STATE OF WEST VIRGINIA

DEPARTMENT OF ADMINISTRATION
BOARD OF RISK AND INSURANCE MANAGEMENT

Loss Control Manual

Issued by:
The West Virginia Board of Risk and Insurance Management
January 2005
 TABLE OF CONTENTS
SECTION 1- INTRODUCTION
Purpose of The Manual 1-1
Definition of Risk Management 1-1
Components of a Loss Control System 1-1
Objective of Risk Management and Loss Control System 1-1
Benefits of Risk Management and Loss Control Program 1-2
Policy Statement 1-3
Duties and Responsibilities 1-3
Safety/Loss Control Committee 1-5

SECTION 2 – CLAIMS ADMINISTRATION/LOSS REPORTING PROCESS

Claims Administration 2-1
Accident Reporting and Investigation 2-3
Appendix 1- Incident Report Form
Appendix 2- Insurance Loss Notice Form

SECTION 3 – FLEET SAFETY PROGRAM

Policy Statement 3-1
Responsibilities 3-1
Operator Responsibilities 3-2
Driver Selection 3-4
Driver Training and Reviews 3-7
Accident Investigation 3-8
Vehicle Accident Review 3-10
Vehicle Selection 3-10
Vehicle Maintenance 3-10
Vehicle Inspections 3-11
Vehicle Maintenance File 3-11
Vehicle Breakdown 3-12
Appendix 1- Sample Vehicle Policy and Acknowledgement Form
Appendix 2- Sample Vehicle Inspection Checklist
Appendix 3- Sample Vehicle Maintenance Acknowledgement Form
Appendix 4- Driver Application Supplement
Appendix 5- Sample Authorization for MVR Form
Appendix 6- Sample MVR Check and Point Structure Plan
Appendix 7- Sample Defensive Driving Policy
Appendix 8- Sample Defensive Driving Course Completion Form
Appendix 9- Sample Accident Reporting Instructions
Appendix 10- Sample Accident Reporting Form
Appendix 11- Determining Preventable/Non-preventable Accidents
Appendix 12- Monthly Vehicle Maintenance and Inspection Schedule

SECTION 4- CONTRACTS AND AGREEMENTS

Introduction 4-1
Screening Contractors 4-1
Safety Requirements for Bid Specifications and Contracts 4-2
Indemnification/Hold Harmless Agreements 4-2
Additional Insured 4-3
Insurance Requirements for Contractors 4-3

SECTION 5- FACILITY AUDIT AND INSPECTION CHECKLISTS

How to Get Started 5-1
Developing a Checklist 5-1
Using the Checklist 5-1
Checklist Index 5-3
Self-Inspection Checklists 5-5
Facility Inspections 5-18
Equipment Inspections 5-41

SECTION 6- EMERGENCY MANAGEMENT PLAN

Emergency Plans and Procedures 6-1
Step 1- Establish A Planning Team 6-1
Step 2- Analyze Capabilities and Hazards 6-2
Step 3- Develop The Plan 5-8
Step 4- Implement The Plan 5-12
Evacuation of Disabled Persons Planning 5-16
Fire Emergency Planning Guide 5-19
Natural Disaster/Severe Weather Emergency Planning 5-21
Hazardous Materials Emergency Planning 5-24
Technological Emergency Planning 5-26
Man-Made Disaster Emergency Planning 5-27
Workplace Violence Prevention 5-31
Disaster Recovery/Business Continuation Planning 5-36
Appendix 1- Sample Emergency Plan Template
Appendix 2- Evacuation Planning and The ADA
Appendix 3- Sample Bomb Threat Checklist
Appendix 4- Sample Workplace Violence Prevention Program
Introduction
 Purpose of the Manual
This manual is designed to help (Enter Entity Name Here) protect its assets through an
efficient and effective risk management and loss control program. It is designed so that
information can be easily updated as needed. The manual is not meant to be the sole
source of risk management and loss control information, nor is it a legal document. Staff
is encouraged to review this manual periodically and suggest changes to keep it current
and to minimize differences between the manual and actual practices.

Definition of Risk Management

Risk management is the process of planning, organizing, staffing, leading, and
controlling resources to minimize the possibility of property damage or injury from
various causes of loss. Simply stated, risk management is the process of identifying and
controlling losses.

Components of a Loss Control System

Loss control is a proactive approach to preventing accidents and resulting
injuries and property damage. Loss control requires the commitment of everyone at all
levels — agency directors, risk management contacts, safety directors, and employees.
Effective loss control, with an emphasis on safety procedures, training, and monitoring,
can minimize the potential for property, general liability, and auto claims and losses.

An effective loss control system includes the establishment of a an effective loss control
policy, assignment of responsibilities, ongoing review of claims data, periodic loss
control audits and inspections, accident reporting and investigation, communication, and
development and regular review of emergency and contingency plans.

Each of these components should be implemented, monitored, clearly communicated to

employees and any visitors and refined as necessary to ensure they are up-to-date.

Objective of Risk Management and Loss Control

System
Reducing the cost of risk is the primary objective of (Enter Entity Name Here)’s risk
management program. The cost of risk for a specified loss is the total value of all related
costs and resources, both direct and indirect. The total cost of risk is the sum of the
following:
• The replacement value of all equipment and property damaged or lost

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Board of Risk and Insurance Management
 • Total claims expenditures, including legal expenditures
• The costs of loss prevention and control measures
• The costs of insurance premiums
• Lost productivity
• Administrative and overhead costs.

Since reduction of the cost of risk is the primary objective of a risk management program,
specific goals that support this primary objective are to:
• Minimize exposures to financial losses
• Protect physical assets
• Reduce the frequency and severity of accidents
• Provide a safe environment for employees and the public
• Minimize interruptions of services provided to the public.

Benefits of Risk Management and Loss Control

Program

(Enter Entity name Here) believes that a well-conceived, comprehensive risk

management and loss control program requires a significant commitment of time and
resources at all levels including Management, Supervisors and Employees. By evaluating
the specific property, general liability, and fleet exposures associated with (Enter Entity
Name Here)’s operations and implementing appropriate loss control measures to prevent
claim and losses, the cost of this commitment is mitigated by the following benefits:

• Reductions in misuse and/or losses to equipment and property

• Reductions in the frequency and severity of accidents

• Reductions in the expenditures of insurance claims

• Providing a safe environment for employees and members of the general public

• Providing a defense against claims of negligence when employees or third parties

are performing assigned tasks in the scope of employment
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 Policy Statement
Conducting work in a safe manner and protecting the safety of employees and the general
public are extremely important to (Enter Entity Name Here). It is the policy of (Enter
Entity Name Here) to establish and adhere to the following risk management and loss
control procedures that will protect the assets of (Enter Entity Name Here), the safety of
its employees and members of the general public. All (Enter Entity Name Here)’s
employees and officials have certain responsibilities in the risk management and loss
control process that must be carried out in order to have a successful program. These
responsibilities include such activities as establishing safe workplaces, following safe
practices, limiting exposure to potential liability and loss, and carrying out the steps
necessary to maintain an effective and efficient risk management and loss control
program.

Duties and Responsibilities

1. Employees
All employees are responsible for assuring safe and healthful working conditions and
practices and for protecting the safety of the public. Each employee will:
• Comply with the rules, regulations and policies set forth in this manual applicable
to personal actions and conduct.
• Operate all equipment and vehicles in a safe manner and refrain from removing,
displacing, or damaging any safety device installed on equipment or property.
• Call unsafe conditions or possible violations of the policy procedures to the
attention of the supervisor.
• Report all accidents according the proper procedures set forth in this manual.
• Operate only those machines and equipment for which the employee has been
trained and authorized to operate.

2. Management
Management Personnel have the responsibility for maintaining safe and healthful
conditions, whether it be out in the field or within (Enter Entity Name Here) facilities.
Although personnel exposure to hazards varies widely from department to department, it

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is expected that an unrelenting effort will be directed toward preventing injuries,
accidents, and liabilities. Therefore, Department Managers will:
• Insure that the policies and procedures set forth herein are complied with by all
personnel under his/her direction and maintain the Safety/Loss Control Manual.
• Provide the leadership and positive direction essential in maintaining firm loss
prevention policies as a prime consideration in all operations.
• Devote a portion of staff meetings, as necessary, to a review of losses (accidents)
and to discuss plans to bring about more positive loss reduction.
• Hold each Supervisor accountable for an explanation of the preventable injuries,
collisions, and liabilities incurred by employees.
• All employees are briefed and fully understand (Enter Entity Name Here)’s work
procedures and existing policies which enforce their use.
• All accidents are thoroughly investigated, recorded and promptly reported in
accordance with existing directives.
• Ensure prompt, corrective action is taken wherever hazards are recognized or
unsafe acts are observed.

3. Supervisory Personnel
Each supervisor has the responsibility and full authority to enforce the provisions of this
manual and (Enter Entity Name Here)’s work practices in order to keep losses at an
absolute minimum. Each supervisor will:
• Assume full responsibility for safe and healthful working areas for all employees
while they are under the supervisor's jurisdiction.
• Be accountable for preventable injuries, accidents, and liabilities occurring in
his/her area of the facility.
• Insure that all management policies pertaining to safety and loss control are fully
implemented for maximum efficiency of each job and maintain the corresponding
manuals and directives.
• Take the initiative in recommending correction of deficiencies noted in facilities,
work procedures, employee job knowledge, or attitudes that adversely affect the
loss control efforts.
• Be firm in enforcement of work policies by being impartial in taking disciplinary
action against those who fail to conform, and by being prompt to give recognition
to those who perform well.

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 • Insure that each employee is fully trained for the job the employee is assigned to
do, and familiar with the published work rules, by certifying in writing that he/she
understands that compliance is mandatory.

4. Safety/Loss Control Officer

The Safety/Loss Control Officer is responsible for the staff direction and administration
of the loss control program to prevent injury, liability, and damage to property. The
Safety/Loss Control Officer will:
• Maintain (Enter Entity Name Here)’s Safety/Loss Control Manual.
• Acquire and make available to department directors, supervisors and employees
all applicable standards and requirements.
• Coordinate and/or conduct safety training programs that are beyond the scope of
individual supervisors.
• Perform ongoing evaluations of (Enter Entity Name Here)’s Safety /Loss Control
program and make recommendations to management for improvements.
• Review and analyze accident reports and investigations for causes and corrective
actions.
• Establish a review of procedures to insure the proper investigation of accidents.
• Consult directly with management and employees on loss prevention matters and
provide guidance to assure effective program administration.
• Chair the Safety/Loss Control Committee
• Establish and evaluate emergency procedures for (Enter Entity Name Here)
facilities and personnel.
• Review of all driver reports including training and safety policies.

Safety/Loss Control Committee

Purpose
The purpose of this section is to outline the goals and function of the Safety/Loss
Control Committee.

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Policy
The Safety Committee is an important part of (Enter Entity Name Here)’s safety and
loss control efforts. Managers and supervisors can gain valuable assistance in their
areas by a joint effort with their committee members. Committee membership is a
voluntary service to (Enter Entity Name Here). All managers, supervisors and
employees are to fully support the efforts of the Safety/Loss Control Committee.

Goals of the Safety/Loss Control Committee

1. Involve employees in safety and loss control management
2. Lower the frequency and severity of accidents and injuries
3. Maintain a safe environment for employees and visitors
4. Involve all employee participation in safety programs

Committee Formation
Membership on the committee is to be voluntary. The committee will represent all
departments, but have the most efficient number of members to assist in accomplishment
of committee goals. Standing members to the committee will include a representative
from Management, Maintenance and Safety. The purpose of the standing membership is
to provide continuity, lend experience and provide a resource for the committee. The
Safety/Loss Control Officer will serve as chairperson and be the main contact for loss
control and safety activities. The committee’s other members represent a cross-section of
employees from various departments with membership rotated on an annual basis with
staggering terms to ensure continuity.

Committee Functions
The suggested functions of the loss control committee include:

1. Developing a loss control and safety policy and communicating that policy to all
employees.

2. Serving as a loss control review board for all accidents or incidents

involving employees, members of the general public, entity vehicles or property.
This includes recommending loss control and safety measures that could prevent
similar occurrences in the future.

3. Establishing a procedure for reporting hazardous conditions or

activities and taking corrective action.

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 4. Periodically inspecting facilities to see that they are complying with established
loss control policies and standards and to identify and correct hazardous
conditions.

5. Preparing checklists to guide and document inspections. (See Section XXX for
Sample checklist )

6. Coordinating evacuation or shelter drills. (See Section XXXX for Emergency

Planning guidelines)

7. Determining loss control and safety training needs, including the

identification, handling, storage, and disposal of hazardous materials, and
developing a plan of action to guarantee required safety training is
accomplished.

8. Ensuring that first aid kits and personal protective equipment needs are met.

9. Developing and conducting loss control and safety orientation program for new
employees.

10. Reviewing compliance status with the agency’s Records Management

System.

Duties and Responsibilities

Safety/Loss Control Officer
The Safety/Loss Control Officer serves as chairperson and will report Committee
activities to Management.
Safety Committee Members
Safety Committee Members have the following responsibilities:
1. Attend each meeting
2. Discuss safety activities and unsafe acts/conditions
3. Encourage all Employees to work safely
4. Report safety and loss control actions to their department during
normally scheduled safety training

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Meetings
The loss control committee will meet on a (Enter time Interval) basis at a regular time
and date. Each meeting will have a fixed agenda that is sent to the members about one
week before the meeting. Following the agenda closely will keep the meeting moving. A
special meeting may be held or an additional committee formed to address an emergency
situation or complicated issue.

The agenda for the meeting can be simple:

1. Call to order
2. Roll call by the secretary
3. Introduction of any visitors, if allowed
4. Reading and approval of minutes of the previous meeting
5. Review of any policies issued since the last meeting
6. Taking care of unfinished business
7. Review of any general liability, property, and auto claims or losses
occurring and preventive measures taken since the previous meeting
8. Discussion of loss control inspections and recommendations
9. Addressing new business
10. Adjournment

Records
Records of all Safety/Loss Control Committee Meetings and actions shall be
maintained by the Safety/Loss Control Officer for at least (Enter Number of months)
months.

Training
Each Safety Committee Member will be provided the necessary training in:
1. Function of the committee
2. Safety and Loss Control Programs and Policies

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Claims Administration
and

Loss Reporting Process

 Claims Administration/Loss Reporting and
Investigation Process
Accidents and incidents that lead to claims and losses can happen in a number of ways.
They may involve property damage, general liability issues involving a third party or
automobile. Promptly investigating and reporting claims and losses is critical in helping
reduce future liability claim and loss costs.

Claims Administration
1.0 Overview

This policy and procedure was developed to outline the claims administration process to
be followed in the event of a loss. A loss includes any loss stemming from natural causes
or human error which results in bodily injury, property damage, or damages to a third
party.

West Virginia Board Risk and Insurance Management will coordinate the adjustment and
settlement of most property and casualty claims. All employee group health, life,
disability, and worker's compensation claims shall be filed with the participants of the
state government responsible for administering those programs.

2.0 Protection of Assets

Immediately following a loss, every necessary precaution shall be taken by the affected
parties to prevent further damage or legal liability to third parties or (Enter Entity Name
Here) assets including property or personnel and to render assistance to injured parties, if
necessary.

3.0 Claims Reporting

Timely and accurate reporting of claims is paramount in protecting the interests
of (Enter Entity Name Here) and its employees. For reporting purposes, claims fall
into one of three categories:

a. Vehicle - These are losses to third parties involving entity owned

or leased/loaned vehicles, mobile equipment, and watercraft; and
losses to fully covered entity vehicles, mobile equipment, and
watercraft.

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 b. Property Damage - These are losses to all other
entity property other than automobile resultant from perils such as
hail, windstorm, earthquake, fire, theft, etc. Property losses
include inland marine, fine arts, crime and other unique coverages,
which involve entity property.

c. Personal Injury - These are general liability which occurs as a

result of errors, omissions, and commissions of entity employees
and officers, and which result in property damage or bodily injury.
This category also includes all other losses not mentioned above.

All claims should be reported in accordance with the procedures and instructions
hereinafter described.

1. After a loss, the employee and his or supervisor most familiar with the
incident should investigate it and complete the Incident Report Form (See
Appendix 1 for Incident Report Form) as well as the Insurance Loss
Notice Form. (See Appendix 2 for Insurance Loss Notice Form)
Instructions for completing the Insurance Loss Notice Form are
incorporated into the form or (see The Board of Risk and Insurance
Management’s website).

2. The immediate supervisor will assure that the forms are accurately
completed, signed, and dated by the employee. The Supervisor and The
Safety/Loss Control Officer will assure that the Insurance Loss Notice
Form is sent to The Board of Risk and Insurance Management. If
possible, photographs and diagrams of the losses should also be provided.

3. Copies of the Insurance Loss Notice Form shall be distributed as

follows:

ORIGINAL West Virginia Board of Risk and Insurance Management

90 MacCorkle Ave., S.W., Suite 203
South Charleston, WV 25303

COPY (Enter Department Here)

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Board of Risk and Insurance Management
 Accident Reporting and Investigation

A successful and well designed loss control program includes unbiased, prompt
and accurate accident reporting and investigation process. All accidents
incidents, and near-misses should be reported and investigated regardless of
extent of injury or property damage. The extent of the investigation may vary but
all accidents and incidents reflect potential hazards which should be identified
and corrected.

1.0 Purpose
The purpose of this section is to establish guidelines for reporting and investigating
incidents in which claims and losses could potentially arise, including occurrences (near-
misses) that could have resulted in injury or property damage but did not, in order to
initiate corrective and/or preventive action as needed.

2.0 Policy
It is the policy of (Enter Entity name here) that the incident reporting and
investigating requirements apply to all incidences involving entity
employees, on-site vendors, contractor employees and visitors, which
results in (or might have resulted in) personal injury, illness, and/or
property and vehicle damage.
The report and investigation of all accidents, incidents and events are to be
conducted in a professional manner to identify probable causes and are used to
develop specific management actions for the prevention of future accidents.

3.0 Responsibilities
1. Management:

• Establish and maintain an effective accident

reporting and record keeping program

• Train all employees in the accident reporting

procedures

• Train record custodians in proper record entry,

maintenance and release procedures

• Conduct annual program audit

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 • Conduct accident prevention and investigation training for
supervisors

• Ensure all accidents and incidents are properly investigated

• Ensure immediate and long term corrective actions are taken to

prevent reoccurrence

• Provide all necessary medical care for injured persons

2. Supervisors

• Conduct immediate initial accident investigations

• Report all accidents to management as soon after the event as

possible

• Collect and preserve all evidence that may be useful in an

investigation

• Conduct interviews of witnesses in a polite professional manner

• Do not attempt to find or assign blame for accidents

• Take action to protect people of accidents and property from

secondary effects

3. Employees

• Comply with the accident reporting procedures

• Immediately report all accidents & injuries to their supervisor

• Assist as requested in all accident investigations

• Report all hazardous conditions and near-misses to supervisors

4.0 Incidents and Accidents

Incidents requiring reporting include those incidents or accidents which

result in any of the following: injury or illness, damage to a vehicle, entity
property damage, or injury to third party or their property.

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Board of Risk and Insurance Management
 5.0 Events (Near Misses)
Other incidents that, strictly by chance, do not result in actual or
observable injury or property damage are required to be reported. The
information obtained from such reporting can be extremely useful in
identifying and mitigating problems before they result in actual personal
injury or property damage.

6.0 Training
To ensure that all employees understand the incident reporting and
investigation requirements, annual training sessions will be held with all
employees to review procedures and responsibilities. New employee
orientation training will include information on incident reporting and
procedures.

7.0 Program Audits

The effectiveness of a program can only be accomplished if the program is
implemented and maintained. Periodic reviews and audits shall be
conducted by The Safety/Loss Control Officer and Supervisors to confirm
that all employees are familiar with the incident reporting and
investigation requirements and that the program is managed properly.
These audits will consist of:
1. Annual review of incident reports to ensure all
records have been maintained and are complete.
2. Annual refresher training for employees involved in
record entry and record keeping
3. Annual refresher training for all employees
detailing the incident reporting procedures.
8.0 Timing
Incidents involving serious bodily injury, death, or serious property damage
must be reported immediately by phone or radio to Supervisor and to The Safety/Loss
Control Officer. All other events should be reported within (Enter number of hours here)
of their occurrence.

