or rules.
Supervisory Personnel are responsible and will be held accountable to ensure that all
employees under their control follow all safety and health policies, procedures, and
rules established by (INSERT COMPANY NAME)and this plan. Furthermore,
supervisors are also responsible for administering training and guidance to employees
under their direction and have the authority to reprimand and recommend disciplinary
actions against employees that choose to violate the safety and health policies of
(INSERT COMPANY NAME).
Employees are responsible and will be held accountable for providing this company
with a personal commitment to this plan and safety and health program. These
responsibilities and requirements include:
9 Reporting any accident or injury to your supervisor immediately.
9 Reporting any observed unsafe work practices or conditions to your supervisor
immediately.
9 Reporting any unsafe or improperly working machinery to your supervisor
immediately.
9 If your supervisor fails to correct unsafe conditions to your satisfaction, immediately
stop all work related activities and report the condition to office or managerial staff.
9 Observing and following all established safety policies, procedures and rules.
9 Completing your work assignments safely.
9 Be actively involved in the safety program in order to assist (INSERT COMPANY
NAME)in providing a safe and healthful workplace.
9 Reporting to work physically able to perform your job in a safe manner.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY COMMITTEE
A Safety and Health Committee is a group of interested salaried and hourly personnel that
meet periodically to monitor the ongoing implementation of the company safety and health
program. The basic purpose of the committee is to promote safety awareness by involving
employees directly in the safety and health programming efforts.
(INSERT COMPANY NAME)will develop a Safety and Health Committee comprised of
manager(s), safety coordinator(s), selected supervisory and employee level personnel.
Supervisory and employee personnel should be rotated each six months.
The committee will be chaired by a member of line management, but the position of
chairperson will also be rotated periodically. The Safety Coordinator will act in an advisory
capacity. The chairperson will chair the meetings; assign committee responsibilities, and
report committee activities and recommendations to his/her immediate manager. A secretary
should be chosen to record minutes of the meetings as directed by the chairperson. Meeting
notes/minutes will be distributed to appropriate personnel and all committees members.
Care should be taken to correctly document all committee activities and to ensure that
corrective actions are followed up on through completion. Do not document the
companys own negligence.
The committee will meet on a periodic basis and meetings should follow an established
agenda. The meetings should be devoted primarily to the following:

Review injuries and accidents that have occurred since the last meeting, along
with corrective measures that have been implemented or scheduled.
Review the status of corrective actions generated by safety inspection/survey
reports.
Discuss unsafe work methods and hazardous conditions that have been
observed or reported by committee members.
Discuss safety educational and promotional activities that may be necessary.
Submit recommendations to appropriate management personnel.

Additionally the safety committee may be involved in providing safety inspections/surveys of

the workplace. If so, then the results of these activities should be discussed during the
scheduled meetings.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY COMMITTEE MEETING MINUTES FORM

Suggested Order of Business

1. Roll Call
2. Reading Of Minutes Of Previous Meeting
3. Consideration of business held over from last meeting
4. Report on progress made on previous recommendations
5. Reading and discussing of reports submitted to committee
6. Discussion of accidents that have occurred since last meeting
7. Recommendations for prevention of such accidents
8. Report on safety instructions to employees (bulletins, talks, etc.)
9. New business and discussion of special safety projects
10. Meeting adjourned

(Please check each item as it is completed)

1.
2.
3.
4.
5.
6.

Company/Department Name: ________________________________________

Chairperson:
________________________________________
Location:
________________________________________
Date of Meeting:
_________________
Date of Last Meeting:
_________________
Committee Members Present:

Printed Name
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________

Signature
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

7. Reading of Previous Minutes/Old Business

8. Review of Loss Experience since last meeting. (Identification of Loss Experience
trends.)
9. Review of Safety Survey/Inspections. Status of Recommendations
10. New Recommendations

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY COMMITTEE ACCIDENT/INJURY REVIEW FORM

INJURIES
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________
Name:
____________________________________________________
Description of Injury: ____________________________________________________
Identified Cause of Injury: ________________________________________________
Solution/Corrective Action: _______________________________________________
Implementation Date: ___________________________________________________

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

INJURY AND ACCIDENT ANALYSIS AND REVIEW

The Management of (INSERT COMPANY NAME)will review and analyze all data,
records and other documentation that pertains to the employee safety and health
program. This review will be conducted on a (monthly, quarterly, semi annual, annual)
basis. The focus of this review will be on deficiencies in the injury prevention plan, which
allowed any injuries to take place. This will include identification of identifiable, including
injury, workplace hazards or unsafe behaviors. Input from all levels of employment will
be gathered to provide information and recommendations for corrective measures to
eliminate identified trends.
Employees will be made aware of identified or developing trends as they are recognized
with the trend factors being a focal point for corrective action and employee training.
Follow-up on implementation of corrective measures will be conducted by Management
until the causal factor has been eliminated or controlled.
Employee training records will also be reviewed on a regular basis to ensure an
adequate and effective training program is maintained and in compliance with regulatory
requirements. Employees will be interviewed from time-to-time to establish retention of
training and determine when information should be supported or repeated.
Documentation of this review process will be completed by using the Injury Prevention
Plan Review and Revision Form located on page 27.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