9.0 Accident Investigation

The objective of any accident investigation is to identify the causal factors and
recommend corrective actions. An accident investigation should determine what
happened, how it happened, and why it happened. It should also lead to measures to
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 prevent similar events from happening in the future. An accident investigation should
take place in timely fashion in order to obtain as much information as possible to reduce
the risk of further injury or property damage.
1. Investigation Team
The qualifications of team members should include technical knowledge,
familiarity with the job, objectivity, and analytical approach to problems.
Investigators need advance training and preparation so they can act effectively
and efficiently. The size and makeup of the team should be dictated by the
seriousness of the accident.

The investigation of minor accidents involving only an employee and or

(Enter Entity Name Here) property only is the responsibility of the involved
employee’s Supervisor.

The Safety/Loss Control Officer will be in charge of the investigation of accidents

involving property damage or injury to a third party or resulting in serious
property damage, injury or death to (a/an) (Enter Entity Name Here) employee.
These investigations may also include outside officials or lawyers and other safety
people. Management may initiate any other accident investigations if deemed
appropriate.

2. Investigation Procedures
The accident investigation has three purposes:
1. Prevent further possible injury and property damage
2. Collect facts about the accident
3. Collect and preserve evidence
Depending upon the severity of the accident, the following activities may be
necessary:
1. Secure the area where accident occurred to prevent other injuries or
property damage.
2. Visit the accident site before the evidence is disturbed.
3. Document observations of the condition of the accident site.
4. Photograph or video tape the accident scene from all angles.
5. Identify and interview eye witnesses and other persons who can provide
pertinent information.
6. Review other sources of information such as design specifications,
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 drawings, maintenance records, or employee training records.

At the scene, the accident investigator(s) will carefully survey the scene, noting
any debris from the accident. The investigator(s) should take photos of the scene,
with careful notes of what the photos depict. A map of the site should be drawn to
scale, with any landmarks near the scene noted as to position. Photos of all
property damages incurred from accident should be taken from all sides, with
careful notes made. It is important that the accident investigator(s) be as objective
as possible ingathering and evaluating data from the accident scene. Investigators
should avoid any emphasis on identifying the individual who could be blamed for
the accident. This does not mean that unsafe
acts, improper actions, poor judgments, or lack of
knowledge of hazards should be ignored.

3. Employee Responsibility in Accident Investigation

Accident investigation begins right at the scene. That means certain employee
responsibilities must be carried out at the scene of an accident.

Two main concerns at the scene of an accident are to deal with immediate
problems and to gather and report pertinent accident information promptly. These
two items can be broken down into a 6-step accident procedure for employees to
follow. For vehicle accidents (See Fleet Safety Plan for driver responsibilities in
accident investigation).

Step 1: Stay calm

Step 2: Do a quick evaluation of accident victims, if any, and provide

assistance.

Step 3: Either contact local law enforcement personnel and your

supervisor yourself or arrange to have someone do it for you. Be
courteous and cooperative when providing information to
authorities. Never admit guilt or liability at the scene of an
accident. Never leave the scene of an accident.

Step 4: Write down names and other information regarding the accident
and those people involved in it. Draw a simple diagram of the
accident scene. The more detail you can provide, the better it will
be for insurance and/or legal purposes later. If you have a camera
for use at the accident scene, document the situation with
photographs from various angles.

Step 5: After the accident area has been secured, warning devices put in
place, assistance rendered to injured person(s) (if any), and law
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 enforcement personnel contacted, you (the employee) should
communicate the
accident to your supervisor.

Step 6: Complete Incident Report Form (Non Vehicle) at the scene of the
accident. (See Appendix 1 for Incident Reporting Form)

4. Making Statements

Following an accident or incident, the involved employee may be contacted by a

number of people seeking information. The employee is should contact his or her
immediate supervisor before making a statement or discussing the incident with
anyone other than law enforcement personnel.

5. Conducting Interviews
Accident Investigators should conduct interviews of all witnesses to any
accidents. The interviews should be conducted in a quite and private
location. It is essential to get preliminary statements as soon as possible
from all witnesses. Investigators should not provide any facts to the
witness - only ask non-leading questions. Proper interviewing techniques
include the following:
1. Explain the purpose of the investigation (accident prevention)
and put each witness at ease.
2. Listen, let each witness speak freely, and be professional,
courteous and considerate.
3. Take notes without distracting the witness.
4. Use sketches and diagrams to help the witness.
5. Emphasize areas of direct observation.
6. Do not argue with the witness.
7. Record the exact words used by the witness to describe each
observation.
8. Identify each witness (name, address, etc)

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 10.0 Accident Review
(Enter Entity name here) is committed to the fair and equitable treatment of its
employees. This commitment includes the fair judging of causes in all accidents.
The accident review, conducted by the Safety/Loss Control Committee, is used to
analyze data and determine the causes and corrective actions necessary to prevent
reoccurrence. For accidents involving (Enter Entity Name Here) vehicles and
drivers, the Committee will determine if the accident was preventable or non-
preventable.

1. Safety/Loss Control Committee Responsibilities

After the accident investigation has concluded, the Committee will convene as
soon as possible to objectively consider evidence presented and determine the
true cause of the accident. The Committee's findings and recommendations
provide guidance for management decisions on loss control policies. The
Committee will take the following steps in reviewing accidents:

1. Analyze the data obtained in the initial accident

investigation and police reports.
2. Repeat any of the prior steps, if necessary.
3. Determine
a. Why the accident occurred
b. A likely sequence of events and probable
causes
4. Determine the most likely causes
5. Conduct a post-investigation briefing
6. Prepare summary report to determine cause of
accident and recommendations for corrective action
and submit to management

11.0 Investigation Report

An accident investigation is not complete until a final formal report is prepared by
The Safety Loss Control Committee and submitted to management. To be and
effective tool, an accident report should be clear and concise. The purpose of the
investigation is to prevent future accidents. The following outline will be useful in
developing the information to be included in the formal report.
1. Background Information
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 a. Where and when the accident occurred
b. Who and what were involved
c. Operating personnel and other witnesses
2. Account of the Accident (What happened?)
a. Sequence of events
b. Extent of damage
c. Accident type
d. Agency or source (of
energy or hazardous material)
3. Discussion (Analysis of the Accident - HOW; WHY)
a. Direct causes (energy sources; hazardous
materials)
b. Indirect causes (unsafe acts and conditions)
c. Basic causes (management policies; personal or
environmental factors)
4. Recommendations (to prevent a recurrence) for immediate and
long-range action to remedy causes.

12.0 Record Keeping

All accident reports will be maintained on file permanently. They shall receive
timely review by management to ensure proper corrective actions have been
taken.

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 Appendix 1 – Incident Report Form

Appendix 1

Sample Report of Incident Form

 Appendix 1 – Incident Report Form

Report of Incident
Incident Date: Incident Time:
File Number: Department Use Only:

Entity Employee Information (You may complete this section at your office)
Name: Date of Birth:
Job Title: Employing Department/MailCode: Work Phone Number:

Incident Details (to be completed at the scene of incident)

Location of Address: City: State: Area Code:
Accident/Incident
Weather
Conditions:

WITNESSES (To be completed at the scene of incident)

Name Address Phone Number

Name Address Phone Number

Name Address Phone Number

Describe How This Incident Occurred

Was There Any Additional Property Damage?

 Appendix 1 – Incident Report Form

Check & Name Agencies Responding to the Incident Scene

Fire Ambulance Highway Patrol City Police Sheriff Other

Was a Report Made? Yes No Incident Report Number:

Name Address
Investigating Agency:
Date & Time County Operator was Notified of Incident

Signature of Entity Employee Date

To Be Completed by Supervisor
Supervisor’s Name: Phone Number:
In Your Opinion, Could This Incident Have Been Prevented? Yes No If YES, explain:

Comments or
Recommendations:

Signature of Supervisor Date

Additional Comments:
 Appendix 2

Insurance Loss Notice Form

Fleet Safety Program
 Fleet Safety Program
Policy Statement

(Enter Entity Name Here) is committed to instituting and maintaining a Fleet Safety
Program. The goal of the Fleet Safety Program is to take the proper steps to prevent loss of life, injury, or
property damage to all employees and members of the general public. (Enter Entity Name Here) recognizes
that the responsibilities for safety and loss prevention must be shared by everyone.

Responsibilities

1. Management

• Assume responsibility for the driving record of employees while they are on duty.
• Frequently check for compliance of the established requirements and policies in which all
personnel are required to adhere to.
• Personally review the decisions on accidents and take all steps necessary to prevent a recurrence.
• Establish and adhere to policies on disciplinary actions in accordance with the policy regarding
actions that will be taken against employees who show a repeated disregard for good driving
practices.
• Insist that all assigned vehicles are maintained adequately for safe operation.
• Establish periodic inspection of assigned vehicles for safety discrepancies, malfunctions, signs of
abuse, unreported damage and cleanliness. Have repairs made as soon as possible.
• Fully support the (Enter Entity Name Here)’s driver training program to promote defensive
driving.
• Review each preventable vehicle accident and unsafe driving report with the employee and his
supervisor to emphasize management's intolerance of irresponsibility behind the wheel.
• Establish an aggressive campaign to enforce the wearing of seat belts on all trips.

2. Supervisors

• Insure that employees do not drive any (Enter Entity Name Here) vehicle unless they have a
VALID Drivers' License and are familiar with (Enter Entity Name Here) driving rules and
regulations.
• Insure that only authorized personnel be allowed to operate (Enter Entity Name Here) vehicles,
special purpose vehicles, and trucks.
• Must be alert in observing unsafe practice of employees and insure that action is taken
immediately to correct the driver.
• Review all preventable vehicle collisions with employees at Safety Meetings and discuss each
unsafe act that was responsible.
• Periodically ride with the vehicle and truck drivers to check for compliance with operating
instructions and traffic regulations.
• Insure that unsafe vehicles are not driven until safety discrepancies have been corrected.
• Fully utilize the decisions and recommendations handed down by the Safety/loss Control
Committee.

SECTION 3 - 1

State of West Virginia

Board of Risk and Insurance Management
 3. Employees

Employees who drive (Enter Entity Name Here) vehicles are responsible for following all of the
guidelines set forth in the Fleet Safety Program. (See Appendix 1 for Sample Vehicle Policy and
Procedure Acknowledgement Form) These responsibilities include:

• Safe operation of vehicles and for the safety of passengers and cargo
• Having a valid driver's license in their possession
• Inspecting the vehicle which they are about to drive, in accordance with established policies
• Reporting any vehicle accidents

4. Safety / Loss Control Officer

The Safety/Loss Control Officer will be in charge of implementing the policies the Fleet Safety Program.
Responsibilities will include:

• Monitoring the driving experience of employees who operate entity vehicles.

• Be sure proper maintenance procedures are being followed to keep vehicles in a safe operating
condition.
• Verify that adequate insurance limits are maintained by drivers who use their personal vehicle for
entity business.

Operator Responsibilities

The driver is responsible for checking the safety and general condition of the vehicle , including gas, oil, and
other fluid levels, lights, and brakes. With the assistance of the Safety/loss Control Officer, supervisors will
furnish vehicles with inspection checklists (See Appendix 2 Sample Vehicle Inspection Checklist and
Appendix 3 Sample Vehicle Maintenance Acknowledgement Form). If there is something wrong with the
vehicle, which may affect safety, repairs will be made before use.
1. Vehicle Abuse
No employee will use a vehicle or equipment for any purpose for which it was not designed, operate
it beyond its designed limits, operate it in areas or locations for which it was not designed, or cause
damage through neglect, misuse, improper driving techniques, or improper handling.
2. Transporting Employees in (Enter Entity name here) Vehicles
No more than (Enter Answer Here) employees will ride in the front seat or cab of a vehicle. Each
position will be equipped with a seat belt, and each person will use the seat belt provided. No
employee will be authorized to ride or work from the bed or rear of a vehicle while it is in motion.
3. Traffic Laws
Employees will adhere to all traffic laws and regulations when operating (Enter Entity Name Here)
vehicles. An employee will at all times operate (Enter Entity Name Here) vehicles in such a manner
as to avoid injury to persons or damage to property.

SECTION 3 - 2

State of West Virginia

Board of Risk and Insurance Management
4. Unauthorized Use of Vehicles
(Enter Entity Name Here) vehicles are to be used for (Enter Entity Name Here) business only.
Persons found using (Enter Entity Name Here) vehicles for their personal errands may be subject to
disciplinary action.
5. Operation and Occupancy of Entity Vehicle by Unauthorized Persons
Employees will not permit unauthorized employees or non-employees of (Enter Entity Name Here) to
ride in (Enter Entity Name ere) vehicles, except when such persons are conveyed in the performance
of duty, or authorized to ride by supervisory staff.
6. Parking Vehicles
All employees will park their vehicles in a legal and proper manner. Employees will remove the keys
and lock the vehicles, except when specifically instructed otherwise. Employees will not park on the
wrong side of a street or highway, unless it is mandatory to park in such a location to perform a job.
All signs, cones, lights, and warning devices as required by law will be used when vehicles are
parked or in use in a public travel lane. Employees will use all safety brakes, lockout devices, and
other parking safety methods when parking equipment.
7. Use of Personal Vehicles for (Enter Entity Name Here) Business
Supervisors will identify and authorize those employees who are required, as part of their normal job
duties to use their personal vehicle to conduct (Enter Entity Name here) business. The employee’s
own insurance policy is the primary coverage and, therefore, (Enter Entity Name Here) will not be
responsible for any claims that arise out of any motor vehicle accident that the employee is involved
while operating their personal vehicle. The mileage reimbursement the employee receives is
intended to fully cover all costs of the operation of the employee’s personal vehicle including but not
limited to fuel, maintenance, repairs, insurance, etc.
8. Transporting Equipment
Employees using (Enter Entity Name Here) vehicles will exercise caution when transporting
equipment, packages or other materials in the driver/passenger compartment that would became
flying projectiles in the event of an accident. Such items as briefcases, laptop computers, tools, etc.
need to be transported in the trunk of passenger vehicles. Pickups, whether standard cab or extended,
should have secured storage capabilities in the bed of the vehicle such as tool storage or camper
shells if they are used with any regularity in the transport of items that could injure the driver or
passenger(s) in the event of an accident. Vans used in the regular transport of such items should have
screen type barriers between such cargo and the driver/passenger compartment. It is always
important to keep the driver/passenger as free as possible of objects that could distract their attention
or could cause from unexpected movement.

SECTION 3 - 3

State of West Virginia

Board of Risk and Insurance Management
 Driver Selection
(Enter Entity Name Here) believes knowing the ability, experience and attitude of drivers is a key factor in
the selection process. An important area in this process is to establish qualification standards for new
employees and existing employees that have driving duties. To enforce these standards, (Enter Entity Name
Here) has implemented the following driver qualification procedures.

1. Driver Age Requirements

All drivers must be a minimum of (enter your answer) years of age.

2. Application for Employment

All driver applicants shall complete an Application for employment and Driving Position Supplement
containing all of the information required for positions in which driving is required. (See Appendix 4
Sample Driver Application Supplement)

(Enter Entity Name Here )'s hiring standards also require that driver applicants list all former
employers for the past (enter number of years) years. Any gaps in employment for more than a (enter
your answer) period must be satisfactorily accounted for on the application.

3. License

(Enter Entity Name Here ) will obtain a legible copy of the license of all driver applicants. A review of
the license will be conducted to be certain it is valid, has not expired, and is the appropriate for the class
of vehicles in which driving is required.
Whenever driving (Enter Entity Name Here) vehicles or operating their personal vehicle for (Enter Entity
Name Here) business, employees must have in their possession a valid driver's license. Employees will
notify their supervisor if their license is suspended, revoked, or expired.
Employees who drive vehicles, which require a Commercial Driver’s License (CDL), will comply with
the West Virginia State Department of Motor Vehicles' requirements for medical examinations and
license renewal.
Supervisors will maintain a system that insures all employees operating vehicles have the proper class of
license and check licenses for current status at frequent intervals.

4. MVR Check and Evaluation

(Enter Entity name ) will request an MVR for driver applicants being considered for employment in
which driving entity vehicles or operating their own vehicle for entity business will be required. An MVR
will be requested from every state the applicant has lived in during the past (enter number of years) years.
The Safety/Loss Control Officer will review all MVR information to determine if driver applicant meets
the qualification standards regarding driving records. (See Appendix 5 Sample Authorization for MVR
Form)

A formal review of the driver’s MVR will be conducted on a/an annual basis (or more frequently where
warranted) to ensure that existing drivers are meeting the established qualification standards.

SECTION 3 - 4

State of West Virginia

Board of Risk and Insurance Management
 MVR’s are personal and confidential and should only be discussed with the driver or other persons
authorized to know. The Safety/Loss Control Officer will receive results of the MVR check and any
needed corrective action will be applied in a timely manner.

5. Driver Qualification Standards

To ensure that potential new and existing drivers meet (Enter Entity Name Here)’s qualification standards
for motor vehicle records set forth in the Commercial Vehicle Safety Program, the following policies
have been instituted regarding:

1. Actions taken based on the number of points and violations shown from the MVR checks and
evaluations
2. Standards and penalties for drivers involved in preventable accidents.

(Enter Entity Name Here) has established a point structure system to evaluate potential new and current
driver motor vehicle records.

If a driver meets or exceeds (enter number here) points total within the previous (enter number of years) or
exceeds (enter number here) points within the previous (enter time interval here), he/she will not be
eligible to drive (a/an) (Enter Entity Name Here) vehicle.

If the MVR reveals (enter violation or number of points here) then the following corrective action will be
taken:

(Enter answer here)

No potential new or existing driver will not be allowed to drive (a/an) (Enter Entity Name Here) vehicle or
other vehicle on (Enter Entity Name Here) business if there MVR reveals:

(Enter violations here)

Each employee involved in a preventable, at fault vehicular accident, whether it involves the public or not,
will be required to:

(Enter answer here)

An employee who receives any moving violation must notify his/her supervisor of the incident within
(enter number here) days. Any corrective action will be evaluated based on the type and severity of the
incident. (See Appendix 6 for a Sample MVR Check and Point Structure Plan)

SECTION 3 - 5

State of West Virginia

Board of Risk and Insurance Management
6. Investigation of Previous Employment

(Enter Entity Name Here ) will contact all former and current employers of the driver applicant for the
previous (enter number of years) years to verify as much of the following information as possible:

• Dates of employment
• Type of work performed
• Type of vehicle(s) operated
• Extent of driving experience
• Vehicle accident record
• Overall work history and performance

All former and current employer information gathered from the inquiries must be in writing and will be
retained in the driver's (if hired) qualification file. In the event a former or current employer refuses to
release information, a note stating this will be placed in the file.

The Safety/ Loss Control Officer will review all former and current employer information to determine if
the driver applicant meets the hiring standards regarding past and current employment, and to determine if
the applicant was truthful about information listed on the employment application.

7. Driver Performance

(Enter Entity name) requires all driver applicants who will require a CDL license for their driving position
to successfully complete a road test examination conducted by (enter your answer) prior to an offer of
employment. Note: the road test may be waived if the employee will only be driving automobiles and mini
vans and has a clean driving record. The road test examination shall be performed in the type of vehicle
the driver will operate. Performance will be monitored during the selection process as well as at periodic
intervals throughout the driver’s career using information obtained form motor vehicle records and file
data.

8. Driver Qualification File

The driver selection process includes developing a driver qualification file. Elements of this file will include
such items as:

• Employment Application
• Interview notes
• MVR checks
• Driver training information
• Driver evaluation and performance reviews

SECTION 3 - 6

State of West Virginia

Board of Risk and Insurance Management
 Driver Training and Reviews

(Enter Entity Name Here )'s goal is to have a process in place to hire only qualified and safe drivers. Once
on board, (Enter Entity Name Here) is committed to retaining these drivers. In order to keep drivers and
supervisors well trained and informed, (Enter Entity Name Here) has instituted a number of policies
regarding driver training. These policies include driver orientation, periodic driver meetings, and driver
performance evaluation and reviews.

1. Driver Orientation

(Enter Entity Name Here ) has an orientation program which all new drivers are required to complete.
The orientation program consists of comprehensive classroom training that will cover a variety of
subjects. Among the topics are established driving policies and procedures, regulatory compliance,
vehicle maintenance and inspections, accident reporting procedures, and defensive driving procedures
(See Appendix 7 Defensive Driving Policy and Appendix 8 for Defensive Driving Course Completion
Form).

After successfully completing the classroom portion of the orientation, all new drivers will be assigned to
a driver trainer. The purpose is to evaluate the new employee's overall driving skills and techniques, and
to apply what has been learned in classroom to an actual job situation. This time should also be used to
familiarize the new driver with paperwork procedures relating to vehicle maintenance and inspections and
to answer any questions or concerns that were not addressed in the classroom training.