EMPLOYEE INVOLVEMENT
(INSERT COMPANY NAME)encourages employee involvement in each component of
the ongoing safety and injury prevention program. Management will solicit this
involvement by giving each employee an opportunity to participate and be responsible
for the implementation, maintenance and compliance of the safety program for their
respective work areas or job assignment.
SAFETY MEETINGS
This company will ensure that all employees meet at least monthly to discuss safety and
health issues or concerns and increase employee awareness of employee safe work
practices, rules and procedures. Regular meetings will be designed to keep the safety
program active in the minds of the employees and offer an avenue for employees to
voice their concerns regarding workplace safety and health. Records of all meetings
will be maintained as indicated in this plan.
REPORTING OF HAZARDS AND UNSAFE CONDITIONS
As a condition and requirement of continued employment, all employees will be required
to report hazards and unsafe conditions in the workplace to their immediate
Supervisor.
The Report of Hazards and Unsafe Conditions Form (Page 23) will be readily available
to all employees and serve as a means for reporting these conditions.
All Supervisors will take prompt action relating to all hazard reports by investigating
and determining if a true hazard or injury potential exists. If it is determined that a
hazard does exist, immediate corrective action will be taken. The reporting employee
will be notified by the Supervisor of the corrective action taken or the procedures used
to conclude that no hazard exists. This information will be shared with all employees of
the work area and, if practical, the entire company.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

EMPLOYEE SAFETY ORIENTATION

AND
TRAINING PROGRAM
(INSERT COMPANY NAME)is committed to providing safety related orientation and
training to all employees at all levels. The Safety Director will develop, implement, and
maintain an aggressive safety and health orientation and training program. Employee
safety training will be administered in two phases consisting of new employee or
reassignment orientation training and regular, refresher or ongoing training. Aside from
the formal safety and health related training classes, employees will receive specific
guidance and instruction on safe operating procedures of each assigned job or task.
The program's purpose will be to educate and familiarize employees with safety and
health procedures, rules, and work practices of (INSERT COMPANY NAME).
(INSERT COMPANY NAME))will encourage and require involvement and
participation of all managers, supervisors, and employees. Furthermore, the executive
level will support the orientation and training program with allocations in funding, staff,
resources, and time to develop and implement this program.
The training subjects and materials will be developed utilizing industry and company
specific criteria relating to identified and potential hazard exposures, injury and incident
data, as well as training required by federal regulations. Training sessions will include,
but not be limited to, the following:
9
9
9
9
9
9
9
9
9

General safety rules and guidelines,

Hazards associated with the work area,
Hazards associated with a specific job or task,
Emergency procedures,
Personal Protective Equipment (requirements, proper use, and maintenance),
Specific safety guidelines for equipment operation,
Employee accident/hazard reporting requirements,
Injury investigation (supervisors and other designated personnel),
Any additional regulatory required training.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY ORIENTATION TRAINING

Safety orientation training will be administered to all newly hired employees prior to the
initial work assignment and to employees assigned to new or different tasks or jobs.
The orientation will consist of a review of the general safety rules, safe lifting guidelines
and/or specific job assignment and work area safety requirements.
All new employees will be given a tour of the assigned work area and an opportunity to
pose questions to expedite the familiarization process. New employees will not be
released to a job assignment until it has been determined by their immediate Supervisor
that the individual has retained the minimal acceptable requirements of the training
provided, received all pertinent information needed to safely perform the assigned job
duties and signed the Employee Acknowledgment Form (Page 22) indicating his/her
understanding of the general safety rules.
REGULAR, REFRESHER AND ONGOING EMPLOYEE TRAINING
All managers, supervisors, and employees are required to participate and become
involved in the ongoing safety and injury prevention training program. The frequency,
repetitiveness, and subject matter will be determined by training assessments, records
review and workplace surveys to be performed as directed in this plan. Training will be
conducted at intervals that ensure demonstration of adequate employee training and at
no time will an employee be approved to work if a period of greater than 12 months has
passed without refresher training. Additionally training will be scheduled as required by
regulatory standards. All employees assigned to attend a training session must
demonstrate competency and retention of the minimal acceptable information prior to
returning to any job assignment.