2. Driver Meetings

Every (enter time interval), a drivers meeting will be conducted by driver supervisors. These meetings
between supervisors and drivers are held to share news and information, and to give our drivers a forum
to discuss issues, questions, or concerns. All drivers are expected to participate in these meetings, and all
driver input is welcomed and appreciated.

3. Driver Evaluation and Performance Reviews

Driver supervisors are responsible for conducting a periodic, structured performance review with each of
their drivers a minimum of every (enter your answer) months.

It is important for (Enter Entity Name Here) drivers to understand that their performance will be
evaluated on an on-going basis, and they may request, or their supervisor may recommend, a review at
any time. However, all drivers will receive periodic structured reviews of their individual performance.

4. On Road Performance Evaluation

The on road evaluation is conducted by the supervisor to monitor the performance of current drivers by
riding with them or following them. The supervisor should document the results and counsel drivers
concerning problems or deficiencies that were observed. This is the best way for the supervisor to ensure
that the driver is following the proper vehicle inspection and defensive driving procedures.

SECTION 3 - 7

State of West Virginia

Board of Risk and Insurance Management
5. The Performance Review

Driver performance reviews should be held in private and away from the operation area. The review is
considered the driver's time and interruptions should not be allowed.

The actual driver performance review should cover, but is not limited to, five basic areas. These are:

1. The measurement of the driver's actual results against established goals and standards of the
company.
2. Recognition of the driver's contributions and accomplishments.
3. Correction of any new or existing performance problems.
4. Establishment of goals or standards for the next review period.
5. Review of Driver’s MVR

Once the driver and his/her supervisor have concluded their discussion of past performance; addressed any
development, training, or corrective action needs; and have established new goals and standards for the
future, they are expected to reach mutual agreement and wrap up the review. The wrap-up should include
the following:

1. A positive summary of the performance review discussion including all mutually agreed upon
plans and goals.
2. An opportunity for the driver to react, ask questions, and give additional ideas and
suggestions.
3. A sincere and meaningful expression of appreciation for the driver's participation, time, and
efforts.
4. A written record of what was discussed, agreed upon, and corrective action/training plans.

6. Recordkeeping

A copy of the written performance review and MVR check shall be given to the driver, the supervisor's
immediate manager, and the original placed in the driver's personnel file.

Accident Investigation

(Enter Entity name here) 's policy is to fully investigate any accident involving (Enter Entity Name Here)
personnel and vehicles. All accidents involving (Enter Entity Name Here) vehicle regardless of the severity
must be reported immediately. (See Appendix 9 Sample Accident Reporting Instructions and Appendix 10
Driver’s Report of Accident Form)

The investigation of minor accidents involving (Enter Entity Name Here) property only is the responsibility
of the driver and supervisor only.

The Safety/Loss Control Officer will be in charge of the investigation of accidents in which serious property
damage or death to (a/an) (Enter Entity Name Here) employee has occurred. The Safety/Loss Control Officer
will also be in charge of accident investigations in which a third party is involved. Management may initiate
any other investigations deemed appropriate.

SECTION 3 - 8

State of West Virginia

Board of Risk and Insurance Management
1. Accident Investigators

At the scene, the accident investigator(s) will carefully survey the scene, noting the position of any debris
from the accident. The investigator(s) should take photos of the scene, with careful notes of what the
photos depict. A map of the site should be drawn to scale, with any landmarks near the scene noted as to
position. Photos of all vehicle and property damages incurred from accident should be taken from all
sides, with careful notes made.

The more accurate the information provided is, the easier it is when it comes to canvassing the accident
scene. It is important that the accident investigator(s) be as objective as possible in gathering and
evaluating data from the accident scene.

2. Driver Responsibility in Accident Investigation

Certain driver responsibilities must be carried out at the scene of an accident.

Two main concerns at the scene of an accident are to deal with immediate problems and to gather and
report pertinent accident information promptly. These two items can be broken down into a 6-step
accident procedure for drivers to follow.

Step 1: Stop, stay calm

Step 2: Turn on your emergency flashers as an immediate warning signal. Then

do a quick evaluation of accident victims, if any, and provide assistance.
Next, set out emergency warning devices on the roadway.

Step 3: Either contact local law enforcement personnel and your supervisor
yourself or arrange to have someone do it for you. Be courteous and
cooperative when providing information to authorities. Never admit
guilt or liability at the scene of an accident. Never leave the scene of an
accident.

Step 4: Write down names, license numbers and other information regarding the
accident and those people involved in it. Draw a simple diagram of the
accident scene. The more detail you can provide, the better it will be for
insurance and/or legal purposes later. If you have a camera for use at the
accident scene, document the situation with photographs from various
angles.

Step 5 : After the vehicle has been secured, warning devices put in place,
assistance rendered to injured person(s) (if any), and law enforcement
personnel contacted, you (the driver) should communicate the accident
to your supervisor.

Step 6 : Complete Vehicle Accident Report Form at the scene of the accident.
(See Appendix 10 for Driver’s Report of Accident Form)

SECTION 3 - 9

State of West Virginia

Board of Risk and Insurance Management
 Vehicle Accident Review

The Safety/Loss Control Committee will review all vehicle accidents to determine the true cause and
whether it was preventable or non-preventable. A preventable collision is one in which the driver failed to
do all that could be reasonably expected of them to avoid the collision (See Appendix 11 Guidelines for
Determining Preventable/Non-preventable Accidents).

The functions of the Committee in reviewing vehicle collisions are as follows:

1. Convene as soon as possible after a collision involving a/an (Enter Entity Name Here) vehicle to
objectively consider the evidence presented. This evidence includes any information given by the
driver, his or her supervisor and the police report of the accident. These same rules also apply to any
employee officially authorized to drive his or her personal cars on official (Enter Entity Name Here)
business.

2. Determine the true cause of the collision and whether it was preventable or non-preventable.

3. Review the driver's past driving record.

4. Report in writing to Management the Committee's findings, and the recommendations for corrective
action.

5. In the case of a preventable ruling, schedule a personal one-to-one meeting with the driver to discuss
the decision, possible remedial training, and/or possible disciplinary action. This meeting will be
scheduled as soon as possible after the preventability determination has been made.

Vehicle Selection

It is important to ensure that vehicles selected for a specific function are adequate in design and capability
for the intended purpose. It is the responsibility of each driver to select the appropriate vehicle to be used in
performing tasks.

Vehicle Maintenance

It is the policy of (Enter Entity Name Here) to keep all vehicles well maintained and in safe and efficient
operating condition at all times. The specifics of that approach will be detailed in the procedures to follow.

1. Preventative Maintenance

A good preventive maintenance program lowers repair frequency and lowers overall maintenance cost.
(See Appendix 12 Sample Monthly Vehicle Maintenance and Inspection Schedule)
The service portion of Preventive Maintenance is actually scheduled maintenance.
(Enter Entity Name Here) vehicles will be given Preventive Maintenance according to the following
schedule:

(enter time interval here)

SECTION 3 - 10

State of West Virginia

Board of Risk and Insurance Management
 Vehicle Inspections

(Enter Entity Name Here) is committed to following a strong daily inspection program. All vehicles are to
be inspected every day they are operated.

1. Driver Pre-trip Inspection

Each driver must be satisfied that his/her assigned vehicle is in proper working condition prior to
operating (See Appendix 2 Vehicle Pre-Trip Inspection Report). Each driver must also be satisfied that
any cargo is properly distributed and secured.

The driver will also review the last completed Driver's Vehicle Inspection Report to verify that any
needed repairs were made to the vehicle. If the defects noted were not acknowledged by an authorized
signature, the driver shall not drive the vehicle until the defects are handled appropriately.

When a driver reports safety related problems or vehicle damage, the vehicle inspection report should be
submitted to his/her Supervisor. The Supervisor will sign the report indicating that repairs have been
made (or are not required to be made). The original inspection report and certification of repairs will be
retained in the Vehicle Maintenance File.

The original inspection reports on which no defects were noted and on which defects were noted, and the
certification of repairs, will be retained in the Vehicle Maintenance File.

2. Driver On-The-Road Inspections

Once on the road, the driver must examine any cargo and its load securing devices and make any
necessary adjustments.

If a problem is found, the driver will notify his/her supervisor and either have the necessary repairs or
adjustments made prior to operating the vehicle, or safely travel to the nearest repair facility.

Vehicle Maintenance File

A complete record on each vehicle in the fleet will be kept. It will include basic vehicle information and
information indicating the nature and due date of any inspection and maintenance operations to be performed
on the vehicle, and a record of any inspections, repairs and maintenance performed on the vehicle in
question, including dates performed and specifics on the nature of the operations.

SECTION 3 - 11

State of West Virginia

Board of Risk and Insurance Management
 Vehicle Breakdown

Driver's responsibilities when a breakdown happens include:

• Safely stopping and securing the vehicle and load,

• Safely placing the warning devices,
• Diagnosing and calling in the breakdown to his/her Supervisor

Supervisor responsibilities when a breakdown occurs include:

• Determining the nature of the breakdown and best course of action

• Locating, contacting, and dispatching a vendor to facilitate repairs
• Obtaining all vehicle repair records

SECTION 3 - 12

State of West Virginia

Board of Risk and Insurance Management
 BRIM Fleet – APPENDIX 1

Appendix 1

Sample Policy and Procedure Acknowledgment Form

 BRIM Fleet – APPENDIX 1

Sample Policy and Procedure Acknowledgement Form

I have received the proper training in the fleet safety policies and procedures. I understand that
it is my responsibility to adhere to these policies. I also understand that it is my responsibility
to observe all policies and procedures concerning the proper and safe operation of an entity
vehicle.

__________________________
Driver Name (Print)

__________________________
Driver Signature

__________________________
Date

__________________________
Supervisor Signature

__________________________
Date
 BRIM Fleet – APPENDIX 2

Appendix 2

Sample Vehicle Pre-Trip Inspection Report

Vehicle Pre-Trip Inspection Report

 BRIM Fleet – APPENDIX 2
Driver: Today’s Date:
Vehicle ID No: License Plate No:
Expiration Date: Odometer Reading:
X – Satisfactory O – Requires Attention
DATES
VEHICLE INSPECTION:
PRE-START UP am pm am pm am pm am pm am pm Comments
Check Oil
Radiator, Washer Fluid
Battery Fluids, Connections
INTERIOR (Start Engine)
Fuel Level
Alternator Function
Heat/ Defrost/ AC
Interior Lights
Upholstery, Loose Object
Child Car Seats/Booster
Seatbelts/ Straps/ Cutter
First Aid Kit/Body Fluids Kit
Fire Extinguisher
Emergency Exits/Doors
Registration/ Insurance
Radio/Cell Phone
Horn
Brakes (Travel, Feel)
Steering Wheel (Play)
WINDOWS/MIRRORS
Cleared of Ice/Snow
Foot Brake/ Parking Brake
Wipers/Washers
Mirrors/ Glass/Scraper
EXTERIOR
Head Lights (High/Low)
Turn Signals (Front/Rear)
Emergency Flashers
Tires (Wear, PSI w/gauge)
Tail Lights/Back-Up Lights
Exhaust (Sound, Emissions)
TRUNK/STORAGE AREA
Spare Tire (Pressure)
Emergency (Chains, Flares,
Flashlight, Blankets)
UNDER VEHICLE
Obvious Leaks
Loose/Hanging Objects
OPERATION
Lift
Transmission
Engine/Idle Speed
DRIVER’S INITIALS
 BRIM – APPENDIX 3

Appendix 3

Sample Vehicle Maintenance Acknowledgement Form

 BRIM – APPENDIX 3

Sample Vehicle Maintenance Acknowledgement Form

I have received the proper training in daily vehicle inspection procedures. I understand that it is
my responsibility to inspect all fluid levels, lights, tires, and safety equipment each day before I
use the vehicle. I understand that it is my responsibility to report any and all vehicle defects
and safety concerns. I also understand that it is my responsibility observe all policies and
procedures concerning the proper and safe operation of an entity vehicle.

__________________________
Driver Name (Print)

__________________________
Driver Signature

__________________________
Date

__________________________
Supervisor Signature

__________________________
Date
 BRIM – APPENDIX 4

Appendix 4

Sample Employment Application

Driving Position Supplement
 BRIM – APPENDIX 4

Applicant Name: Date:

Present Street Address: Social Security:

City: State: Zip Code: How Long? Telephone Number:

Previous Street Address if less than three years at present address:

City: State: Zip Code: How Long? License Restrictions:
Yes No

If YES, List Restrictions:

Employment Application Driving Position Supplement

Driver Licenses (List all licenses in the spaces below)
State License Number Expiration Date

Traffic Violation Record (List all Traffic Convictions & Forfeitures in the past 3 years except Parking Violations)
Location Date Court Charge Penalty

Has your License or Permit to Operate a Motor Vehicle ever been suspended or revoked? Yes No
When Where Why

If YES,

Accident Record (List all accidents in which you have been involved in the past 3 years)
Date Location Description

Driver’s Signature Date

 BRIM – APPENDIX 5

Appendix 5

State of West Virginia

Request for Driving Record
 BRIM – APPENDIX 5

DMV-101-PS WEST VIRGINIA DIVISION OF MOTOR VEHICLES

Rev.12/99
DRIVER IMPROVEMENT SECTION
1800 Kanawha Boulevard, East, Building 3
Charleston, WV 25317

REQUEST FOR DRIVING RECORD

This form may be used for multiple requests, and a fee of $5.00 per name must accompany each request. Driver's license number and
last name must be provided. If you do not have the Driver's license number, you must provide the social security number and an
additional $1.00 fee. All fees are non-refundable.

Driver's License Number Name Purpose Social Security Number

I hereby certify the driving records shall be used only for the purpose indicated. This department may furnish driving records only
under the following circumstances. Please use these codes.

Purpose Code
1. Employment Investigation EI
2. Underwriting Insurance INS
3. Credit Transaction CT
4. Legitimate Business or Legal Transaction BT
5. Individual Request ID

If you are requesting a record for another individual and your reason does not pertain to any of the above codes, you would need a
waiver signed by the individual.
If you do not have a waiver signed, your reason will be reviewed and if accepted, you will receive a driving record which excludes
all personal information from the record. Under purpose you would put OPT.
Any person who knowingly or willfully obtains information under false pretenses will be in violation of federal law, and if convicted,
will be fined not more than $1,000 and/or imprisoned not more than one year.
You may duplicate this form or contact the Division of Motor Vehicles for additional forms by phoning (304) 558-3900.
Walk-In:
You must have a driver's license or WV Identification Card as proof of identification.
I hereby certify that the information obtained from the Division of Motor Vehicles will be used for the sole purpose stated above.

Signature of Requester: ID Verified By:

Employee Name & ID Number
(Attach copy of Identification to each Request Form)

NOTARY STATEMENT BELOW MUST BE COMPLETED ONLY IF REQUEST IS MAILED:

I hereby certify that the information obtained from the Division of Motor Vehicles will be used for the sole purpose stated above.

Signature of Requester:
Address of Requester:
Notary Statement: State of County of . I certify that the Requestor has provided
identification to me by driver's license or West Virginia ID and signed this form before me this day of
. My commission expires .

Notary Public
 BRIM – APPENDIX 5
(Attach copy of Identification to each Request Form)
 BRIM – APPENDIX 6

Appendix 6
Sample MVR Check and
Point Structure Plan
 BRIM – APPENDIX 6

MVR Check and Point Structure System

MVR Check

If a potential employee will be required to operate an entity vehicle as part of his/her job requirements, an MVR
check must be completed either by The Safety/Loss Control officer or the supervisor for that employee before
an employee may be offered employment.

A point system structure has been established to evaluate new hire and current employee motor vehicle records.
If a potential new employee meets or exceeds seven (7) points total within the previous three (3) years or
exceeds four (4) points within the previous 12 months, they are not eligible for a position that requires driving
an entity vehicle.

The same point policy applies to existing employees as in the hiring process in terms of points assigned to
traffic violations or motor vehicle offenses. Driver must not meet or exceed seven (7) points accumulated in a
three (3) year period. Motor Vehicle Records will be obtained on all entity vehicle drivers every twelve
months. Each MVR received will be reviewed in a timely manner and evaluated for compliance. A copy of all
records will be maintained in the employees file along with any corrective action documentation.

Point Structure

Automatic Disqualification to operate an entity vehicle

No potential new or current employee will allowed to drive An entity vehicle (including personal vehicle) for
entity business if his/her MVR reveals:

• Murder or assault with a motor

• Theft of a vehicle
• Hit and run
• Negligent homicide
• An alcohol related offense in the last 3 years
• Illegal drug offense in the last 3 years

7 point offenses:
• DWI, DUI, OWI (alcohol or drugs)
• Reckless driving resulting in bodily injury or property damage
• Fleeing a police official
• Leaving the scene of an accident
• Driving with a suspended/cancelled/revoked license
• Racing on public road

4 point offenses:
• Speed in excess of 15 mph over posted speed limit
• Failing to stop for a school bus
• Failing to stop at a railroad crossing
• Second preventable accident
 BRIM – APPENDIX 6

3 point offenses:
• Failure to obey a traffic control device
• Failure to yield right of way
• Speed too fast for conditions
• Following too close
• Careless/Reckless driving
• One preventable accident

1 point offenses:
• Seat belt violations
• Failure to use turn signal
• Improper stop/parking
 BRIM – APPENDIX 7

Appendix 7

Sample Defensive Driving Policy

 BRIM – APPENDIX 7

Defensive Driving Policy

(Enter Entity Name Here) is strongly committed to a sound and thorough defensive driving policy.

While operating entity vehicles, drivers should always drive in the safest manner possible. Specifically, our
drivers must operate entity vehicles in accordance with all provisions of The Commercial Vehicle Safety
Program.

Full-time and designated part-time employees driving (Enter Entity Name Here) vehicles shall be required to
attend the Defensive Driving Course.

1. Assignments for classes shall be made by the employee's supervisor to

insure class quotas are met and to maintain satisfactory work schedules.

2. Frequency of employee attendance of Defensive Driving Courses shall be once per year.

3. New employees required to drive Entity vehicles shall be required to complete the
Defensive Driving Course satisfactorily before starting their driving assignment.

The core concepts of defensive driving are:

• Recognize the hazard.

• Understand the defense.
• Act in time.

Defensive Driving Procedures

Intersection

Getting into and out of intersections without an accident is a mark of a good defensive driver. Besides your own
skill level, intersections also demand anticipation of the actions of other drivers and taking appropriate evasive
action as required.

Backing

Backing is an extremely hazardous maneuver. If you are backing with the assistance of a guide, the ultimate
responsibility for the safety of the backing maneuver remains with you as the driver.

Front-End Collisions

The primary way to avoid front-end collisions is by maintaining a safe and adequate following distance. You
should be prepared for possible obstructions on the roadway, either in plain sight or hidden by curves or the
crests of hills. A special situation occurs at night, when speed should be kept to a level that will allow you to
stop within the distance illuminated by the headlights of your vehicle.

Rear-End Collisions

As a driver, you risk being struck from behind if you do not maintain an adequate margin of safety in your own
following distance. If enough space is not allowed in front of your vehicle, chances go way up that somebody
 BRIM – APPENDIX 7
can (and will) impact you from the rear.

Passing

Failure to pass safely indicates faulty judgment on your part as a defensive driver, and failure to consider one
or more of the factors that need to be checked:

• Is there enough room ahead?

• Is there adequate space to move back into your lane of traffic after passing?
• Have you signaled your intentions?

Being Passed

As a driver, you must be aware of the actions of other drivers, and give way if another driver begins to
sideswipe you or to cut you off. A good defensive driver will avoid problems with this kind of accident
situation.

Encroaching on Other Traffic Lanes

Observant defensive drivers will not usually get trapped when other drivers change lanes abruptly. In the same
manner, entrapment in merging traffic can be successfully avoided by a good defensive driver with a little
preplanning and willingness to yield. Blind spots are not valid excuses for this kind of accident - allowances
must be made in areas of limited sight distance.

Railroad Grade Crossings

Driving across railroad crossings, or in areas where there are rail vehicles of some sort, demands special care.
Careful observance of the traffic situation is your best defense.

Oncoming Traffic

A defensive driver will avoid a collision with an oncoming vehicle at all costs. Even if the vehicle enters your
lane of traffic, an accident can be avoided with some evasive maneuvers.