(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY SURVEYS AND INSPECTIONS

(INSERT COMPANY NAME)has implemented a program to identify, correct, and
control workplace hazards on an ongoing basis. This program utilizes multiple
resources to ensure maximum effectiveness.
COMPREHENSIVE SURVEYS
(INSERT COMPANY NAME)has arranged to receive a safety and health survey by the
workers compensation insurance provider on at least an annual basis. These surveys
will be established to identify existing and potential hazards and non-compliance issues
that should be addressed. The findings of the surveys will be discussed and
recommendations for corrective actions suggested. The survey will also include an
evaluation of the overall effectiveness of this Injury Prevention Plan and its employee
safety training policies and procedures.
SAFETY INSPECTIONS
(INSERT COMPANY NAME) will conduct (weekly, monthly, quarterly) and document inhouse safety inspections that will include the entire work area and related equipment.
All inspections will be conducted on an ongoing basis without interruption. Management
will allocate adequate staff time and resources to perform the surveys. (Conducted by
Safety Committee or Department Heads, Safety Director, etc.) to be determined
and specified.
An inspection checklist(s) will be used to assist with completing the inspection process.
The list will be evaluated and updated with hazard exposures that are identified during
the inspections and through other pertinent data as determined necessary. The
contents of this checklist will be reviewed on a regular basis to ensure effectiveness.
The checklist will be and become a part of the permanent record of the inspection and
will serve as a confirmation of the survey.
Management will review the inspection checklists to ensure that a course of corrective
action and time line has been established for eliminating each deficiency.
INFORMAL DAILY INSPECTIONS
Supervisors and employees will conduct informal safety inspections in the form of
general observation and awareness of their assigned work area or work position on an
ongoing basis and as part of their daily regular job duties. All hazards identified by this
observation will be reported to an immediate supervisor for corrective action. The
Report of Hazards and/or Unsafe Conditions Form will be used.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

Employees will be notified of the hazards that pose an immediate threat of physical
harm or property damage and informed of measures or steps that will be taken to
eliminate, correct, or control the identified hazard.

HAZARD CORRECTION AND CONTROL

(INSERT COMPANY NAME) is committed to and will correct or control all hazards
identified through any of the avenues of recognition established in this plan. All
identified hazards will receive a timely response.
HAZARD CORRECTION
Whenever possible and feasible, hazards identified in the work area will be corrected by
eliminating the cause of the hazard at the source. This will include, but not be limited to
the following:
9 Discontinuation or removal of identified hazardous chemicals, materials, or
substances from the work area.
9 Discontinuation from use or removal of hazardous equipment or machinery until
replaced or repaired to safe operating condition.
9 Repair of facilities to remove identified hazards.
9 Implementation of additional corrective action as identified.
9 Retraining of employees to correct any unsafe employee act or behaviors existent in
the work area.
HAZARD CONTROL
When identified hazards cannot be eliminated from the work area, the hazard will be
effectively controlled by engineering, administrative, procedures, work practices,
personal protective equipment, or any suitable combination of these measures.
Engineering controls include, but not limited to the following: Isolation of employee
exposure to the hazard, guarding or displacement of employee exposure to the hazard
or preventative maintenance and repair of machinery and equipment
Administrative controls and procedures will include, but not be limited to the
following: Written programs to establish administrative guidelines for safe work
practices, and additionally established and implemented safety work rules and
procedures
Work practice controls will include, but not be limited to the following: Careful
planning and performance of each assigned job, task, or duty; reduction in duration of
exposure to hazards; and adherence to safety and health rules and procedures.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

INJURY REPORTING AND INVESTIGATION

(INSERT COMPANY NAME)will investigate all work related accidents and near miss
incidents involving employees or company property to develop preventative measures
and implement corrective actions.
Employees are required to report any of the following to their immediate
supervisor: Accidents/incidents with injury/illness of any magnitude (including first aid
related cases); Accidents/incidents resulting in property or equipment damage of any
magnitude; and Any near miss incidents that could potentially have resulted in
injury/illness or property damage
(INSERT COMPANY NAME)will report the following situations to state or federal
agencies as required: OSHA; All fatalities and accidents involving hospitalization of (3)
or more employees will be reported within 8 hours.
ACCIDENT AND INJURY INVESTIGATION
All accidents and/or injuries will be formally investigated. An investigative team of at
least the Immediate Supervisor, the employee(s) involved and any witnesses will come
together and conduct a thorough investigation of the situation. Upon notification of an
injury or near miss incident, the immediate supervisor will be responsible for initiating
the investigative proceedings to determine the following:
1)
2)
3)
4)
5)

What happened?
Why did it happen?
What was the basic cause (s) for it happening?
What will be done to prevent it from ever happening again?
Who is responsible for implementing the corrective action and when will it be
implemented?

All activities and findings of the investigators will be documented and recorded for
review. The Supervisors Accident Investigation Report Form will be used as minimum
documentation of the investigation.
Management will review all investigation reports for thoroughness and corrective action
determination and implementation.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY DISCIPLINARY POLICY

(INSERT COMPANY NAME)will enforce an employee disciplinary policy that relates to
rules, policies and procedures established in (INSERT COMPANY NAME)safety and injury
prevention plan. The disciplinary policy will be a managerial tool to ensure a safe and
healthful working environment. The disciplinary policy applies to all employees.
VERBAL WARNINGS
Management, Safety Director and Supervisors will be allowed to issue verbal warnings to
employees that commit minor infractions or violations of established safety rules or safe
work practices. Continued violations of safety rules will lead to additional disciplinary
actions.
WRITTEN WARNINGS
Management or supervisors will issue written warnings for the following:
9 Repeated minor violations of safety rules or procedures.
9 Single serious violations of a rule or procedure that could have resulted in injury to them
or another employee or could have caused property damage.
DISCIPLINARY LEAVE, TERMINATION
Supervisors may recommend and management may institute disciplinary leave or
employee termination for the above reasons and/or the following:
9 A single serious or willful violation of a safety rule or procedure that results in an injury
to an employee or property damage.
9 Repeated violations and/or non-conformance to established safety rules or procedures.
DOCUMENTATION
Violations of established company safety rules, regulations, policies or procedures will be
documented in writing. The report will state the type and seriousness of the violation and
will include a description of disciplinary action taken. The employee must read and sign the
report acknowledging that they understand the seriousness of the violation. All safety
violation information will be maintained in the employees personnel file.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY RECORD KEEPING

The only means of documenting actions, reviewing results and identifying trends and
deficiencies in an employee injury prevention and safety program is through an effective
safety record keeping program. Safety record keeping is also essential in tracking the
performance of assigned duties and responsibilities under the program. This company is
committed to implementing and maintaining up to date injury prevention and safety
program records.
The Safety Director will maintain records of all work related injuries and illnesses. The
records will be maintained at (INSERT COMPANY NAME) Office, certain information, such
as medical information is considered confidential and will be maintained so.
The following records relating to work related injuries and illnesses and will be maintained.
9 OSHA 300, Log of Recordable Injuries and Illnesses (or equivalent),
9 Texas Workers' Compensation Commission, Employer's First Report of Injury Forms,
9 First Aid Log or other form of non-recordable accident/incident data.
The OSHA 300 Log of Recordable Injuries and Illnesses or an equivalent record will be
maintained at (INSERT COMPANY NAME)Office. The information will be maintained
current within six working days as required.
The completed summary portion of the OSHA 300 Log will be posted, in a conspicuous
location, for employee review no later than each February 1, for the previous calendar year
and will remain in place until the end of April.
All data pertaining to employee injuries/illnesses that did not require medical treatment or
were otherwise not recordable on the above mentioned documents, will be maintained in
written record form. This will include first aid treatment of any kind.
All injury/illness documentation will be reviewed on a monthly basis by Management,
Supervision, Safety Director (or others, safety committee, workers comp, carrier, etc.) to
analyze occurrences, identify developing trends, and plan courses of corrective actions to
prevent future accidents.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

SAFETY AND HEALTH SURVEYS AND INSPECTIONS

(INSERT INDIVIDUAL NAME OR POSITION)will maintain and review records of all safety
related audits and inspections that are conducted within or that affect (INSERT COMPANY
NAME), our employees, or facilities.
The following records relating to safety and health surveys and inspections will be
maintained:
9 Comprehensive survey reports and records of action taken,
9 Documented checklists of in house self-inspection and records of action taken.
Reports generated and received as a result of comprehensive surveys conducted by
outside professional agencies will be maintained for record and periodic review as well as
made available for all employees' information. Members of management that receive these
reports will ensure that recommendations are followed and that corrective actions are taken
and documented for record keeping purposes.
Checklist (Page 24) used during the completion of an in-house self-inspection process will
be maintained to document these inspections. The checklist will be and become a part of
the permanent record of the inspection and will serve as a confirmation of the inspection.
SAFETY MEETINGS
(INSERT COMPANY NAME)will maintain accurate records of all employee safety
meetings.
These records will include the following information:
Name of recorder,
List of attendees, with signature,
9 Details of topics discussed,
9 Action or corrective measures suggested, recommended, or implemented.
9

Safety Meeting Attendance Form is found on page 25.