Turning

Turning, like passing, is a dangerous maneuver, and demands special care and an observant eye from you as a
defensive driver. You should be aware of other vehicles in your path, and of the complete configuration of the
turn you are about to undertake.

Pedestrians

As a sensible defensive driver, always assume that if there is a pedestrian (or small vehicle of some sort)
involved in a situation, slowing down is your best defense. Be certain to give people and small vehicles the
benefit of the doubt.

Extreme Weather and Road Conditions

 BRIM – APPENDIX 7
Bad weather and other road hazards place special stress upon any defensive driver. The best rule in any kind of
bad weather or extreme road condition is get off the road safely and as soon as possible. If you absolutely must
continue, slowing way down and increasing following distance are your best defenses, along with increased
awareness.

Fog

Fog reduces available visibility and impairs distance perception, making it perhaps the most dangerous type of
extreme weather condition.

Because of this, it is the policy of ( Enter Entity Name Here) that, whenever possible, drivers are to avoid
driving in foggy conditions. Pull off the road and park safely until such time as the fog dissipates or is burned
off, if at all possible. If you cannot safely pull off the road, follow these procedures:

• You should never assume the depth or thickness of any fog. Fog can range from a momentary
blurring of the windshield to being several miles thick.
• Slow your vehicle's speed. Reduction in speed should be done gradually in order to avoid
becoming a hazard for other motorists. Determining a correct and safe speed depends on the
thickness of the fog and is left to your best judgment.
• Use low-beam headlights only when driving in fog. Low-beams serve two purposes. They help
you see the immediate roadway and also allow other motorists to see your vehicle.
• Avoid the use of high-beam headlights while driving in fog. The water particles that make up fog
will reflect more light back at you than onto the roadway when high beams are used, and will
further reduce visibility for you.
• You should make use of windshield wipers and the defroster when driving in fog. Driving in
foggy conditions will cause a constant fine mist of water to develop on the vehicle's windshield,
reducing visibility in the process. Using the windshield wipers and defroster will alleviate this
condition.
• Avoid passing other vehicles while driving in fog.
• You should avoid stopping on any roadway while driving in foggy conditions unless absolutely
necessary. If you must stop, use the emergency or breakdown lane, activate your emergency
flashers, turn off the headlights, and follow (Enter Entity name here) 's breakdown procedures
(see Vehicle Breakdown & Road Repair policy).

Rain

Rain causes roadways to become slippery, especially when it first begins. Roadways become covered with a
thin layer of oil and other residues. When rain mixes with this layer, it results in an extremely slippery and
dangerous road surface. This condition remains until additional rain can break down and wash away the oily
mixture from the pavement. This process can take anywhere from a few minutes to several hours, depending on
the severity of the rain.

Water on the road surface can also create a potential hazard of hydroplaning. Hydroplaning happens when a
thin layer of water separates the vehicle's tires from the road surface. When a vehicle is hydroplaning, it is
literally riding on water. When the tires ride on water, they lose all traction and create an extremely dangerous
situation. The faster a vehicle travels on standing water, the greater the chance of hydroplaning. Reducing
speed is the best and safest way to avoid hydroplaning.
 BRIM – APPENDIX 7
Rain also reduces visibility. Because rain presents these hazards, drivers are expected to adhere to the following
procedures when driving in rainy conditions:

• You should slow the vehicle's speed to avoid hydroplaning. Reduction in speed should be done
gradually in order to avoid becoming a hazard for other motorists. Determining the correct and
safe speed depends on how heavy the rain is and will be left to your best judgment.
• You are expected to increase your following distance from other motorists. Since rain causes the
road surface to become slippery, you need to allow for greater stopping distance if the need to
stop arises.
• You should make use of windshield wipers and the defroster when driving in rain. Driving in
rainy conditions will cause a constant film of water to develop on the vehicle's windshield,
reducing visibility in the process. Using the windshield wipers and defroster will alleviate this
condition.
• You should avoid passing other vehicles while driving in rain. In addition, you are encouraged to
follow other vehicles at a safe distance since vehicles traveling ahead will throw water off the
pavement and leave "tracks". Driving in these tracks will give you the best possible traction
under rainy conditions.

Snow

Snow, depending on the type and severity, can present a variety of dangerous conditions. Because of this, the
following procedures have been developed for this defensive driving policy:

• Light, powdery snow presents few problems since it is quickly blown of the road surface.
However if there is enough of this type of snow to cover the roadway, it will form a slick, smooth
surface. You should reduce speed and increase following distance. Determining the correct speed
and safe following distance will be left to your best judgment.
• Heavier, slushy snow can affect vehicle control. If snow becomes hard packed it can cause an ice
hazard on the road surface. Again, you should reduce speed and increase following distance.
Determining the correct speed and safe following distance will be left to your best judgment.
• All slow maneuvers such as starting out, steering, backing, and turning should be done smoothly
and with extreme care to minimize skids and slides.
• Falling or blowing snow can greatly reduce visibility. In addition, falling and blowing snow can
make it hard to see the road, road markings, road signs, and off ramps. If you must continue in
snowy conditions, reducing speed and increasing following distance are the best techniques a
driver can use to maintain vehicle control.
• As with driving in foggy conditions, the use of high beam headlights while driving in snowy
conditions should be avoided at all times. The high-beam "shooting" light will reflect off falling
and blowing snow and reflect back at you, further reducing visibility.
• Drivers will also be educated on the dangers of "snow hypnosis". Snow hypnosis occurs when a
driver is traveling directly into heavy snow and begins to focus on the falling snow instead of the
road ahead. This can cause a hypnotic-like effect on the driver. The danger of snow hypnosis is
especially prevalent at night.
• In extreme conditions, chains may be necessary

Ice
 BRIM – APPENDIX 7
All drivers need to be aware of changes in road surface conditions that may affect the vehicle's traction. To
help, the following procedures for driving on icy roads for this defensive driving policy have been developed:

• As with all extreme weather conditions, if you must continue, the safest techniques to employ are
to reduce speed and increase your following distance. But of these two, increasing following
distance is by far the most important. Depending on the temperature and road conditions,
stopping distance (distance needed to come to a complete stop) on icy roads can increase four to
ten times versus stopping from the same speed on a dry road.
• “Black Ice” forms when temperatures drop rapidly and any moisture on the road surface freezes
into a smooth, almost transparent layer of ice. What makes black ice particularly dangerous is
that you may not realize you are on it until it's too late. Determining the correct speed and safe
following distance will be left to your best judgment.
• Bridges and overpasses are other areas to which you should give special attention. Ice will tend
to form first on bridges and overpasses because cold air circulates both above and below these
structures causing the temperature to drop more rapidly than on normal roads. Any moisture on
the road surface of a bridge or overpass will freeze quicker and harder than elsewhere on the
road. Extreme caution and a reduction in speed should be used while traveling over bridges and
overpasses.

Night Driving

All drivers need to be aware of the potential hazards driving at night present. These hazards include fatigue,
reduced visibility, poor lighting, other (impaired) motorists, and animals on the road. To help drivers better
prepare for driving at night, the following procedures have been developed for this defensive driving policy:

Fatigue is perhaps the most dangerous hazard of driving at night. Nothing we do is worth any one getting hurt.
Fatigue usually sets in at night, but a tired driver, at any time of day, is an unsafe driver. Fatigue reduces drivers'
reaction time and perception. All drivers are to review the following fatigue warning signs:

• Your eyes close or go out of focus by themselves.

• You can't stop yawning.
• You are experiencing trouble keeping your head up.
• You experience short-term memory loss. For example, you can't remember the last several miles
you have driven.
• Your thoughts wander or you begin to daydream.
• You start drifting into other lanes of traffic, tailgate, or miss traffic signs.
• You experience an inability to maintain a constant rate of speed.
• You must jerk the steering wheel hard to correct a drift and get back into your lane.

If you experience any of these signs, it's time to get off the road as soon as safely possible and get some rest.

• Reduced visibility is a hazard of driving at night. At night, visual acuity (degree of perception)
and peripheral vision (side vision) are reduced, and the eyes may have difficulty adjusting from
light to darkness. These factors all contribute to reduced visibility while driving at night. The best
and safest techniques to counteract these night driving hazards are to reduce your speed and
increase your following distance. Reducing speed is also the best way to prevent "out driving"
your headlights.
• Poor lighting on the open highway or on rural roads is another hazard drivers should be made
 BRIM – APPENDIX 7
aware of. At night, with poor or no lighting aside from the vehicle's headlights, hazards in the
road are much more difficult to see and avoid. You should reduce speed and use extra caution
when traveling on poorly lit or unfamiliar roads.
• Impaired motorists (drunk drivers) are a hazard to everyone on the road. Drivers should be
especially cautious when driving between the hours of midnight and 0300 (typical bar and tavern
closing times). Drivers should be wary of motorists driving in an erratic manner including
weaving in and out of traffic lanes, having difficulty maintaining a constant rate of speed, or
braking suddenly. If you, as a driver, suspect that you are sharing the road with an impaired
motorist, reduce your speed, let the motorist pass, and increase following distance.
• Animals on the road present another kind of hazard while driving at night. Drivers are to be
especially alert when driving on roadways lined by woods or tall grass. Animals, especially deer,
can jump out in front of an oncoming vehicle with little or no warning. The best techniques to
avoid collisions with animals are to not "outdrive" your headlights and to reduce speed. If a
collision with an animal is unavoidable, you should drive "through" the animal. This will help
prevent a jackknife or rollover type accident.

Road Construction

We realizes that chances are good that from time to time our drivers will be faced with having to drive on
roadways that are being repaired or under construction. Road construction presents several hazards. Because of
this, our drivers are expected to approach road construction work zones the same way they would any adverse
driving situation and follow these procedures:

• You should reduce speed and maintain a safe following distance.

• You should drive at or under all special or reduced posted speed limits while traveling through
road construction work zones. Safe following distance will be left to your best judgment.
• You should be constantly aware of your immediate surroundings, anticipate the possible actions
of other motorists, and expect sudden stops.
• You should watch for construction workers or vehicles crossing the roadway.
• You should use the lane furthest from a construction zone when possible.
• You should avoid sudden lane changes and use headlights and four-way flashers when traveling
through construction zones.

Road Hazards

Drivers should be aware of the potential danger of encountering various types of road hazards including:

• Soft shoulders or severe pavement drop-offs that can cause rollover type accidents.
• Road debris such as tire recaps, metal or lumber can cause severe damage to tires, tire rims,
electrical systems, and brake lines. You should be aware of the road ahead to identify potential
road debris early and take safe and appropriate avoidance maneuvers.

Underpasses
 BRIM – APPENDIX 7
Hitting a bridge, underpass, or viaduct is a danger you should be constantly aware of. This type of accident,
often referred to as "topping" a trailer, is always preventable. Drivers need to be aware that the posted height
of an underpass is not always accurate. Re-paving and packed snow can reduce the clearance of an overpass
enough to cause a problem. In addition, an empty trailer will ride higher than when it is loaded. You should
make thorough trip plans. When in doubt of the clearance of an underpass, you should get out of your vehicle
and make a visual inspection or find an alternate route.

Fixed Objects and Special Intersections

A good defensive driver will observe items in the area around the vehicle that might cause problems. Checking
to be certain there is adequate clearance is the primary thing to watch. In the areas of driveways, alleyways or
plant entrances, the effective defensive driver will analyze the situation carefully, slow down, sound a warning
when appropriate, and be ready to yield to the other driver involved.

Physical and Mental Condition

Drivers are expected to manage their physical and mental condition. That especially means keeping a positive
attitude when behind the wheel, and taking good care of their physical health. Fatigue is an especially
dangerous factor to be aware of.

Following Distance

Tailgating is probably the single most common complaint lodged by the general driving public against truck
drivers. Here are some specific following distance guidelines:

• 3-second interval at speeds up to 40 mph,

• 4-second interval at any speed over 44 mph,
• add extra time in bad weather or poor road conditions,
• add extra following distance if you are being tailgated.

Driving Speed

You should drive consistent with posted speed limits, with due regard given to existing traffic, weather and
highway conditions. Never overdrive your headlights at night. That means you should be able to stop safely in
the distance you can see clearly in your headlights.

Right of Way

As a defensive driver, you should never attempt to exercise the right of way principle. Let the other driver go
first. Keep to the right except to pass, or when getting into position to turn left. In town, when you enter a main
thoroughfare from a side street, alley, driveway or a highway ramp, make a full stop at any crosswalk, then
another full stop before actually moving into traffic.

Meeting Other Vehicles

Keep to the right when meeting other vehicles on a roadway. If a vehicle approaches on your side of the road,
 BRIM – APPENDIX 7
slow down and pull to the right as far as you safely can. If you have to take this kind of evasive action, and
have actually gone off the highway onto the shoulder, be certain you slow the vehicle down sufficiently before
you attempt to come back onto the highway. Never pull to the left to avoid an oncoming vehicle.

When merging onto a highway drivers are expected to:

• Signal early,
• Be patient and watch for an opening,
• Build speed and merge smoothly,
• Check mirrors constantly.

When exiting a highway drivers are expected to:

• Signal and change into the right-hand lane early and safely,
• Signal intentions to exit early,
• Check mirrors constantly,
• Reduce speed and exit.

Curves and Turns

The biggest thing to remember in successfully negotiating curves and turns is to slow down. That way you will
be able to make any needed adjustments in steering, etc. as required.
 BRIM – APPENDIX 8

Appendix 8

Sample Defensive Driving Course Completion Form

 BRIM – APPENDIX 8

Defensive Driving Course Completion Form

_______________________ has successfully completed the Defensive Driving Course

Training. Completion of this course is required before any employee is authorized to drive an
entity vehicle. The Entity requires that this course be repeated on an annual basis for employees
to remain eligible to drive entity vehicles.

__________________________
Driver Name (Print)

__________________________
Driver Signature

__________________________
Date

__________________________
Supervisor Signature

__________________________
Date
 BRIM – APPENDIX 9

Appendix 9

Sample Accident Reporting Instructions

 BRIM – APPENDIX 9

Driver Instructions For Reporting Vehicle Accidents

Step 1: Stop, stay calm

Step 2: Turn on your emergency flashers as an immediate warning signal. Then

do a quick evaluation of accident victims, if any, and provide assistance.
Next, set out emergency warning devices on the roadway.

Step 3: Either contact local law enforcement personnel and your supervisor
yourself or arrange to have someone do it for you. Be courteous and
cooperative when providing information to authorities. Never admit
guilt or liability at the scene of an accident. Never leave the scene of an
accident.

Step 4: Write down names, license numbers and other information regarding the
accident and those people involved in it. Draw a simple diagram of the
accident scene. The more detail you can provide, the better it will be for
insurance and/or legal purposes later. If you have a camera for use at the
accident scene, document the situation with photographs from various
angles.

Step 5 : After the vehicle has been secured, warning devices put in place,
assistance rendered to injured person(s) (if any), and law enforcement
personnel contacted, you (the driver) should communicate the accident
to your supervisor.

Step 6 : Complete Vehicle Accident Report Form at the scene of the accident.
(See Appendix 10 for Vehicle Accident Reporting Form)
 BRIM – APPENDIX 10

Appendix 10

Sample Driver’s Report of Accident Form

 BRIM – APPENDIX 10

Driver’s Report of Accident

Accident/Incident Date: Accident/Incident Time:
File Number: Department Use Only:

Entity Driver Information (You may complete this section at your office)
Name: Date of Birth:
Job Title: Employing Department/MailCode: Work Phone Number:

Driver’s License Number: Expiration Date: Date Last Completed Defensive Driver Seat Belt On?
Training? Yes No

Entity Vehicle Information (You may complete this section at your office)
Vehicle Make: Vehicle Model: County Vehicle Number:

Vehicle License Plate Number: Vehicle Color: Odometer at time of accident / incident:

Describe Damages to County Minor Moderate Major

Vehicle:
Is this a rental Yes No Is this a Personal Vehicle? Yes No
vehicle? If YES, provide name of rental company

Accident Details (to be completed at the scene of accident/incident)

Location of Address: City: State: Area Code:
Accident/Incident
Road Conditions: Weather Conditions:
Traffic How fast were you Est .speed of other
Conditions: driving? vehicle:

Other Driver / Vehicle Information (To be completed at the scene of accident/incident)

Driver’s Name: Date of Birth: Driver’s License State: Expiration Date:
No.:
Home Phone Number: Work Phone Number: Number of Passengers in Other Vehicle:

Driver’s Address Street: City: State: Zip Code:

Registered Owner of Other Vehicle Home Phone Number: Work Phone Number:
(If different from Driver)

Owner’s Address Street: City: State: Zip Code:

Other Party’s Insurance Co: Address: Phone Number: Policy Number:

Insurance Info
Vehicle Vehicle Year: Color:
Make: Model:
Extent of Damages to Other Minor Moderate Major
Vehicle:
License Plate of Other Plate Number: State: Describe Damages to Other Vehicle:
Vehicle

WITNESSES (To be completed at the scene of accident/incident)

Name Address Phone Number

Name Address Phone Number

Name Address Phone Number

 BRIM – APPENDIX 10

Passengers in Entity Vehicle (You may complete this section at your office)
Name: Address: Phone Number: Describe Injury (If Applicable)

Name: Address: Phone Number: Describe Injury (If Applicable)

Passengers in Other Vehicle (To be completed at the scene of accident/incident)

Name: Address: Phone Number: Describe Injury (If Applicable)

Name: Address: Phone Number: Describe Injury (If Applicable)

Describe How This Accident/Incident Occurred

Was There Any Additional, Non-Vehicle Property Damage?

Check & Name Agencies Responding to the Accident/Incident Scene

Fire Ambulance Highway Patrol City Police Sheriff Other

Was a Report Made? Yes No Accident Report Number:

Name Address
Investigating Agency:
Date & Time County Operator was Notified of
Accident/Incident

Signature of Entity Driver Date

To Be Completed by Supervisor
Supervisor’s Name: Phone Number:
In Your Opinion, Could This Accident/Incident Have Been Prevented? Yes No If YES, explain:

Comments or
Recommendations:

Signature of Supervisor Date

 BRIM Fleet – APPENDIX 11

Appendix 11

Sample Guidelines for Determining

Non-Preventable/Preventable Accidents
 BRIM Fleet – APPENDIX 11

Guidelines for Determining

Non-Preventable/Preventable Accident
The following guidelines will be used by The Safety/Loss Control Committee for the purpose of determining
accident preventability.

General guidelines – barring extenuating circumstances and maintaining the reasonable action standards,
accidents are generally preventable if:

• Driver was inattentive or failed to accurately observe and assess existing conditions that
contributed to an accident.
• Driver’s speed was not consistent with posted (prescribed) limits or existing road, weather, or
traffic conditions.
• Driver’s speed precluded stopping within available clearances or assured clear distance.
• Driver misjudged (or did not confirm) available clearances (above, below, or on the sides)
resulting in the striking of a fixed object.
• Driver failed to control the vehicle.
• Driver failed to yield the right of way resulting in an accident (or to avoid an accident).
• Driver failed to communicate the vehicle’s presence or intended actions through the use of
directional lights (signal flashers), horn, or other means.
• Driver was in violation of company operating rules or special instructions, the regulations of any
federal of state regulatory agency, or any applicable traffic law or ordinance.

Struck in rear by other vehicle – Non-preventable if:

• Driver's vehicle was legally and properly parked: unless there were extenuating circumstances
recognizable to the alert driver whose judgment should suggest "park elsewhere".
• Driver was proceeding in his or her own lane of traffic at a safe and lawful speed.
• Driver was stopped in traffic due to existing conditions or was stopped in compliance with traffic
sign or signal, or the directions of a police officer or other person legitimately controlling traffic.
• Driver was in proper lane, waiting to make turn, and was flashing a signal indicating his or her
intention to turn.
• Driver's vehicle was disabled and was protected by emergency warning devices as required by
DOT and state regulations, or if driver was in the process of setting out or retrieving signals -
except, see "Mechanical Defects Accidents" - except, if opportunity was available for driver to
remove vehicle off road.

Preventable if:

• Driver was passing slower traffic near an intersection and had to make a sudden stop.
• Driver made a sudden stop to park, load or unload.
• Driver was improperly or illegally parked.
• Driver made any other type of unnecessary sudden stop.
• Driver's vehicle rolled back into vehicle immediately behind while starting on a grade.

Struck while parked – Non-preventable if:

 BRIM Fleet – APPENDIX 11
• Driver was properly parked in an area where permitted. - Unless there was extenuating
circumstances recognizable to the alert driver, whose judgment should suggest "park elsewhere."-
Unless there was off-the-road parking available.
• Vehicle was protected by emergency warning devices as required by DOT and state regulations,
or if driver was in the process of setting or retrieving signals. The use of 4-way flashers as
emergency warning lights under DOT regulations meets this provision for only the first 10
minutes.

Mechanical defect or breakdown accidents – Preventable if:

• Defect was of a type which driver should have detected during a proper pre-trip inspection of
vehicle.
• Defect was of a type that the driver should have detected during the normal operation of the
vehicle.
• Defect was caused by the driver's abusive operation of the vehicle.
• Defect was known to the driver but was operated regardless of this knowledge.

Side-swiped or head-on collisions – Preventable if:

• Driver was not entirely in the proper lane of travel.

• Driver did not pull to the right or left, slow down and/or stop for the encroaching vehicle lane
when such action could have been taken without additional danger and to prevent a collision.
• Driver changed lanes without ascertaining that sufficient space was available or failed to signal
intent, or give sufficient warning of intent, to change lane.
• Driver was weaving to the right or left, thus crowding the passing vehicle.

Striking other vehicle in rear collisions – Non-preventable if:

• Other vehicle rolled backward while starting on grade.

• Driver's vehicle was stopped but was hit from behind and pushed into other vehicle.

Preventable if:

• Driver failed to maintain safe following distance and have the vehicle under control.
• Driver failed to stay alert and ascertain that traffic was slowing down or that vehicle ahead was
moving slowly, stopped, or slowing down.
• Driver misjudged rate of overtaking vehicle.
• Driver came too close before pulling out to pass.
• Driver started up too soon or too fast for vehicle ahead.
• Driver failed to leave sufficient room for passing vehicle to get safely back in line.
• Driver was passing and misjudged approaching traffic, and returned to right lane too fast.

Accidents at intersection – Non-preventable if:

• Driver was stopped in compliance with traffic sign or signal or at the direction of a police officer
or other person legitimately controlling traffic.

Preventable if:
 BRIM Fleet – APPENDIX 11
• Driver failed to control speed so that the vehicle could stop within available sight distance.
• Driver failed to check cross traffic and wait for it to clear before entering intersection.
• Driver pulled out in the face of oncoming traffic.
• Driver collided with person, vehicle, or object while making a right or left turn.
• Driver collided with vehicle making turn in front of him. Driver had collision with vehicle
coming from either side, regardless of location of traffic signs or signals or whether light was
green.

Backing accidents – Preventable if:

• Driver backed up when backing could have been avoided by better route planning.
• Driver backed into traffic stream when such backing could have been avoided.
• Driver failed to get out of cab and check the immediate situation and proposed path of backward
travel.
• Driver depended solely on mirrors when it was practicable to look back.
• Driver failed to get out of cab periodically and recheck conditions when backing a long distance.
• Driver failed to sound horn while backing.
• Driver failed to check behind vehicle parked at curb before attempting to leave parking space.
• Driver backed from blind side when a sight-side approach could have been made.
• Driver failed to use a guide (spotter) to help back, or depended solely on a guide.
• Driver relinquished all responsibility to guide.

Accidents while passing or being passed – Preventable if:

• Driver passed where view of road ahead was obstructed by hill, curve, vegetation, traffic, adverse
weather conditions, etc.
• Driver attempted to pass in the face of closely approaching traffic.
• Driver failed to warn driver of vehicle being passed.
• Driver failed to signal change of lanes.
• Driver pulled out in front of other traffic overtaking from rear.
• Driver cut-in short returning to right lane.
• Driver failed to stay in own lane of traffic.
• Driver failed to hold speed or reduce speed to permit other vehicle to pass safely.

Accidents while entering traffic (merging) – Preventable if:

• Driver failed to signal when pulling out from curb.

• Driver failed to check traffic before pulling out from curb.
• Driver failed to look back to check traffic if he was in position where mirrors did not show traffic
conditions.
• Driver attempted to pull out in a manner that forced other vehicle(s) to change speed or direction.
• Driver failed to make full stop before entering from side street, alley, or driveway.
• Driver failed to make full stop before crossing sidewalk.
• Driver failed to yield right-of-way to approaching traffic.

Accidents involving pedestrians and bicycles – Non-preventable if:

• Pedestrian or bicycle driver collided with driver's vehicle while it was legally parked or stopped.
 BRIM Fleet – APPENDIX 11
Preventable if:

• Driver did not reduce speed in area of heavy pedestrian traffic.

• Driver was not prepared to stop.
• Driver failed to yield right of way to pedestrian.
• Driver failed to stop when passing a streetcar or bus on the right.

Accidents involving rail operated vehicles (railroad crossings) – Preventable if:

• Driver attempted to cross tracks directly ahead of train or streetcar.

• Driver ran into side of train or streetcar.
• Driver stopped or parked on or too close to tracks.
• Driver failed to yield right-of-way to trolley.
• Driver failed to stop at the railroad crossing.

Miscellaneous accidents – Preventable if:

• Driver was making a "U" turn.

• Driver was pulling away from the curb or other parking space.
• Driver was entering traffic from a driveway, or private alley.
• Driver was giving a push or was being pushed.
• Vehicle moved due to faulty brakes.
• Driver left vehicle unattended (with or without motor running) and failed to set parking brake
and wheel chocks.
• Collision with fixed objects - poles gates, light stanchions, etc.
• Non-collision accidents, such as an overturn, or running off road.
• Skidding accidents in which the vehicle is damaged because it jackknifes.
 BRIM Fleet – APPENDIX 12

Appendix 12

Suggested Monthly Vehicle Maintenance

and Inspection Schedule
 BRIM Fleet – APPENDIX 12

Suggested Monthly Vehicle Maintenance

and Inspection Schedule

1. Routine Service Schedule:

-Lube-Oil-Filer Every 3,000 miles
-Rotate tires and balance Every 5,000 miles

-Air Filter )
- PCV Valve )
-Brake Service )
-Front-end alignment ) Every 12,000 miles
-Engine tune-up )
-Transmission Service )

-Shock absorbers )
- Automatic Transmission ) Every 20,000 miles
drain /refill )

-Differential drain/refill ) Every 36,000 miles

- Wheel bearing package )

2. Every 3 months inspect the following: (make required repairs)

• All fan, A/C, power belts
• Radiator, heater, A/C hoses
• A/C, heater system
• Power steering
• Windshield wiper blades and arms
• Doors and windows

3. Every 6 months inspect the following: (make required repairs)

• Alternator/generator
• Battery
• Exhaust system, muffler, converter, tail pipe
• Emission control system
• Ignition system
 BRIM Fleet – APPENDIX 12
• Door locks and window mechanisms
• Fuel tank and suspension system

4. Annually inspect and/or conduct the following: (make required repairs)

• Comprehensive engine tune-up and analysis
• Comprehensive steering/brake system evaluation
• Comprehensive body/paint check
• Comprehensive evaluation of emission control system
• Drain, flush, and clean cooling system-refill
• Electrical wiring
• Suspension system
• Mechanical linkages
• Interior condition
 Contracts
and

Agreements
 Contracts and Agreements

Introduction
(Enter Entity Name Here) often enters into contracts that expose it to third-party claims
for bodily injury, personal injury or property damage. If work performed on the (Enter
Entity Name Here)’s behalf by a contractor results in damage to a third party, (Enter
Entity Name Here) could be held liable even if the contractor is solely negligent.
An important part of (Enter Entity Name Here)’s Risk Management and Loss Control
Program is loss avoidance and the transfer of risk through the terms and conditions of
contract agreements. This section explains four ways (Enter Entity Name Here) deals
with contractual risk. The topics include:
1. Screening contractors
2. Safety requirements for bid specifications and contracts
3. Contractual risk transfer through indemnification/hold harmless clauses
4. Insurance requirements

Screening Contractors
There simply is no substitute for dealing with a safety-conscious contractor
who prevents or minimizes damages and injuries through safe work
practices. All contractors will be screened carefully before entering into any contract.
Screening is probably the simplest and yet most effective method of controlling
contractual risk. The Screening steps that (Enter Entity Name Here) takes include:

1. Dealing only with reputable firms

In some cases, (Enter Entity Name Here) may request a clause may be inserted
into the bid proposal mandating contractors explain their safety program and
safety problems or violations over the past five years. Also, (Enter Entity Name
Here) may conduct a review records from other projects performed by that
contractor.

2. Check references

Bid proposals may require the contractor to disclose the name,

address and telephone number of at least three people who have hired
the contractor to do a similar job in the past five years. The bid
proposal will also provide that (Enter Entity Name Here) may contact each
reference for additional information.

SECTION 4 - 1

State of West Virginia

Board of Risk and Insurance Management
 3. Monitor compliance with contract terms

(Enter Entity Name Here) will determine if contractor's activities are consistent
with each part of the contract. However (Enter Entity Name Here) will not
monitor contracts by retaining control over the means, method and manner of
producing the result because that blurs the line between whether the contractor is
actually an independent contractor, for which (Enter Entity Name Here) may have
very limited liability, or an employee, for which (Enter Entity Name Here) may
have much greater liability.

Safety Requirements for Bid Specifications and Contracts

A key step in a major construction project is preparing the bid specifications
outlining the scope and requirements of the project. Safety requirements are a vital part of
the bid specifications.

The Contractor shall submit to (Enter Entity Name Here) a copy of the written safety
program to be used as guidelines and direction for the Contractor's and subcontractors'
activities. This program must meet all federal, state and local laws, regulations and other
legal requirements and include the following minimum provisions:

1. A worksite safety policy statement

2. Assigned responsibilities among management, supervisors and employees
3. A system for periodic self-inspections, including inspections of job sites,
materials, work performance and equipment
4. A thorough accident and injury reporting and investigation process
5. A safety orientation and training program

Indemnification/Hold Harmless Agreements

Contractual risk is generally transferred with an indemnification/hold harmless
agreement. The hold harmless and indemnification agreement should be written to take
effect immediately upon execution of the contract. It should contain provisions that
(Enter Entity Name Here) be held harmless, defended and indemnified, and should
describe the extent of such indemnification.

SECTION 4 - 2

State of West Virginia

Board of Risk and Insurance Management
 Additional Insured
Some of the recommended insurance provisions require (Enter Entity Name Here) be
included as an “additional insured” under the policies of the contractor. The contractor’s
insurance policy must be specifically endorsed to add (Enter Entity Name Here) as an
“additional insured.” Merely obtaining a certificate of insurance to this effect does not
guarantee that the endorsement has been issued, so (Enter Entity Name Here) will obtain
a copy of the actual policy endorsement whenever possible.

Insurance Requirements for Contractors

All contractors are required to maintain reasonable insurance coverage and provide
written proof of this protection. This insurance becomes especially important when the
contractor has agreed to defend and indemnify (Enter Entity Name Here).
The insurance required in the various contracts will vary and will depend on the nature of
the work being performed and the resulting exposures. Different types of contracts may
include:
1. Construction and Service Contracts
Includes projects such as most construction and remodeling, janitorial services,
on-site equipment maintenance agreements, plumbing, painting and electrical
work.
2. Tenants, Facility Use, Concessionaires and Vendors
Includes tenants, food and beverage concessionaires, space rental to lessees,
facility use, exhibitors (i.e. exhibitors within student centers) and vendors who
supply equipment or other products
3. Professional Services
Includes professional services such as architects, engineers, consultants, attorneys
or accountants.

SECTION 4 - 3

State of West Virginia

Board of Risk and Insurance Management
Insurance Guidelines
Before commencing work, the contractor shall obtain at its own cost and for the duration
of the contract, the following insurance:
1. Commercial General Liability: At least a $1,000,000 dollar combined single limit
per occurrence for bodily injury, personal injury and property damage should be
obtained. Coverage shall include, Premises and Operations, Independent
Contractors, Products and Completed Operations, Contractual Liability and Broad
Form Property Damage coverage.
2. Automobile Liability: Coverage extends to owned, hired and non-owned
automobiles.
3. Professional Liability
4. Workers’ Compensation and Employers Liability: Statutory coverage in
compliance with the Compensation laws of the State of West Virginia.

Verification of Coverage
The Contractor is required to provide (Enter Entity Name Here) with all the appropriate
written proof of insurance coverage and additional insured documentation. "Written
proof" consists of certificates of insurance and endorsements to policies.
A Certificate of Insurance must provide clear evidence that the contractor’s insurance
policies contain the minimum limits of coverage, terms and conditions. Additionally, the
certificate must include the following:

• Certificate shall clearly identify (Enter Entity Name Here) as an Additional

Insured.

• Certificate shall clearly indicate project name, project number or some easily
identifiable reference to the relationship to (Enter Entity Name Here).

• Certificate shall indicate a minimum thirty(30) day endeavor to notify

requirement in the event of cancellation or non-renewal of coverage.
The certificate is to be received and approved by (Enter Entity Name Here) before work
commences.

SECTION 4 - 4

State of West Virginia

Board of Risk and Insurance Management
 Facility Audit
and

Inspection Checklists
 Facility Audit and Inspection Checklists
The ability to recognize hazards is the core of an effective loss control program. One
effective method to identify, detect, correct or control potential hazards is to conduct
periodic safety and loss control inspections.

How to Get Started

The checklists contained in this Section may first appear to be overwhelming. It is not
intended that the entire checklist be used when conducting the inspections. You should
pick and choose the lists that specifically apply to the areas you will be inspecting.
However, it may be useful for the Safety/Loss Control Committee or the inspection team
to review the checklists grouped under the General heading. The information contained
in those lists is generic and applies more to policies and procedures than to specific
exposures.

Developing a Checklist
When the inspection team is ready to begin the inspection process they should first
determine the area they will be inspecting. For example, if they choose to begin in the
administrative offices, copy the “Building Inspection – Interior” portion of the checklist.
Add or delete portions or items that do not apply your operations. If they are inspecting a
maintenance area, they may need to use a number of lists under Equipment Inspections as
well as some under Facility Inspections. As you develop your inspection process you will
learn to adapt the lists to meet your needs. Highlight and print the portion you wish to
copy.

Using the Checklist

The following is an example of how to use the checklist you develop.

BUILDING INSPECTION – INTERIOR (including offices)

Electrical

Yes Are all electrical panels secured?

No (#1) Is a 3-foot clearance provided around all electrical
panels?
Yes Are all electrical rooms free from combustible storage?
Yes Are all electrical panels cool to the touch?
Yes Are all electrical panels free from evidence of burning?
Yes Have all electrical circuits been identified?

SECTION 5 - 1

State of West Virginia

Board of Risk and Insurance Management
No (#2) Are all electrical switches and receptacles in good
repair?
No (#3) Has the use of extension cords been discontinued?
Yes Have GFCIs been provided on circuits in proximity to
water?

Heating system

Yes Is a 3-foot clearance provided around all heating

equipment?
No (#4) Are furnace/boiler rooms kept locked?
Yes Are furnace/boiler rooms free from combustible storage?

Smoking

Yes Is smoking prohibited in the building?

Yes Are designated smoking areas properly identified?
Yes Are non-combustible receptacles provided in smoking
areas?
Yes Are smoking materials disposed of properly?

Housekeeping

Yes Is the work area clean and orderly?

Yes Have all unnecessary items been removed?
Yes Are floors clean, dry and not slippery?
Yes Are spills mopped up in a timely manner?
No (#5) Is someone designated to monitor removal of slip, trip and fall hazards
(slippery rugs, upturned rug edges, frayed carpet, loose cords, melting
ice and snow)?
Yes Are aisles and passageways clearly marked?
Yes Is trash removed from the building daily?
No See #1 Is storage restricted to designated areas?
Yes Is storage neatly arranged?

INSPECTION COMMENTS/RECOMMENDATIONS

#1 There are files stored in front of electrical panels that need to be moved, a three foot
clearance around all electrical panels is required.

#2 Broken faceplate on receptacle on west wall of break-room. Replace.

#3 There is an extension cord running from the pop machine into an outlet.
Relocate the machine or have it rewired so that it may be plugged directly into
outlet. Monitor the cord placement so it will not work its way under the machine
possibly wearing through the cord causing it to short out on the chassis.

SECTION 5 - 2

State of West Virginia

Board of Risk and Insurance Management
#4 Boiler room is unlocked. Should be locked to prevent unauthorized
personnel from entering.____________________________________

#5 Rug at the west entrance had upturned edges - trip or fall hazard.
Consider routinely replacing with clean rug by rug service________
company._______________________________________________

Checklist Index
GENERAL INSPECTIONS

ACCIDENT INVESTIGATION ........................................................ ...............................5

AUDIT/INSPECTION........................................................................................................5
EMERGENCY RESPONSE............................................................................. ................6
EMPLOYER POSTING........................................ .............................................................6
EMPLOYEE PROTECTION..............................................................................................7
ENVIRONMENTAL CONTROLS....................................................... .............................7
FIRE PROTECTION.......................................................... ...............................................9
FIRST AID AND MEDICAL SERVICES........................................................................10
HAZARDOUS CHEMICAL EXPOSURE ......................................................................10
HAZARDOUS SUBSTANCES COMMUNICATION ...................................................12
NOISE................................................................................................................................13
PERSONAL PROTECTIVE EQUIPMENT AND CLOTHING......................................14
RECORD KEEPING................................... .....................................................................15
SAFETY AND HEALTH PROGRAM ............................................................................15
SAFETY AND HEALTH TRAINING ............................................................................16
SANITATION – PROCEDURES FOR EQUIPMENT AND CLOTHING ....................17
TRANSPORTING EMPLOYEES AND MATERIALS ..................................................17

FACILITY INSPECTIONS

AISLES/WALKWAYS ....................................................................................................18
BUILDING INSPECTION – EXTERIOR........................................................................18
BUILDING INSPECTION – INTERIOR (INCLUDING OFFICES) .............................19
CONFINED SPACES........................................................................................................21
ELECTRICAL...................................................................................................................22
ELEVATED SURFACES, FLOOR AND WALL OPENINGS.......................................24
EXITING OR EGRESS............. .......................................................................................25
FLAMMABLE AND COMBUSTIBLE MATERIALS....................................................26
GROUNDS (INCLUDING CAMPGROUNDS)...............................................................28
HAZARDOUS WASTE/CHEMICAL STORAGE AREAS............................................29
HOUSEKEEPING AND GENERAL WORK ENVIRONMENT ...................................30
LABORATORIES – SCIENCE .......................................................................................31
MATERIAL HANDLING....... .........................................................................................33

SECTION 5 - 3

State of West Virginia

Board of Risk and Insurance Management
OFFICES – SEE “BUILDING INSPECTION – INTERIOR”..........................................34
PARKING LOTS – SEE “BUILDING INSPECTION – EXTERIOR”............................34
PIPING SYSTEMS IDENTIFICATION...........................................................................34
SIDEWALKS....................................................................................................................35
STAIRS AND STAIRWAYS ...........................................................................................36
VEHICLE MAINTENANCE AREA ...............................................................................37
WATERFRONT FACILITIES .........................................................................................38

EQUIPMENT INSPECTIONS

BATTERY CHARGING AREA – SEE VEHICLE MAINTENANCE AREA................42

COMPRESSED GAS CYLINDERS – SEE WELDING, CUTTING AND BRAZING..42
COMPRESSORS/COMPRESSED AIR............................................................................42
FALL PROTECTION........................................................................................................43
FISH CLEANING STATIONS............ ............................................................................44
FORKLIFTS – INDUSTRIAL TRUCKS .......................................... .............................44
FUELING – SEE VEHICLE MAINTENANCE AREA ..................................................46
GRINDERS – ABRASIVE WHEEL EQUIPMENT........................................................46
HAND/POWER TOOLS AND EQUIPMENT ................................................................46
HOIST AND AUXILIARY EQUIPMENT.......................................................................47
LADDERS – PORTABLE ...............................................................................................49
LOCK-OUT TAG-OUT PROCEDURES ........................................................................49
MACHINE GUARDING...................................................................................................50
PLAYGROUNDS .............................................................................................................52
PORTABLE (POWER OPERATED) TOOLS AND EQUIPMENT – SEE HAND
TOOLS AND EQUIPMENT.............................................................................................57
POWDER ACTUATED TOOLS .....................................................................................57
SCOFFOLDS.....................................................................................................................57
SPRAYING OPERATIONS..............................................................................................58
TIRE INFLATION – SEE VEHICLE MAINTENANCE AREA.....................................59
WELDING, CUTTING, AND BRAZING........................................................................59

SECTION 5 - 4

State of West Virginia

Board of Risk and Insurance Management
Self-Inspection Checklists
GENERAL INSPECTIONS