TRAINING RECORDS
(INSERT COMPANY NAME) will maintain documentation (Pages 22 and 25) of all safety
and health related training as part of the employees permanent personnel file or in a
designated employee safety training file. This documentation will be maintained as proof of
training attendance. Records and documentation of employee safety related training will
include:
The trainer's or presenter's name,
Date of training,
9 Details of topic or subject covered,
9 Legible identification of attendees,
9 Attendees signature.
9

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

INJURY INVESTIGATION
(INSERT COMPANY NAME)will ensure proper records and documentation of all accident,
incident, and near-miss incidents investigation activities are maintained and reviewed.
Records and documentation will include:
9 Designated Injury investigation form(s),
9 Any other supporting data including photographs,
9 Records of corrective action or preventative measures implemented.
Supervisors Accident Investigation Form is found on page 28.
EQUIPMENT INSPECTION AND MAINTENANCE
Safety Director will maintain records and data pertaining to equipment inspection and
preventative maintenance programs performed involving company owned and controlled
equipment or vehicles. Records and documentation will include:
Routine inspection and maintenance records,
Documentation of services performed by contract agreement
9 Documentation of repair and replacement of parts or equipment
9
9

This documentation will be periodically reviewed by SAFETY DIRECTOR or

MAINTEMANCE MANAGER. The documentation will be utilized to determine an effective,
ongoing equipment maintenance program and to ensure regulatory compliance with
regulations that require inspections on certain equipment.

HIRING PRACTICES AND INJURY PREVENTION

(INSERT COMPANY NAME)will carefully review the written employment application of
each prospective employee prior to consideration for an interview or job offer. The
following steps will be followed to ensure hiring of the best qualified candidate.
9 Incomplete applications will not be considered as viable candidates for employment.
9 Employment history review will be conducted to include dates of employment. If there
are gaps between the various periods of employment, the applicant should be asked to
explain them.
9 Reference checks will be conducted on all applicants. When checking references an
attempt to speak with the applicant's immediate supervisor will be made.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

INJURY PREVENTION PLAN REVIEW AND REVISION

Management/Safety Committee/Board/Department Heads and/or other designated
representatives will periodically (at least annually) review and revise this Safety and Injury
Prevention Plan for effectiveness and implementation. Special attention will be devoted to
areas and criteria that demonstrate failure in a program component, introduction of new
procedures, processes or equipment.
Corrective measures will be taken as needed to reemphasize or restructure the plan to
perform at the optimum effectiveness.
Information will be solicited from all levels of employees to determine the effectiveness of
each program component, and for assistance in developing adjustments and corrections.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

GENERAL EMPLOYEE SAFETY RULES

1.

Follow Instructions. If you do not understand, ask for additional explanation on

how to do the job safely. All employees are expected to abide by the safety rules
while performing work assignments or on Company property.

2.

Warning Signs. Respect and obey all safety related warning signs.

3.

Unsafe Conditions. You may notice conditions that appear hazardous. You should
correct unsafe conditions if you can. If you can't, then report it to your supervisor
promptly so they can be corrected.

4.

Work Habits. You will do a service to yourself and your fellow workers by reporting
unsafe working habits of other employees. You don't have to mention names. By
doing this, you may prevent serious injury to yourself or others.

5.

Unfamiliar Equipment. Avoid using any machine, equipment or tools that you have
not been authorized, qualified, or trained to operate.

6.

Housekeeping. Keep your work area clean.

7.

Personal Protective Equipment. When protective clothing and equipment is

issued to you, it is required that you use it for your safety. Take care of the
equipment and have it replaced if damaged or worn out. Use the equipment only for
its designed purpose.

8.

Foot Protection. Wear appropriate footwear that will protect your feet while on the
job.

9.

Loose Clothing. Do not wear loose sleeves, shirt tails, loose or ragged clothing
and jewelry around moving machines, especially long chains and rings.

10. Horseplay. Don't let your friendship or familiarity with fellow workers lead to playing
a joke or thoughtless prank that could result in an injury. Horseplay on company
premises or in company owned vehicles is strictly forbidden.
11. Reporting of Accidents. Immediately report an Injury to your supervisor. If injured,
regardless of how minor, get the required medical attention or first aid promptly. All
injuries must be reported to your supervisor immediately
12. Lighting. Employees should report burned-out light bulbs or dimly lit work areas to
their supervisors.

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(INSERT COMPANY NAME)

Safety & Injury Prevention Program

13. Floors. Keep floors clean, free of oil, strings, rags, paper and any material that may
cause slips and falls. Avoid stepping on loose objects on the floor. If using stairs,
always keep one hand free to hold onto the rail.
14. Fire Extinguishers. You should know the location of the fire extinguishers in your
work area and know how to use them. Report discharged and inoperative fire
extinguishers to your supervisor.
15. Observe, "No Smoking" signs.
16. Always use the safety guards that are provided for your machine or equipment.
Never remove material that is being used for injury prevention purposes, such as
machine guards, lockout devices, and safety barriers.
17. Use the proper tool for the job. Hammering with wrenches, prying with a file, etc.,
are unsafe practices.
18. Never turn on switches, open valves, etc., without first checking to ensure that no
one is in a position to be injured and that all safeguards are in their proper place.
19. Never attempt to perform repairs or perform service or maintenance on machinery,
electrical equipment or other facilities unless you are authorized and trained to do
so.
20. When using ladders, make sure they are in good condition and have good footing.
21. Never use shortcuts or by-pass safety features or methods when doing a job.
22. Fighting or abuse and destruction of Company property are prohibited and will be
considered grounds for termination.
23. Obey all rules and abide by the regulations to help develop safety awareness among
your fellow workers.