ACCIDENT INVESTIGATION

______ Have accident investigation guidelines/procedures been established?

______ Are responsibilities assigned for all phases of investigation process?
______ Who is responsible?
______ Who completes the records/logs?
______ Are Risk Management forms used?
______ Who completes the accident investigation report?
______ Who ensures corrective actions are implemented and effective?
______ Are all accidents and near misses investigated?
______ Are accident investigation recommendations/corrective actions
implemented?
______ Are personnel involved in investigation process trained in investigation
techniques and procedures?
______ Is the accident prevention plan reviewed at least annually?
______ Are results documented and shared with
management/supervisors/employees?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

AUDIT/INSPECTION

Are there regularly scheduled and conducted inspections of

______ facilities?
______ work-site stations?
______ vehicles?
______ equipment and tools?
______ personal protective equipment?
______ Are inspection checklists utilized?
______ Have procedures been established to ensure inspection deficiencies are
corrected?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SECTION 5 - 5

State of West Virginia

Board of Risk and Insurance Management
__________________________________________________________________

EMERGENCY RESPONSE

______ Are emergency response procedures included in you facility plan?

______ Are emergency routes designated and posted in work areas?
______ Has emergency organization been established and people designated by
name or position?
______ Does your emergency communication system include an emergency
reporting system?
______ Does your emergency communication system include posted phone
numbers for emergency assistance?
______ Have all employees been trainee d to understand hazards in the workplace?
______ Have all employees been trained to understand evacuation procedures?
______ Have all employees been trained to understand use of protective
equipment and clothing?
______ Are drills programmed and conducted regularly?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

EMPLOYER POSTING

______ Is the required Workers Compensation workplace poster displayed in a

prominent location where all employees are likely to see it?
______ Are emergency telephone numbers posted where they can be readily found
in case of an emergency?
______ Where employees may be exposed to any toxic substances or harmful
physical agents, has appropriate information concerning employee access
to their personal medical and exposure records made readily available to
affected employees? (it should be noted that this information must remain
confidential and be kept separate from personnel records),
______ Material Safety Data Sheets” (MSDS) (See Hazardous Substances
Communication Section.)
______ Are signs concerning “Exiting from buildings,” room capacities, floor
loading, exposures to X-ray, microwave, or other harmful radiation or
substances posted where appropriate?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 6

State of West Virginia

Board of Risk and Insurance Management
EMPLOYEE PROTECTION

______ Are first-aid supplies adequate for the type of potential injuries in the
workplace?
Are there quick water-flush facilities available where employees are
Exposed to corrosive materials?
______ Are hard hats provided and worn where any danger of falling objects
exists?
______ Are protective goggles, glasses and /or face shields worn where there is
any danger of flying particles or splashing of corrosive materials?
______ Are protective gloves, aprons, shields or other means for protection from
sharp, hot or corrosive materials?
______ Are approved respirators provided for regular or emergency used where
needed?
______ Is all protective equipment maintained in a sanitary condition and readily
available?
______ Where special equipment is needed for electrical workers, is it available?
______ Is protection against the effects of occupational noise exposure provided
when the sound levels exceed recommended noise standards?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ENVIRONMENTAL CONTROLS

______ Are all work areas properly illuminated?

______ Are employees instructed in proper first aid and other emergency
procedures?
______ Are hazardous substances identified which may cause harm by inhalation,
ingestion, skin absorption or contact?
______ Are employees instructed with established guidelines concerning hazards
involved with the various chemicals they may be exposed to in their work
environment, such as ammonia, chlorine, epoxies, caustics, etc.?
______ Has the training been documented?
______ Is employee exposure to chemicals in the workplace kept within
acceptable levels?
______ Can a less harmful method or product be used?
______ Is the work area’s ventilation system appropriate for the work being
performed?
______ Are spraying operations done in approved spray rooms or approved booths
equipped with an appropriate exhaust system?

SECTION 5 - 7

State of West Virginia

Board of Risk and Insurance Management
______ Is employee exposure to welding fumes controlled by ventilation, use of
respirators, exposure time or other means?
______ Are welders and other workers nearby provided with flash shields during
welding operations?
______ If forklifts and other vehicles are used in buildings or other enclosed areas,
are the carbon monoxide levels monitored with use of proper equipment
i.e. color metric tube, etc. and maintained below maximum acceptable
concentration?
______ Has there been a determination that noise levels in the facilities are within
acceptable levels?
______ Are steps being take to use engineering controls to reduce excessive noise
levels?
______ Are proper precautions being taken by AUTHORIZED PERSONNEL
ONLY when handling asbestos and other fibrous materials (only by
certified contractors)?
______ Are caution labels and signs used to warn of asbestos?
______ Are wet methods used, when practicable, to prevent the emission of
airborne asbestos fibers, silica dust and similar hazardous materials?
______ Is vacuuming with appropriate equipment used whenever possible rather
than blowing or sweeping dust?
______ Are grinders, saws, and other machines that produce respirable dust
vented to an industrial collector or central exhaust system?
______ Are local exhaust ventilation systems designed and operating properly
such as airflow and volume necessary for the application, ducts not
plugged or belts slipping?
______ Is personal protective equipment provided, used and maintained whenever
required?
______ Are there written standard operating procedures for the selection, use, and
care of respirators where needed?
______ Are restrooms and washrooms kept clean and sanitary?
______ Is all water provided for drinking, washing, and cooking potable?
______ Are all outlets for water not suitable for drinking clearly identified?
______ Are employees’ physical capabilities assessed before being assigned to
jobs requiring heavy works?
______ Are employees instructed in the proper manner of lifting heavy objects?
______ Where heat is a problem, have all fixed work areas been provided with
administrative control (exposure times, break time, etc.), spot cooling or
air conditioning?
______ Are employees screened before assignment to areas of high heat to
determine if their health condition might make them more susceptible to
having an adverse reaction?

______ Are employees working on the streets or roadways where they are exposed
the hazards of traffic, required to wear bright colored (traffic orange)
warning vests?

SECTION 5 - 8

State of West Virginia

Board of Risk and Insurance Management
______ Are exhaust stacks and air intakes so located that contaminated air will not
be re-circulated within a building or other enclosed area?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FIRE PROTECTION

______ Is your local fire department well acquainted with your facilities, its
location and specific hazards?
______ If you have a fire alarm system, is it certified as required?
______ If you have a fire alarm system, is it tested at least annually?
______ If you have interior standpipes and valves, are they inspected regularly?
______ If you have outside fire hydrants, are they flushed at least once a year and
on a routine preventative maintenance schedule?
______ Are fire doors and shutters in good operating condition?
______ Are fire doors and shutters unobstructed and protected against
obstructions, including their counterweights?
______ Are fire doors and shutter fusible links in place?
______ Are automatic sprinkler system water control valves, air and water
pressure checked annually as required?
______ Is the maintenance of automatic sprinkler systems assigned to responsible
persons or to a sprinkler contractor?
______ Are sprinkler heads protected by metal guards, when exposed to physical
damage?
______ Is proper clearance maintained below sprinkler heads?
______ Are smoke detectors operational and tested monthly?
______ Are portable fire extinguishers provided in adequate number and type?
______ Are fire extinguishers mounted in readily accessible site and their
location clearly identified?
______ Are fire extinguishers inspected monthly by assigned personnel to ensure
adequate charge, serviceability, mounted properly and documented on the
inspection tag; inspected annually by authorized distributor?
______ Are employees periodically instructed in the use of extinguishers and fire
protection procedures?
______ Is there a minimum clearance of three feet between the front of electrical
panels and equipment and any combustibles?
______ Is there a minimum clearance of four feet in front of heating equipment or
any open flame devices?
______ Do elevators return to the ground floor when the fire alarm goes off?

SECTION 5 - 9

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FIRST AID AND MEDICAL SERVICES

______ Is there a hospital, clinic, or infirmary for medical care in proximity (20
minutes of your work place)?
______ If medical and first aid facilities are not in proximity of your workplace, is
at least one employee on each shift currently qualified to render first aid?
______ If an employee is expected or required to render first aid, have proper
precaution been taken by the employer (offered the Hepatitis B series and
document the acceptance or declination, universal precaution training,
blood-borne pathogen training offered and documented)?
______ Are medical personnel readily available for advice and consultation on
matters of employee’s health?
______ Are emergency phone numbers posted?
______ Are first aid kits easily accessible to each work area, with necessary
supplies available, periodically inspected and replenished as needed?
(Ensure the kit contains one-way microshield CPR devices, disposable
gloves (protective), and does not contain oral medications.)
______ Are means provided for quick drenching or flushing of the eyes and body
(for a minimum of 15 minutes) in areas where corrosive liquids or
material are handled?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HAZARDOUS CHEMICAL EXPOSURE

______ Are employees trained in safe handling of hazardous chemicals such as

acids, caustics, etc.?
______ Are bulk drums of flammable liquids and transfer vessels grounded and
bonded during dispersing (drums must be part of the grounding system)?
______ Are employees aware of the potential hazards involving various chemicals
stored or used in the workplace such as acids, bases, caustics, epoxies,
phenols,
etc.?
______ Is employee exposure to chemicals kept within acceptable levels?
______ Are eye wash fountains and safety showers provided in areas where
corrosive chemicals are handled?

SECTION 5 - 10

State of West Virginia

Board of Risk and Insurance Management
______ Are all containers, such as vats, storage tanks, etc., labeled as to their
contents, e.g., “CAUSTICS”?
______ Are all employees required to use personal protective clothing and
equipment when handling chemicals (gloves, eye protection, respirators,
etc.)?
______ Are flammable or toxic chemicals kept in closed containers when not in
use?
______ Are chemical piping systems clearly marked as to their content?
______ Where corrosive chemical liquids are frequently handled in open
containers or drawn from storage vessels or pipelines, is adequate means
readily available for neutralizing or disposing of spills or overflows
properly and safely?
______ Have standard operating procedures been established and are they being
followed when cleaning up chemical spills?
______ Where needed for emergency use, are respirators stored in a convenient,
clean, and sanitary location with an appropriate inspection record?
______ Are respirators intended for emergency use adequate for the various uses
for which they may be needed?
______ Are employees prohibited from eating in areas where hazardous chemicals
are present?
______ Is personal protective equipment provided, used, and maintained
whenever necessary?
______ Are there written standard operating procedures for the selection and use
of respirators where needed?
______ If you have a written respirator protection program, are your employees
instructed on the correct usage and limitations of the respirators? Are the
respirators NIOSH approved for this particular application? Are they
regularly inspected and cleaned, sanitized and maintained? Is the
inspection documented?
______ Are you familiar with the Threshold Limit Values or Permissible
Exposure Limits of airborne contaminants and physical agents used in
your workplace?
______ Have control procedures been instituted for hazardous materials, where
appropriate, such as respirators, ventilation systems, handling practices,
etc.?
______ Whenever possible are hazardous substances handled in properly designed
and exhausted booths or similar locations?
_______Do you use general dilution or local exhaust ventilation systems to
control dusts, vapors, gases, fumes, smoke, solvents, or mists which may
be generated in your workplace?
______ Is ventilation equipment provided for removal of contaminants from such
operations as: production grinding, buffing, spray painting, and/or vapor
degreasing, and is it operating properly?
______ Do employees complain about dizziness, headaches, nausea, irritation, or
other factors of discomfort when they use solvents or other chemicals?

SECTION 5 - 11

State of West Virginia

Board of Risk and Insurance Management
______ Is there a dermatitis problem? Do employees complain about dryness,
irritation, or sensitization of the skin?
______ If internal combustion engines are used, is carbon monoxide kept within
acceptable limits?
______ Is vacuuming used, rather than blowing or sweeping dust whenever
possible for clean up?
______ Are materials that give off toxic asphyxiate, suffocation, or anesthetic
fumes, stored in remote locations when not in use?
______ Have you considered the use of an industrial hygienist or environmental
health specialist to evaluate your operation?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HAZARDOUS SUBSTANCES COMMUNICATION

______ Is Hazardous Communication Act “Notice to Employees” posted in all

work areas?
______ Have new employees received initial training?
______ Have all employees received annual refresher training?
______ Have you considered the use of an industrial hygienist or environmental
health specialist to evaluate your operation?
______ Is there a list of hazardous substances used in your workplace?
______ Is there a Material Safety Data Sheet readily available for each hazardous
substance used?
______ Are the MSDS sheets filed in available workbooks?
______ Are hazardous materials storage standards practiced?
______ Do you determine and provide the personal protective equipment required
for the handling of the hazardous materials?
______ Is each container for a hazardous substance (i.e., vats, bottles, storage
tanks, etc.) labeled with product identity and a hazard warning
(communication of the specific health hazards and physical hazards)?
______ Is there a written hazardous communication dealing with Material Safety
Data Sheets (MSDS), labeling, and employee training?
______ Is there an employee training program for hazardous substances?

Does this program include:

______ an explanation of what an MSDS is and how to use and obtain one?
______ MSDA content for each hazardous substance or class of substance?
______ an explanation of “Right to Know?”

SECTION 5 - 12

State of West Virginia

Board of Risk and Insurance Management
______ identification of where an employee can see the employers written hazard
communication program and where hazardous substances are present in
their work areas?
______ the physical and health hazards of substances in the work area, and
specific protective measures to be used?
______ details of the hazard communications program, including how to use the
labeling system and MSDSs?
______ require the review of the MSDS sheets by all employees who will be
working with the hazardous material?
______ train employees in the proper handling of the hazardous materials
including the use of properly fitted personal protective equipment?
______ monitor and enforce the use of the personal protective equipment?
______ document the training?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

NOISE
______ Are there areas in the workplace where continuous noise levels exceed
85dBA?
______ Is there an ongoing preventive health program to educate employees in
safe levels of noise, exposures; effects of noise on their health; and the use
of personal protection?
______ Have work areas where noise levels make voice communication between
employees difficult been identified and posted?
______ Are noise levels being measured for an 8 hour time weighted average and
records being kept?
______ Have engineering controls been used to reduce excessive noise levels?
Where engineering controls are determined to not be feasible, are
administrative controls (i.e. worker rotation) being used to minimize
individual employee exposure to noise?
______ Is approved hearing protective equipment (noise attenuating devices with
the proper Noise Reduction Rating) available to every employee working
in noisy areas?
______ Have you tried isolating noisy machinery from the rest of your operation?

______ If you use ear protectors, are employees properly fitted and instructed in
their use?
______ Have you considered conducting a baseline audiometric test been
performed on an employee prior to employment?
______ Have you considered conducting audio-metric testing on employees in
high noise areas to ensure that you have an effective hearing protection
system?

SECTION 5 - 13

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

PERSONAL PROTECTIVE EQUIPMENT AND CLOTHING

(Employee Protection)

______ Are first-aid supplies adequate for the type of potential injuries in the workplace?
______ Are protective goggles or face shields provided and worn where there is any
danger of flying particles of corrosive materials?
______ Are approved safety glasses required to be worn at all times in areas where
there is a risk of eye injuries such as splashing of liquids, punctures,
abrasions, contusions, or burns?
______ Are employees who need corrective lenses (glasses or contacts) in working
environments having harmful exposures, required to wear safety glasses,
protective goggles, or use other medically approved precautionary
procedures?
______ Are protective gloves, aprons, shields, or other means provided against cuts,
hot or corrosive liquids and chemicals?
______ Are hard hats provided and worn where danger of falling objects exists?
______ Are hard hats inspected periodically for damage to the shell and suspension
system?
______ Is appropriate foot protection required where there is the risk of foot injuries
from hot, corrosive, poisonous substances, falling objects, and crushing or
penetrating action?
______ Are approved respirators provided for regular or emergency use where
needed?
______ Is all protective equipment maintained in a sanitary condition and ready for
use? If protective clothing is provided and maintained by the employer is it a
requirement that the employee may not bring the possibly contaminated
clothing out of the work area?
______ Do you have eyewash and a quick drench shower within the work area where
employees are exposed to injurious corrosive materials?
______ Where special equipment is needed for electrical workers, is it available?
______ Where lunches are eaten on the premises, are they eaten in areas where there
is no exposure to toxic materials or other health hazards?
______ Is safety accountability included in all annual performance communications
documents?
______ Is protection against the effects of occupational noise exposure provided
when the sound levels exceed recommended noise standards?

SECTION 5 - 14

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

RECORD KEEPING

______ Are employee's medical records and the record of employee’s exposure
harmful to hazardous substances or physical agents up-to-date (must be kept
confidential and separate personnel files)?
______ Are employee training records maintained and available for employee
review?
______ Have arrangements been made to maintain required records for the legal period
of time for each specific type record?
______ Are operating permits and records up-to-date for such items as elevators, air
pressure tanks, and liquefied petroleum gas tanks, etc.?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SAFETY AND HEALTH PROGRAM

______ Is there a written policy statement?

______ Are current policy statements signed by management?
______ Are copies of the policy provided to new employees?
______ Is someone responsible for the development, implementation and
enforcement of the accident prevention plan?
______ Are employee/supervisor responsibilities and authority assigned?
______ Has a safety team been established to monitor the safety and health program?
______ Is there an established procedure for handling employee safety and health
complaints?
______ Do you have an active safety and health program in operation?
______ Is one person clearly responsible for the overall activities of the safety and
health program?
______ Do you have a safety committee or group made up of management and labor
representatives that meet regularly and report in writing on its activities?
______ Do you have a working procedure for handling in-house employee
complaints regarding safety and health?

SECTION 5 - 15

State of West Virginia

Board of Risk and Insurance Management
______ Are you keeping your employees advised of the successful effort and
accomplishments you and/or your safety committee have made in assuring
they will have a workplace that is safe and healthful?
______ Are professional safety services or other sources utilized in revising or updating
safety program?
______ Are follow-up procedures in place?
______ Is safety accountability included in all annual performance communications
documents?
______ Are records kept on job-related accidents, injuries and illnesses?
______ Is there written documentation of safety activities( meetings, training,
inspections, etc.)?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SAFETY AND HEALTH TRAINING

______ Have new employees received orientation training?

______ Do employees participate in regularly scheduled safety meetings?
______ Does management provide resources and participate in employee training?
______ Have employees received and documented required training?
______ Do all employees receive refresher training at least annually?
______ Have employees received instruction on reporting procedures to report unsafe
conditions, defective equipment, unsafe acts, incidents, accidents and near
misses?
______ Have supervisors received instruction in accident investigation and hazard
abatement?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SANITATION - PROCEDURES FOR EQUIPMENT AND CLOTHING

______ Is personal protective clothing or equipment that employees are required to

wear or use, of a type capable of being cleaned easily and disinfected?
______ Are employees prohibited from interchanging personal protective equipment,
unless it has been properly cleaned?
______ Are machines and equipment, which process, handle or apply materials that
could be injurious to employees, cleaned and/or decontaminated before being
overhauled or placed in storage?

SECTION 5 - 16

State of West Virginia

Board of Risk and Insurance Management
______ Are employees prohibited from smoking or eating in any area where
contaminates that could be injurious if ingested are present?
______ When employees are required to change from street clothing into protective
clothing, is a clean change room with separate storage facility for street and
protective clothing provided?
______ Are employees required to shower and wash their hair as soon as possible after
a known contact has occurred with a carcinogen?
______ When equipment, materials, or other items are taken into or removed from a
carcinogen-regulated area, is it done in a manner that will contaminate
nonregulated areas or the external environment?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

TRANSPORTING EMPLOYEES AND MATERIALS

______ Do employees who operate vehicles on public thoroughfares have valid

operator’s licenses?
______ When seven or more employees are regularly transported in a van, bus or
truck, is the operator’s license appropriate for the class of vehicle being
driven?
______ Is each van bus or truck used regularly to transport employees, equipped with
an adequate number of seats?
______ When employees are transported by truck, are provisions provided to prevent
their falling from the vehicle?
______ Are vehicle used to transport employees equipped with lamps, breaks, horns,
mirrors, windshields and turn signals in good repair?
______ Are transport vehicles provided with handrails, steps, stirrups or similar
devices, so placed and arranged that employees can safely mount or
dismount?
______ Are employee transport vehicles equipped at all times with at least two
reflective type flares?
______ Is a full charged fire extinguisher, in good condition, with at least 4 B:C
rating maintained in each employee transport vehicle?
______ When cutting tools or tools with sharp edges are carried in passenger
compartments of employee transport vehicles, are they placed in closed
boxes or containers which are secured in place?
______ Are employees prohibited from riding on top of any load that can shift,
topple, or otherwise become unstable?

SECTION 5 - 17

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Facility Inspections
AISLES/WALKWAYS

______ Are aisles and passageways kept clear?

______ Are aisles and walkways marked appropriately?
______ Are wet surfaces covered with non-slip materials?
______ Are holes in the floor, sidewalk or other walking surfaces repaired properly,
covered or otherwise made safe?
______ Are there safe clearances for walking in aisles where motorized or
mechanical handling equipment is operating?
______ Are materials or equipment stored in such a way that sharp objects will
not interfere with the walkway?
______ Are spilled materials cleaned up immediately?
______ Are changes of direction or elevation readily identifiable?
______ Are aisles or walkways that pass near moving or operating machinery,
welding operations or similar operations arranged so employees will not be
subjected to potential hazards?
______ Is adequate headroom provided for entire length of any aisle or walkway?
______ Are standard guardrails provided whenever aisle or walkway surfaces are
elevated more than 30 inches above any adjacent floor or the ground?
______ Are bridges provided over conveyors and similar hazards?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

BUILDING INSPECTION – EXTERIOR

______ Is building address or identification clearly visible?

______ Is an unobstructed access road to the building provided?
______ Are all building sides accessible to emergency equipment?
______ Are fire hydrants accessible?
______ Are sprinkler/standpipe connections accessible?

SECTION 5 - 18

State of West Virginia

Board of Risk and Insurance Management
______ Are sprinkler/standpipe connections clearly marked?
______ Does building appear to be in good repair?
______ Is building free from signs of vandalism?
______ Are exterior walls free from cracks or other damage?
______ Are windows free from cracks or broken panes?
______ Has vegetation been cut back from the building?
______ Are combustible materials stored away from the building?
______ Are there any signs of damage to the building?

Parking Lots
______ Are parking lots free of hazardous breakup, damage and debris?
______ Are dead tree limbs trimmed?
______ Are parking barriers in good repair and properly placed?
______ Are parking lots included in the inspection program?

Sidewalks (also see “SIDEWALKS” checklist section)

______ Are sidewalks free of hazardous cracks, break-up, damages and debris?
______ Are sidewalks surfaces have non-slip characteristics?
______ Are sidewalks included in the inspection program?

Steps and Stairs (also see “STAIRS AND STAIRWAYS” checklist section)
______ Are steps and stairs free of hazardous cracks, break-up, damages and debris?
______ Are stairs and stairways surfaces non-slip in character?
______ Are handrails in place and in good repair where appropriate?
______ Are steps and stairs included in the inspection program?

INSPECTION COMMENTS/RECOMMENDATIONS
____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

BUILDING INSPECTION – INTERIOR (including offices)

Electrical
______ Are all electrical panels secured?
______ Is a 3-foot clearance provided around all electrical panels?
______ Are all electrical rooms free from combustible storage?
______ Are all electrical panels cool to the touch?
______ Are all electrical panels free from evidence of burning?
______ Have all electrical circuits been identified?
______ Are all electrical switches and receptacles in good repair?
______ Has the use of extension cords been discontinued?
______ Have GFCIs been provided on circuits in proximity to water?
SECTION 5 - 19

State of West Virginia

Board of Risk and Insurance Management
Heating system
______ Is a 3-foot clearance provided around all heating equipment?
______ Are furnace/boiler rooms kept locked?
______ Are furnace/boiler rooms free from combustible storage?

Smoking
______ Is smoking prohibited in the building?
______ Are designated smoking areas properly identified?
______ Are non-combustible receptacles provided in smoking areas?
______ Are smoking materials disposed of properly?

Housekeeping
______ Is the work area clean and orderly?
______ Have all unnecessary items been removed?
______ Are floors clean, dry and not slippery?
______ Are spills mopped up in a timely manner?
______ Is someone designated to monitor removal of slip, trip and fall hazards
(slippery rugs, upturned rug edges, frayed carpet, loose cords, melting ice and
snow)?
______ Are aisles and passageways clearly marked?
______ Is regular pest control performed (if necessary)?
______ Is trash removed from the building daily?
______ Is storage restricted to designated areas?
______ Is storage neatly arranged?

Fire protection
______Is building equipped with an automatic sprinkler system?
______ Is main sprinkler control value accessible?
______ Are all valves supplying water or air to the system open?
______ Is sprinkler system tested on a quarterly basis?
______ Are spare sprinkler heads available in the building?
______ Is building equipped with a fire detection system?
______ Does the system protect the entire building?
______ Does system provide an alarm signal in the building?
______ Does an alarm company monitor alarm system operation?
______ Is alarm system tested on a monthly basis?
______ Is main alarm panel in normal operating condition?
______ Are all fire extinguishers inspected on a monthly basis?
______ Do all extinguishers have a current inspection tag?

Emergency Evacuation

______ Are all exits and travel paths identified with “EXIT” signs?
______ Are travel paths leading to exits free of obstructions?
______ Are exits unlocked and operational?
SECTION 5 - 20

State of West Virginia

Board of Risk and Insurance Management
______ Are working emergency lights provided in the building?
______ Are evacuation diagrams posted throughout the building?
______ Have all employees been trained to understand evacuation procedures?

Steps and Stairs (also see “STAIRS AND STAIRWAYS” checklist section)

______ Are steps and stairs free of hazardous cracks, break-up, damages and debris?
______ Are stairs and stairways surfaces non-slip in character?
______ Are handrails in place and in good repair where appropriate?
______ Is storage in the stairwell prohibited?
______ Are steps and stairs included in the inspection program?

Miscellaneous

______ Has flammable storage been limited to designated areas?

______ Is all cooking equipment protected by extinguishing systems?
______ Is cooking equipment clean?
______ Are all computer areas free from combustible storage?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

CONFINED SPACES

______ Are confined spaces thoroughly emptied of any corrosive or hazardous

substances, such as acids or caustics, before entry?
______ Are all lines to a confined space, containing inert, toxic, flammable, or
corrosive materials valved off and blanked or disconnected and separated
before entry?
______ Are all impellers, agitators, or other moving equipment inside confined spaces
locked-out if they present a hazard?
______ Is either natural or mechanical ventilation provided prior to confined space
entry?
______ Are appropriate atmospheric test performed to check Oxygen deficiency, toxic
substances and explosive concentrations in the confined space before entry?
______ Is adequate illumination provided for the work to be performed in the confined
space?
______ Is the atmosphere inside the confined space frequently tested or continuously
monitored during conduct of work?

SECTION 5 - 21

State of West Virginia

Board of Risk and Insurance Management
______ Is there an assigned safety standby employee outside of the confined space,
when required, whose sole responsibility is to watch the work in progress,
sound an alarm if necessary, and render assistance?
______ Is the standby employee appropriately trained and equipped to handle an
emergency?
______ Is the standby employee or other employees prohibited from entering the
confined space without lifelines and respiratory equipment if there is any
question as to the cause of an emergency?
______ Is the approved respiratory equipment required if the atmosphere inside the
confined space cannot be made acceptable?
______ Is all portable electrical equipment used inside confined spaces either grounded
or insulated, or equipped with ground fault protection?
______ Before gas welding or burning is started in a confined space, are hoses check
for leaks, compressed gas bottles forbidden inside of the confined space,
torches lighted only outside of the confined area and the confined area tested
for an explosive atmosphere each time before a lighted torch is to be taken into
the confined space?
______ If the employees will be using oxygen-consuming equipment such as
salamanders, torches, furnaces, etc., in a confined space, is sufficient air
provided to assure combustion without reducing the oxygen concentration of
the atmosphere below 19.5% by volume?
______ Whenever combustion-type equipment is used in a confined space, are
provisions made to ensure that exhaust gases are vented outside the enclosure?
______ Is each confined space for decaying vegetation or animal matter that may
produce methane?
______ Is the confined space checked for possible industrial waste that could contain
toxic properties?
______ If the combined space is below the ground and near areas where motor vehicles
will be operating, is it possible for vehicle exhaust or carbon monoxide to enter
the space?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ELECTRICAL

______ Do you specify compliance with National Electrical Code (NEC) for all
contract electrical work?
______ Are all outlets grounded?
______ Are “cheater plugs” (3 prong to 2 prong) being used?
______ Are all employees required to report as soon as practicable any obvious
hazard to life or property observed in connection with electrical equipment or
lines?

SECTION 5 - 22

State of West Virginia

Board of Risk and Insurance Management
______ Are employees instructed to make preliminary inspections and/or appropriate
tests to determine what conditions exist before starting work on electrical
equipment or lines?
______ When electrical equipment or lines are to be serviced, maintained, or adjusted,
are necessary switches opened, locked-out and tagged whenever possible?
______ Are portable electric tools, electrical appliances such as vacuum cleaners,
polishers, vending machines etc., and equipment grounded or of the double
insulated type?
______ Do extension cords being used have a grounding conductor?
______ Are multiple plug adapters prohibited?
______ Are ground-fault circuit interrupters (GFCI) installed on each temporary 15 or
20 ampere, 120 volt AC circuit at locations where construction, demolition,
modifications, alterations, or excavations are being performed?
______ Are all temporary circuits protected by suitable disconnecting switches or plug
connectors at the junction with permanent wiring?
______ Do you have electrical installations in hazardous dust or vapor areas? If so, do
they meet the National Electrical Code (NEC) for hazardous locations?
______ Is exposed wiring and cords with frayed or deteriorated insulation repaired or
replaced promptly?
______ Are flexible cords and cables free of splices or taps?
______ Are clamps or other securing means provided on flexible cords or cables at
plugs, receptacles, tools, equipment, etc., and is the cord jacket securely held
in place?
______ Are all cord, cable and raceway connections intact and secure?
______ In wet or damp locations, are electrical tools and equipment appropriate for the
use or location or otherwise protected?
______ Is the location of electric power lines and cables (overhead, underground,
under-floor, other than side-walls, etc.) determined before digging, drilling, or
similar work is begun?
______ Are metal measuring tapes, ropes, hand-lines or similar devices with metallic
thread woven into the fabric prohibited where they could come into contact
with energized parts of equipment or circuit conductors?
______ Is the use of metal ladders prohibited in areas where the ladders or the person
using the ladder could come into contact with energized parts of equipment,
fixtures, or circuit conductors?
______ Are all disconnecting switches and circuit breakers labeled to indicate their use
or equipment served?
______ Are disconnecting means always opened before fuses are replaced?
______ Do all interior wiring systems include provisions for grounding metal parts of
electrical raceways, equipment and enclosures?
______ Are all electrical raceways and enclosures securely fastened in place?
______ Are all energized parts of electrical circuits and equipment guarded against
accidental contact by approved cabinets or enclosures?
______ Is sufficient access and working space provided and maintained about all
electrical equipment to permit ready and safe operations and maintenance?
SECTION 5 - 23

State of West Virginia

Board of Risk and Insurance Management
______ Are all unused openings (including conduit knockouts) in electrical enclosures
and fittings closed with appropriate covers, plugs or plates?
______ Are electrical enclosures such as switches, receptacles, junction boxes, etc.,
provided with tight-fitting covers or plates?
______ Are disconnecting switches for electrical motors in excess of two horsepower,
capable of opening the circuit when the motor is in a stalled condition, without
exploding? (Switches must be horsepower rated equal to or in excess of the
motor hp rating)
______ Is low voltage protection provided in the control device of motors driving
machines or equipment, which cause probable injury from inadvertent
starting?
______ Is each motor disconnecting switch or circuit breaker located within sight of the
motor control device?
______ Is each motor located within sight of its controller or the controller
disconnecting means capable of being locked in the open position or is a
separate disconnecting means installed in the circuit within sight of the motor?
______ Is the controller for each motor in excess of two horsepower, rated in
horsepower equal to or in excess of the rating of the motor it serves?
______ Are employees who regularly work on or around energized electrical
equipment or lines instructed in the cardio-pulmonary resuscitation (CPR)
methods?
______ Are employees prohibited from working alone on energized lines or
equipment over 500 volts?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ELEVATED SURFACES, FLOOR AND WALL OPENINGS

______ Are floor openings guarded by a cover, a guardrail, or equivalent on all sides
(except at entrance to stairways or ladders)?
______ Are standard 4-inch toe-boards installed around the edges of permanent floor
opening beneath which people or machinery could be exposed to falling
objects)?
______ Are skylight screens of such construction and mounting that they will withstand
a load of at least 200 pounds?
______ Is the glass in the windows, door, glass walls, etc., which are subject to human
impact, of sufficient thickness and type for the condition of use?
______ Are grates or similar type covers over floor openings such as floor drains of
such design that foot traffic or rolling equipment will not be affected by the
grate spacing?
______ Are unused portions of service pits and pits not actually in use either covered or
protected by guardrails or equivalent?

SECTION 5 - 24

State of West Virginia

Board of Risk and Insurance Management
______ Are manhole covers, trench covers and similar covers, plus their supports
designed to carry a truck rear axle load of at least 20,000 pounds when located
in roadways and subject to vehicle traffic?
______ Are floor or wall openings in fire resistive construction provided with doors or
covers compatible with the fire rating of the structure and provided with
self closing feature when appropriate?
______ Are signs posted, when appropriate, showing the elevated surface load
capacity?
______ Are surfaces elevated more than 30 inches above the floor or ground provided
with standard guardrails?
______ Is a permanent means of access and egress provided to elevated storage and
work surfaces?
______ Is required headroom provided where necessary?
______ Is material on elevated surfaces piled, stacked or racked in a manner to prevent
it from tipping, collapsing, rolling or spreading?
______ Are dock boards or bridge plates used when transferring materials between
docks and trucks or rail cars?

INSPECTION COMMENTS/RECOMMENDATIONS
_______________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

EXITING OR EGRESS

______ Are all exits marked with an exit sign?

______ Are the directions to exits, when not immediately apparent, marked with visible
signs?
______ Are doors, passageways or stairways, that are neither exits nor access to exits
and which could be mistaken for exits, appropriately marked “NOT AN
EXIT,” “TO BASEMENT,” “STOREROOM’” etc.?
______ Are exit signs provided with the word “EXIT” in lettering at least 5 inches high
and the stroke of the lettering at least ½ inch wide?
______ Are exit doors side-hinged?
______ Are aisles width maintained?
______ Are all exits kept free of obstructions?
______ Are at least two means of egress provided from elevated platforms, pits or
rooms where the absence of a second exit would increase the risk of injury
from hot, poisonous, corrosive, suffocating, flammable, or explosive
substances?
______ Are there sufficient exits to permit prompt escape in case of emergency?

SECTION 5 - 25

State of West Virginia

Board of Risk and Insurance Management
______ Are special precautions taken to protect employees during construction and
repair operations?
______ Is the number of exits from each floor of a building and the number of exits
from the building itself, appropriate for the building occupancy load and
function?
______ Are exit stairways which are required to be separated from other parts of the
building, enclosed by at least a 2 hour fire-resistive construction in buildings
more than 4 stories in height, and not less than 1 hour fire-resistive
construction elsewhere?
______ Where ramps are used as part of required exiting from a building, is the ramp
slope limited to 1 foot vertical and 12 feet horizontal?
______ Where exiting will be through flameless glass doors, glass exit doors, storm
doors, etc., are the doors fully tempered and meet the safety requirement s for
human impact?
______ Are doors, which are required to serve as exits, designed and constructed so
that the way of exit travel is obvious and direct?
______ Are windows, which could be mistaken for exit doors, made inaccessible by
means of barriers and railings?
______ Are exit doors operable from the direction of exit travel without the use of a
key or any special knowledge or effort (opened with one motion) when the
building is occupied?
______ Is a revolving, sliding or overhead door prohibited from serving as a required
exit door?
______ Where panic hardware is installed on a required exit door, will it allow to door
to open by applying a force of 15 pounds or less in the direction of the exit
traffic?
______ Are doors on cold storage rooms provided with an inside release mechanism,
which will release the latch and open the door even if it is padlocked or
otherwise locked on the outside?
______ Where exit doors open directly onto any street, or other area where vehicles
may be operated, are adequate barriers and warnings provided to prevent
employees stepping into the path of traffic?
______ Are doors that swing in both directions and are located between rooms where
there is frequent traffic, provided with viewing panels in each door?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FLAMMABLE AND COMBUSTIBLE MATERIALS

______ Are combustible scraps, debris, and waste materials (oily rags, etc.) stored in
covered metal receptacles and removed from the work-site daily?

SECTION 5 - 26

State of West Virginia

Board of Risk and Insurance Management
______ Is proper storage practiced to minimize the risk of fire including spontaneous
combustion?
______ Are approved containers and tanks used for the storage and handling of
flammable and combustible liquids?
______ Are all connections on drums and combustible liquid piping, vapor and
liquid tight?
______ Are all flammable liquids kept in closed containers when not in use (e.g. pans,
cleaning tanks etc.)?
______ Are bulk drums of flammable liquids and transfer vessels grounded and bonded
during dispersing (drums must be part of the grounding system)?
______ Do storage rooms for flammable and combustible liquids have explosion-proof
lights?
______ Do storage rooms for flammable and combustible liquids have mechanical or
gravity ventilation?
______ Is liquefied petroleum gas stored, handled, and used in accordance with safe
practices and standards?
______ Is liquefied petroleum gas storage tanks guarded to prevent damage from
vehicles?
______ Are no smoking signs posted in the area of liquefied petroleum gas tanks?
______ Are liquefied petroleum storage tanks guarded to prevent damage from
vehicles?
______ Are all solvent wastes, and flammable liquids kept in fire-resistant, covered
containers?
______ Is vacuuming used whenever possible rather than blowing or sweeping
combustible dust?
______ Are firm separators placed between containers of combustibles or flammables,
when stacked one upon another, to assure their support and stability?
______ Are fuel gas cylinders separated by distance, fire resistant barriers, etc. while in
storage?
______ Are fire extinguishers selected and provided for the types of materials in the
areas where they are to be used?
Class A Ordinary combustible material fires.
Class B Flammable liquid, gas or grease fires.
Class C Energized-electrical equipment fires.
______ Are appropriate fire extinguishers mounted within 75 feet of outside areas
containing flammable liquids, and within 10 feet of any inside storage area for
such materials?
______ Are extinguishers free from obstructions or blockage?
______ Are all extinguishers serviced, maintained, and tagged at intervals not to exceed
one year?
______ Are all extinguishers fully charged and in their designated places?
______ Where sprinkler systems are permanently installed, are the nozzle heads so
directed or arranged that water will not be sprayed into operating electrical
switchboards and equipment?
______ Are “NO SMOKING” signs posted and rules enforced in appropriate areas
where flammable or combustible materials are used or stored?
SECTION 5 - 27

State of West Virginia

Board of Risk and Insurance Management
______ Are safety cans used for dispensing flammable or combustible liquids at a point
of use?
______ Are all spills of flammable or combustible liquids cleaned up promptly?
______ Are storage tanks adequately vented to prevent the development of excessive
vacuum or pressure as a result of filling, emptying, or atmosphere temperature
changes?
______ Are storage tanks equipped with emergency venting that will relieve
excessive internal pressure caused by fire exposure?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

GROUNDS (including campgrounds)

______ Are there any apparent signs of physical contamination: dead vegetation,
noticeable stains on the ground, standing oil?
______ Are any chemicals or fuels handled on the grounds; were there ever?
______ Could activities on adjacent properties pose any environmental risks?
______ Do you have any underground storage tanks (UST) in use at this time?
______ Does your facility have any old unused USTs on the premises?
______ Do you store any hazardous materials in USTs?
______ Do you store any petroleum products in USTs?
______ Has your plant notified the appropriate state agency about its USTs?
______ Have you determined and used the proper EPA or state notification form?
______ Are the USTs on your premises visually inspected on a regular basis?
______ Have you instituted a method of release detection for your USTs?
______ Do you know and follow release reporting, investigation and confirmation
procedures?
______ Do you have any areas (parking lot, excavation area, refuse area) where storm
water runoff would be contaminated with hazardous pollutants?
______ If hazardous waste is stored on the grounds, are all hazardous waste
requirements complied with?
______ Are there any dead branches that could break off and cause damage in the event
of a strong wind?
______ Are there dead branches or other debris on the ground, potholes, protruding
rocks or campsite indicators causing trip and fall hazards?
______ Is there surface water standing on the ground that requires drainage?
______ Is there any naturally occurring skin irritants or dermatitis-inducing agents such
as Poison Ivy, Poison Oak, and Poison Sumac that should be removed?