19

(INSERT COMPANY NAME)

24.

Safety & Injury Prevention Program

Lifting, Six Rules of Safe Lifting:

a.

GET A FIRM FOOTING: Keep your feet apart for a stable base; point toes
out.

b.

BEND YOUR KNEES: Don't bend at the waist. Keep the principles of
leverage in mind at all times.

c.

TIGHTEN STOMACH MUSCLES: Abdominal muscles support your spine

when you lift, offsetting the force of the load. Train muscle groups to work
together.

d.

LIFT WITH YOUR LEGS: Let your powerful leg muscles do the work of
lifting, not your weaker back muscles.

e.

KEEP THE LOAD CLOSE: Don't hold the load away from your body. The
closer it is to your spine, the less force it exerts on your back.

f.

KEEP YOUR BACK UPRIGHT: Whether lifting or putting down the load, don't
add the weight of your body to the load by bending at the waist. Avoid
twisting at the waist, twisting the body while lifting can cause injury.

20

SAFETY AND INJURY PREVENTION PROGRAM

FORMS SECTION
1.

EMPLOYEE ACKNOWLEDGMENT FORM

2.

REPORT OF HAZARDS AND/OR UNSAFE CONDITIONS

3.

SAFETY SELF-INSPECTION CHECKLIST

4.

SAFETY MEETING ATTENDANCE FORM

5.

INJURY PREVENTION PLAN REVIEW AND REVISION FORM

6.

SUPERVISORS ACCIDENT INVESTIGTION REPORT

21

SAFETY AND INJURY PREVENTION PROGRAM

EMPLOYEE ACKNOWLEDGMENT FORM

1.

SAFETY RULES: I fully understand that working in a safe manner, keeping my work
area neat, clean and orderly is most important to my own safety and the safety of
those around me. I have received and read WILLOW BROOK COUNTRY CLUB's
safety rules and understand that I must abide by these rules at all times. I have
been given a copy of these safety rules and instructed to refer to them on a regular
basis. Whenever I see an unsafe work condition, I must report it immediately to my
supervisor or management.

2.

LIFTING: I have read the policy concerning the proper lifting techniques and do
understand that I am expected to use these techniques in moving or lifting objects. I
have been informed and do fully understand that I am not encouraged to lift or
transfer any object by myself, unless I know I can safely lift or transfer the object by
myself.

3.

REPORTING ACCIDENTS AND UNSAFE CONDITIONS: I have been informed and

fully understand that any injury that occurs to me or another employee or the
identification of any unsafe condition must be immediately reported to my supervisor.

Employee Signature
__________________
Date
__________________________________________
Printed Name

22

SAFETY AND INJURY PREVENTION PROGRAM

REPORT OF HAZARDS AND/OR UNSAFE CONDITIONS

DATE OF REPORT: __________________
PERSON REPORTING: ________________________________
HAZARD/CONDITION IDENTIFIED: ___________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
COMPANY FINDINGS: _____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
CORRECTIVE ACTION TAKEN: ______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
DATE COMPLETED: __________________
COMPLETED BY: ____________________________________
Management Review by: _______________________________ Date: _____________
Additional Comments/Recommendations: _______________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

23

SAFETY AND INJURY PREVENTION PROGRAM

SAFETY SELF-INSPECTION CHECKLIST

Date of Inspection:
Person Conducting Inspection:
Location Inspected:

______________________________
______________________________
______________________________

(Use back if needed for comments concerning identified exposures.)

YES

NO

1.

Housekeeping - Is the work area clean and orderly?

2.

Floors - Are floors in good condition and free of trip hazards?

3.

Stairways - Are stairways safe and free of tripping hazards?

4.

Storage - Are materials, products, and supplies stored safely?

5.

Ladders - Are proper sized ladders provided where needed and

of standard construction, and in safe working condition?

Machines & Equipment - Are machines and equipment in safe

working condition with necessary protective guards in place?

Tools - Are the right tools for the job being used? Are all tools,
including power tools, in safe working condition?

Electrical - Are grounds provided on power tools and extension

cords? Are electrical power supply panels and boxes securely
protected from accidental contact? Are circuits properly marked?

Lighting - Is adequate lighting provided in all work areas?

Personal Protective Equipment - Are all employees provided

personal protective equipment when their work duties require
the use of this equipment? Are they trained in proper use?

11.

First Aid - Are first aid supplies provided?

12.

Fire Extinguishers - Are fire extinguishers easily accessible and

properly inspected? Have employees who would be expected
to use fire extinguishers had training in their safe use?

Exits - Are emergency exits properly marked and readily accessible?

6.
7.
8.

9.
10.

13.

SAFETY AND INJURY PREVENTION PROGRAM

24

SAFETY MEETING ATTENDANCE FORM

DATE OF MEETING: __________________
PERSON CONDUCTING: Printed Name: ___________________________________
Title:
___________________________________
Signature:
___________________________________
TOPIC/SUBJECT MATTER COVERED: ________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
ATTENDANCE ROSTER:
PRINTED NAME

SIGNATURE

FOLLOW UP ACTIONS NEEDED AS RESULT OF TRAINING SESSION: _____________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
SAFETY AND INJURY PREVENTION PROGRAM

SAFETY TRAINING ACKNOWLEDGMENT FORM

25

DATE OF TRAINING SESSION: __________________

PERSON CONDUCTING: Printed Name: ___________________________________
Title:
___________________________________
Affiliation (if not employee): _________________________
Signature:
___________________________________
TOPIC/SUBJECT MATTER COVERED: _______________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
ACKNOWLEDGEMENT: By signature below, I acknowledge that I have attended this
training session. Through the discussion and presentation of the subjects covered and the
interaction of this session, I understand how the issues, materials and subjects covered
apply to me and the completion of my job duties in a safe manner. I agree to apply the
information presented to my job to the best of my abilities.
ATTENDANCE ROSTER:
PRINTED NAME

SIGNATURE

26

SAFETY AND INJURY PREVENTION PROGRAM

INJURY PREVENTION PLAN REVIEW AND REVISION FORM

DATE OF REVIEW: _____________________
PERSON(S) INVOLVED IN REVIEW:
Printed Name: _________________________
Title:
_________________________
Signature:
_________________________

Printed Name: ______________________

Title:
______________________
Signature:
______________________

Printed Name: _________________________

Title:
_________________________
Signature:
_________________________

Printed Name: ______________________

Title:
______________________
Signature:
______________________

PARTS/ELEMENTS REVIEWED: ____________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
FINDINGS: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
ACTIONS: _______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
FOLLOW UP RECOMMENDATIONS: _________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

27

Supervisor's Accident Investigation Report

GENERAL INFORMATION
COMPANY:

NAME OF INJURED:

EST.
MARRIED:
OCCUPATION:
Yes No
AGE:
WORKSITE OR EXACT LOCATION OF ACCIDENT:

EMPLOYMENT
DATE:

EVENT DATE:
HOUR:

AM

PM

ACTIVITY AT TIME OF INJURY OR OCCURRENCE:

DESCRIBE INJURY:

WAS INJURED ACTING IN REGULAR LINE OF DUTY?

YES

NO (EXPLAIN):

NAME OF WITNESSES:

UNSAFE ACT (What Happened)

Operating without authority; failure to secure or warn
Operating or working at unsafe speed
Making safety devices inoperative
Using unsafe equipment, hands instead of equipment, or
equipment unsafely
Failure to use safe attire or personal protective
equipment
turn lane usage backing interval signal
Improper:

Unsafe loading, placing, mixing, combining, etc.

Taking unsafe position or posture
Working on moving or dangerous equipment
Distracting, teasing, abusing, startling, etc.
Lack of job training or instruction
judgment

other:

UNSAFE CONDITIONS
Improper guarding (unguarded, inadequately guarded,
guard removal, etc.)
Defective substances or equipment (broken, poorly
design of, slippery, etc.)
Hazardous arrangement (unsafely piled material, poor
layout, poor housekeeping, no aisle markings, etc.)
improper dress or apparel (goggles, gloves, shoes,
masks, sleeves, etc.)
brakes motor lights wipers steering
Defective:

Improper illumination (none, glaring light, etc.)

Improper ventilation (poor, dusty, gassy, high humidity, etc.)
Poor road or visibility conditions

tires

wheels or rims

other:

STEPS TAKEN TO PREVENT RECURRENCE

Unsafe Act:
Supplied safeguard
Supplied personal protective
Warned employee
equipment
Other action (please explain):
Instructed employee

Unsafe Conditions:
Eliminated condition
Reported condition to:
Repaired condition
Guarded machine
Other action (please explain):

SUPERVISOR'S SIGNATURE

DATE

BREAKDOWN OF UNSAFE ACTS AND CONDITIONS

UNSAFE ACTS

UNSAFE CONDITIONS

OPERATING WITHOUT AUTHORITY, FAILURE TO

SECURE OR WARN

FAILURE TO USE SAFE ATTIRE OR PERSONAL

PROTECTIVE DEVICES

-Starting, stopping, using, operating, firing, moving machinery,

vehicles or equipment without authority or without giving proper
signal.
-Failing to shut off equipment not in use.

-Failing to wear goggles, gloves, masks, aprons, shoes, leggings or

protective hats.
-Failure to report defective safety apparel.

28

-Failing to place warning signs, signals or tags.

-Failure of crane signalman to give proper signal.

INADEQUATELY GUARDED
-Weak or defective guard.
-Improper shoring in trenching, construction or excavatio.

OPERATING OR WORKING AT UNSAFE SPEED

DEFECTIVE TOOLS, EQUIPMENT OR MATERIALS

-Running or walking backwards; jumping from vehicles, platforms.

-Feeding, throwing or supplying material too rapidly.
-Driving too rapidly or too slowly; working too fast or too slow
endangering self and others.

-Rough, slippery, sharp-edged.

-Low material strength.
-Poorly constructed.
-Inferior composition.
-Decayed, aged, worn frayed, cracked.

MAKING SAFETY DEVICES INOPERATIVE

-Removing or disconnecting safety devices
-Blocking, plugging, tying or failing to secure safety devices.
-Replacing safety devices with those of improper capacity, (higher
amperage, electric fuses, low capacity safety valves); misadjusting
safety devices.

USING UNSAFE EQUIPMENT, HANDS INSTEAD OF

EQUIPMENT OR EQUIPMENT UNSAFELY
-Using defective equipment (mushroomed chisel head, chipped
grinding wheel).
-Unsafe use of equipment (operating pressure valves at unsafe
pressures or volume).
-Gripping objects insecurely, taking wrong hold of objects.
-Gripping objects insecurely, taking wrong hold of objects.

UNSAFE LOADING, PLACING MIXING, COMBINING

-Overloading, crowding or carrying too heavy load; crowding or unsafe
piling.
-Arranging or placing objects or material unsafely (parking, placing,
stopping, or leaving vehicles, elevators, and conveying apparatus in
un-safe position for loading and unloading).
-Injecting, mixing or combining one substance with another so that
explosion, fire, or other hazard is created (injecting cold water into
hot boiler, pouring water into acid).
-Introducing objects or materials unsafely (portable electric light or extension cord inside of boilers or in areas containing combustibles or
explosives); smoking where explosives or combustibles are kept.
-Placing or leaving on working surfaces unnecessary tools, materials,
debris, rope, chain, hose, or electrical leads.
-Leaving spilled oil, water, grease or paint on working surfaces, floors
or stairways.

TAKING UNSAFE POSITION OR POSTURE

-Exposure under suspended loads; unnecessarily putting body or its
parts into shaftways or openings.
-Not using proper methods of ascending or descending
-Entering vessel or enclosure when unsafe because of temperature,
gases, wiring or other exposures.
-Working on high tension conductors from above instead of below.
-Lifting with bent back or while in awkward position.
-Riding in unsafe position (on platforms, tailboards, and running
boards of vehicles); tailing or stealing rides, riding on apparatus
designed only for materials.
-Passing on grades and curves, cutting in and out, road hogging.
-Exposure to falling or sliding objects.

HAZARDOUS ARRANGEMENT OR PROCEDURE

-Unsafely stored or piled tools or material.
-Congestion of working space.
-Inadequate aisle space or exits.
-Unsafe planning and/or layout of traffic or process operations.
-Misaligning
-Inadequate drainage.

IMPROPER ILLUMINATION
-Insufficient or no light.
-Glare
-Unsuitable location or arrangement (producing shadows or
contrasts).

IMPROPER VENTILATION
-Insufficient air changes or concentration of toxic fumes, vapors, or
dust.
-Unsuitable capacity, location or arrangement of system.
-Impure air source
-Abnormal temperature or humidity

UNSAFE DRESS OR APPAREL

-Goggles or face shields defective, unsafe, or unsuited for work or
missing.
-Gloves or mitts defective, unsafe, or unsuited for work or missing.
-Apron defective, unsafe, or unsuited for work or missing.
-Shoes defective, unsafe, or unsuited for work or missing.
-Respirator defective, unsafe, or unsuited for work or missing.
-Leggings defective, unsafe, or unsuited for work or missing.
-Protective hard hat defective, unsafe, or unsuited for work or
missing.
-Welders helmet or hand shields defective, unsafe, or unsuited for
work or missing.
-Safety belts defective, unsafe, or unsuited for work or missing.

UNGUARDED
-Lack of guard, screen, enclosure, barricade, fence, insulation
railing, rope, (as opposed to inadequate guarding).

UNSAFE DESIGN OR CONSTRUCTION

-Hazard built into new equipment or structures.
-Faulty architecture, design or engineering.
-Faulty assembly, manufacture or erection (as opposed to
"Defective" through wear and tear or abuse).

WORKING ON MOVING OR DANGEROUS EQUIPMENT

-Getting on and off moving equipment (vehicles, conveyors, elevators).
-Cleaning, oiling, or adjusting moving equipment containing dangerous
chemical substances.

DISTRACTING, TEASING, ABUSING (Horseplay)

-Calling, talking, or making unnecessary noise; startling by throwing
material.
-Practical joking; quarreling or fighting.

29