SECTION 5 - 28

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HAZARDOUS WASTE/CHEMICAL STORAGE AREAS

______ Have all employees been trained to understand specific responsibilities in an

emergency?
______ Is emergency information posted in every area where you store hazardous
waste an all containers appropriately labeled with contents?
______ Is the necessary emergency equipment available (fire extinguishers, spill
control supplies, absorbents, MSDSs)?
______ Do you have containers that you use to store waste temporarily (accumulate)
before transport?
______ Does each accumulation container meet hazardous waste container
requirements?
______ Are all solvent wastes and flammable liquids kept in fire-resistant, covered
containers until they are removed from the work site?
______ Is each accumulation container marked with the date accumulation began
and contents?
______ Is each container kept closed, except when adding or removing waste?
______ Does your storage area provide secondary containment?
______ Are areas where containers are stored inspected for leaks at least weekly?
______ Are containers holding ignitable or reactive wastes stored at least 50 feet
within the facility’s property line?
______ Is there sufficient aisle space to allow unobstructed movement of personnel
and equipment?
______ Is each container that is being shipped marked in accordance with DOT
requirements?
______ Is vacuuming used whenever possible rather than blowing or sweeping
combustible dust?
______ Are firm separators placed between containers of combustibles or
flammables when stacked one upon another to assure their support and
stability?
______ Are all containers over 30 gallons stacked individually?
______ Are combustible scrap, debris, and waste materials (oily rags, etc.) stored in
covered metal receptacles and removed from the work site promptly?
______ Is proper storage practiced to minimize the risk of fire including spontaneous
combustion?
______ Are all connections on drums and combustible liquid piping, vapor and
liquid tight?
______ Are all flammable liquids kept in closed containers when not in use (e.g.
parts cleaning tanks, pans, etc.)?
______ Are bulk drums of flammable liquids grounded and bonded to containers

SECTION 5 - 29

State of West Virginia

Board of Risk and Insurance Management
 during dispensing?
______ Are safety cans used for dispensing flammable or combustible liquids at
point of use?
______ Are all spills of flammable or combustible liquids cleaned up promptly?
______ Are storage tanks adequately vented and equipped with emergency venting?
______ Is smoking ban enforced in the areas involving storage and use of hazardous
materials?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HOUSEKEEPING AND GENERAL WORK ENVIRONMENT

______ Is smoking only permitted in “designated” smoking areas?

______ Are “no smoking” and “smoking” signs prominently posted?
______ Are approved covered metal containers used for oily and paint-soaked
waste?
______ Are flammables stored in approved flammable cabinets?
______ Are waste receptacles provided and emptied regularly?
______ Are spray paint booths, dip tanks and their exhaust ducts cleaned regularly?
______ Is lighting in all areas adequate?
Are building exit signs operating and emergency exits clear and provided
with inside opening devices?
______ Are floor load capacities posed in second floor lofts and storage areas?
______ Are floor openings protected with toe boards and railings, or a floor hole
cover?
______ Are stairway in good condition, with standard railings provided for every
flight having four or more risers?
______ Are portable ladders adequate for their purpose, in good condition, and
provided with secure footing?
______ Are fused ladders equipped with side rails, cages or special safety climbing
devices and in good condition?
______ Are aisles and passageways marked and free of obstructions?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 30

State of West Virginia

Board of Risk and Insurance Management
LABORATORIES - SCIENCE

Work Habits

______ Is it the policy of the facility to encourage people to never work alone in a
science laboratory or storage area?
______ Is eating, drinking, smoking, chewing gum or tobacco banned in a science
laboratory or storage room unless a designated “clean area” is provided?
______ Is the storage of food or beverages in the laboratory environment prohibited?
______ Is it a policy to never pipette by mouth?
______ Is washing hands before and after work in a science laboratory, and after
spill cleanups required?
______ Are loose clothing (e.g. sleeves, full cut blouses, neckties etc.), long hair and
dangling jewelry prohibited?
______ Is it required to tape all Dewar flasks?
______ Is it a policy to never leave heat sources unattended (e.g. gas burners, hot
plates, heating mantles, sand baths, etc.)?
______ Is it required that the storage of reagents and/or apparatus be on a lab bench,
and that lab shelves be kept organized?
______ Is it a policy to never place reactive chemicals (in bottles, beakers/flasks,
wash bottles, etc.) near the edges of a lab bench?
______ Is a fume hood required when working with volatile substances?
______ Are employees instructed not to lean into the fume hood?
______ Is the use of the fume hood as a storage area prohibited?
______ Are the Material Safety Data Sheets (MSDS) for each chemical obtained and
read before beginning an experiment and kept in a designated area for easy
access?
______ Are new lab procedures analyzed in advance to determine hazardous areas?
______ Are accidents analyzed to prevent repeat occurrences?
______ Is protection provided for not only the lab worker but also the lab partner
working nearby?
______ Is mixing and disposing of chemicals in the sink drain prohibited?
______ Are co-workers always informed of plans to carry out hazardous work?
______ In order to allow meaningful retrospective contamination studies, is a record
kept of who worked with what, when, and how long?
______ Are regular in-house safety and health inspections performed with an
emphasis on improvement rather than guilt?
______ Are lab occupants informed in regard to the alarm bell and what to do if it
sounds?
______ Does your facility conduct regular fire or emergency drill
with critical reviews of the results?
______ Have all employees been trained to understand specific responsibilities in an
emergency?
______ Is there a established procedure in case of an emergency (e.g. what devices
should be turned off, which escape route to use, a personnel meeting place
outside the building, a person designated to authorize re-entry into the
building)?
SECTION 5 - 31

State of West Virginia

Board of Risk and Insurance Management
______ Have lab personnel received current training in first aid, CPR, etc?

Safety Wear

______ Is American National Standards Institute (ANSI) or equivalent standard

approved eye or face protection worn continuously?
______ Are employees required to wear gloves which will resist penetration by the
chemical being handled and which have been checked for pin holes, tears, or
rips?
______ Are personnel required to wear a laboratory coat or apron to protect skin and
clothing from chemicals?
______ Must employees wear footwear that covers the feet completely - no open-toe
shoes?

Facilities and Equipment

______ Are separate containers for trash and broken glass required?
______ Are emergency response procedures indicated in the facility plan?
______ Have all employees been trained to understand specific responsibilities in an
emergency?
______ Are emergency routes designated and posted in work areas?
______ Are all escape routes, and alternate escape routes monitored to ensure they
are not obstructed?
______ Are fire doors monitored to ensure that they are not blocked open?
______ Is it a facility policy to never store materials in lab or in aisles?
______ Do all moving belts and pulleys have safety guards?
______ Are lab personnel instructed in the proper use of the eyewash fountain,
emphasizing rolling of the eyeballs, and turning eyelids “inside-out”?
______ Are eyewash fountains installed which supply at least 15 minutes of water
flow?
______ Are safety showers and eyewash fountains regularly inspected and
documented?
______ Does your facility sample breathing air space for measurement of possible
contaminants, and document the report?
______ Are fire blankets regularly inspected for rips and holes and keep good
records of the inspections?
______ Are current emergency phone numbers posted next to the phone?
______ Are fire extinguishers placed near an escape route, not in a “dead end”?
______ Does your facility regularly maintain fire extinguishers, maintain records,
and train personnel in the proper use of extinguishers?
______ Are personnel familiarized with the meaning of “Class A fire”, “Class B
fire”, etc., and how they relate to fire extinguisher use?
______ Are hoods regularly checked for proper draft and ensure that exhaust air
from an external hood vent is not redrawn into room air?

SECTION 5 - 32

State of West Virginia

Board of Risk and Insurance Management
______ Are all compressed gas cylinders secured when in use and while being
transported?
______ Does your facility have installed chemical storage shelves with lips (never
use stacked boxes in lieu of shelves)?
______ Is it required that your lab use only an explosion-proof refrigerator for lab
storage?
______ Does your facility have appropriate equipment and materials available for
spill control and replaced when it becomes out dated?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

MATERIAL HANDLING

______ Is there safe clearance for equipment through aisles and doorways?
______ Are aisle-ways designated, permanently marked, and kept clear to allow
unhindered passage?
______ Are motorized vehicles and mechanized equipment inspected daily or prior
to use?
______ Are vehicles shut off and breaks set prior to loading or unloading?
______ Are containers of combustible or flammables, when stacked while being
moved, always separated by dunnage sufficient to provide stability?
______ Are dock boards (bridge plates) used when loading or unloading operations
are taking place between vehicles and docks?
______ Are trucks and trailers secured from movement during loading and unloading
operations?
______ Are dock plates and loading ramps constructed and maintained with
sufficient strength to support imposed loading?
______ Are hand trucks maintained in safe operating condition?
______ Are chutes equipped with sideboards of sufficient height to prevent the
materials being handled from falling off?
______ Are chutes and gravity roller sections firmly placed or secured to prevent
displacement?
______ At the delivery end of the rollers or chutes, are provisions made to brake the
movement of the handled materials?
______ Are pallets usually inspected before being loaded or moved?
______ Are hooks with safety latches or other arrangements used when hoisting
materials so that slings or load attachments won’t accidentally slip off the
hoist hooks?
______ Are securing chains, ropes, chocks, or slings adequate for the job to be
performed?
______ When hoisting material or equipment, are provisions made to assure no one
will be passing under the suspended loads?

SECTION 5 - 33

State of West Virginia

Board of Risk and Insurance Management
______ Are material safety data sheets available to employees handling hazardous
substances?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

OFFICES – see “Building Inspection – Interior”

PARKING LOTS – see “Building Inspection – Exterior”

PIPING SYSTEMS IDENTIFICATION

______ When non-potable water is piped through a facility, are outlets or taps posted
to alert employees that it is unsafe and not to be used for drinking, washing
or other personal use?
______ When hazardous substances are transported through above ground piping, is
each pipeline identified at points where confusion could introduce hazards to
employees?
______ When pipelines are identified by color painting, are all visible parts of the
line so identified?
______ When pipelines are identified by color painted bands or tapes, are the bands
or tapes located at reasonable intervals and at each outlet, valve or
connection?
______ When pipelines are identified by color is the color code posted at all
locations where confusion could introduce hazards to employees?
______ When the contents of pipelines are identified by name or name abbreviation,
is the information readily visible on the pipe near each valve or outlet?
______ When pipelines carrying hazardous substances are identified by tags, are the
tags constructed of durable materials, the message carried clearly and
permanently distinguishable and are tags installed at each valve or outlet?
______ When pipelines are heated by electricity, steam or other external source, are
suitable warning signs or tags placed at unions, valves, or other serviceable
parts of the system?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 34

State of West Virginia

Board of Risk and Insurance Management
SIDEWALKS

______ Are proper standards used when designing or modifying a sidewalk?

Is there a standard established to inspect sidewalks for defects and the type,
size/severity, and locations:

______ blow-up
______ depression
______ cracking
______ gaps
______ faulting
______ tilting
______ separating
______ scaling
______ swelling
______ rises and drop-offs
______ improper drainage, etc.?

Are sidewalks routinely inspected for obstructions:

______ vehicles
______ tree limbs
______ dirt/debris
______ vegetation, etc.?
______ Are bridges provided over permanent hazards that cannot be bypassed?
______ Are the deficiencies documented and repaired?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

STAIRS AND STAIRWAYS

______ Are stairways free of hazardous cracks, break-up, damage and debris?
______ Are standard stair rails or handrails on all stairways having four or more
risers?
______ Are all stairways are least 22 inches wide?
______ Do stairs have at least a 6’6” overhead clearance?
______ Do stairs angle no more than 50 and no less than 30 degrees?
______ Are stairs of hollow pan type treads and landings filled to noising level with
solid material?
______ Are step risers on stairs uniform from top to bottom, with no riser spacing
greater than 7 ½ inches?

SECTION 5 - 35

State of West Virginia

Board of Risk and Insurance Management
______ Are steps on stairs and stairways designed or provided with a surface that
renders them slip resistant?
______ Are stairway handrails located between 30 and 34 inches above the leading
edge of stair treads?
______ Do stairway handrails have at least 1½ inches of clearance between the
handrails and the wall or surface they are mounted on?
______ Are stairway handrails capable of withstanding a load of 200 pounds applied
in any direction?
______ Where stairs or stairways exit directly into any area where vehicles may be
operated, are adequate barriers and warnings provided to prevent employees
from stepping into the path of traffic?
______ Do stairway landings have a dimension measured in the direction of travel, at
least equal to the width of the stairway?
______ Is the vertical distance between stairway landings limited to 12 feet or less?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

VEHICLE MAINTENANCE AREA

______ Are correct lockout/tagout procedures in use?

______ Is compressed air for cleaning less than 30 psi?
______ Are storage cabinets used to hold flammable liquids, labeled “Flammable –
Keep Fire Away?”
______ Are flammable liquids, such as gasoline, kept in a safety can?
______ If carbon monoxide is present, due to forklifts, heaters or idling vehicles, are
signs posted warning of its presence?
______ Is all machinery and equipment kept clean and properly maintained?
______ Is protective clothing and equipment provided and used when cleaning up
spilled toxic or otherwise hazardous materials or liquids?
______ Are work surfaces kept dry or appropriate means taken to assure the surfaces
are slip-resistant?
______ Are all spilled materials or liquids cleaned up immediately?
______ Do you have emergency eye wash and shower facilities within the work area
where employees are exposed to injurious corrosive materials?
______ Is it prohibited to fuel and internal combustion engine with a flammable
liquid while the engine is running?
______ Are fueling operations done in such a manner that likelihood of spillage will
be minimal?
______ When spillage occurs during fueling operations is the spilled fuel washed away
completely, evaporated, or other measures taken to control vapors before
restarting the engine?

SECTION 5 - 36

State of West Virginia

Board of Risk and Insurance Management
______ Are batteries charged in a properly vented room?
______ Is smoking ban enforced?
______ Are facilities provided for flushing spilled electrolyte?
______ Do you prevent open flames, sparks in immediate area?
______ Is required personal protective equipment used?
______ Are eye wash fountains and safety showers provided in areas where corrosive
chemicals are handled?
______ Is it prohibited to fuel an internal combustion engine with a flammable liquid
while the engine is running?
______ Are fueling operations done in such a manner that likelihood of spillage will be
minimal?
______ When spillage occurs during fueling operations is the spilled fuel washed away
completely, evaporated, or other measures taken to control vapors before
restarting the engine?
______ Are fuel caps replaced and secured before starting the engine?
______ In fueling operations, is the proper grounding maintained between the container
and the fuel tank?
______ Are fueling hoses of a type designed to handle the specific type of fuel?
______ Is it prohibited to handle or transfer gasoline in open containers?
______ Are open lights, open flames, or sparking, or arcing equipment prohibited near
fueling or transfer of fuel operations?
______ Is smoking prohibited in the vicinity of fueling operations?
______ Are fueling operations prohibited in building or other enclosed areas that are
not specifically ventilated for this purpose?
______ Where fueling or transfer of fuel is done through a gravity flow system, are the
nozzles of the self-closing type?
______ Where tires are mounted and/or inflated on drop center wheels, is a safe
practice procedure posted and enforced?
______ Where tires are mounted and/or inflated on wheels with split rims and/or
retainer rings, is a safe practice procedure posted and enforced?
______ Does each tire inflation hose have a clip-on chuck with at least 24 inches of
hose between the chuck and an in-line hand valve and gauge?
______ Does the tire inflation control valve automatically shutoff the airflow when
the valve is released?
______ Is a tire-restraining device such as a cage, rack or other effective means used
while inflating tires mounted on split rims, or rims using retainer rings?
______ Are employees strictly forbidden from taking a position directly over or in
front of a tire while it is being inflated?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 37

State of West Virginia

Board of Risk and Insurance Management
WATERFRONT FACILITIES

Warning Signs and Bulletin Boards

______ Are signs posted relative to waterfront safety (warnings, rules, regulations,
etc.)?
______ Are signs and bulletin boards located so they will be seen by all using the
facilities before they enter the area?
______ Where life guards are not provided are there signs denoting this placed at
obvious points along the swimming area?

Parking Lots

______ Are parking lots free of hazardous breakup, damage and debris?
______ Are dead tree limbs trimmed?
______ Are parking barriers in good repair and properly placed?
______ Are parking lots included in the inspection program?

Sidewalks (also see “SIDEWALKS” checklist section)

______ Are sidewalks free of hazardous cracks, break-up, damages and debris?
______ Are sidewalks surfaces have non-slip characteristics?
______ Are sidewalks included in the inspection program?

Steps and Stairs (also see “STAIRS AND STAIRWAYS” checklist section)

______ Are steps and stairs free of hazardous cracks, break-up, damages and debris?
______ Are stairs and stairways surfaces non-slip in character?
______ Are handrails in place and in good repair where appropriate?
______ Are steps and stairs included in the inspection program?

Zoned Swimming Beaches

______ Where life guards are not provided are there signs denoting this placed at
obvious points along the swimming area?
______ Are beaches free of hazardous debris?
______ Are swimming areas inspected on a regular basis for underwater hazards and
removed where feasible?
______ Are appropriate warning signs in place?
______ Are dead tree limbs trimmed and removed?
______ Are zoned swimming beaches included in the inspection program?

Playground Slides in Water

______ Does slide meet U.S. Consumer Product Safety Guidelines?

SECTION 5 - 38

State of West Virginia

Board of Risk and Insurance Management
______ Has slide been installed in accordance with manufacture’s instructions?
______ Is the slide included in the inspection program?

Regulatory signs, markers, buoys, and other warning or marking devices

______ Are all regulatory signs, markers, buoys, and warning or marking devices
placed, marked and meet specification with required standards?
______ Are these devices in serviceable condition?
______ Are these devices included in the inspection program?

Boat Docks

______ Have all missing, broken, weak or rotting deck, and structural lumber been
replaced?
______ If planking is used, are gaps between planks less than ½ inch after shrinkage?
______ Are all frames, anchors, and supports solid and stable?
______ Are all floats securely attached?
______ Have loose fasteners, protruding nails, screws, or bolts repaired?
______ Have exposed open ends of upright stand supporters been covered?
______ Have any gaps over one inch between dock sections been covered?
______ Have pull cables on slide-in docks retracted as far as possible?
______ Are appropriate warning signs in place?
______ Is a slip free surface maintained on all decking (especially when wet)?
______ Is all wood material in the structure and decking pressure treated with a
preservative?
______ Do docks have adequate and approved-type floatation material (material
which will not become waterlogged or sink when punctured)?
______ Do docks/slip fingers exceed the minimum freeboard (6 inches above water
level)?
______ Does the substructure have any broken, rusted, or missing members?
______ Is the access bridge between the shore and the dock stable, slip free and wide
enough to permit safe pedestrian passage?
______ Are all handrails structurally sound and in safe, well-maintained condition?
______ Does the roof and roof superstructures have any broken, rusted or missing
members?
______ Is there one Coast Guard approved throw-type floatation device with 60 feet
of 3/8-inch diameter rope attached or a reach pole on each main walkway or
every 200 feet?
______ When constructing new facilities or alteration of existing facilities, are they
barrier free and usable by persons with disabilities?
______ Are boat docks included in the inspection program?

Boat Ramps

______ Have damaged surfaces been repaired?

SECTION 5 - 39

State of West Virginia

Board of Risk and Insurance Management
______ Are boat ramps clear of excess debris?
______ Has the boat ramp area been checked for underwater hazards and removed
where feasible?
______ Are appropriate warning signs in place?
______ Are boat ramps included in the inspection program?

Changehouses/Bathhouses/Comfort Stations

______ Have loose or deteriorating lumber, protruding nails or fasteners, loose shingles
and other structural damages repaired?
______ Are floors free on hazardous cracks?
______ Have hot water heaters and mixing valves been adjusted properly?
______ Are automatic door closures properly adjusted to prevent slamming?
______ Are Ground Fault Circuit Interrupters (GFCI) breakers or receptacles
installed?
______ Are all indoor, outdoor, and security lighting operational?
______ Are all fixtures in good repair?
______ Are all well pipes/casings, septic system covers, cistern covers and other
above-ground fixtures secured and landscaped or marked to make visible if
near areas of foot traffic?
______ Are changehouses/bathhouses/comfort stations included in the inspection
program?

Facilities for accessibility of disabled persons

______ Are standard facilities for disabled persons provided at comfort stations and
pedestrian access points?
______ Can disabled persons easily gain access to the waterfront facilities?
______ Are accessibility of disabled persons to the facilities included in the
inspection program?

Miscellaneous structures and equipment on beaches

Inspect the following to ensure that all are in good state of repair, functioning
properly and properly placed, secured or anchored when applicable:
______ individual picnic shelters;
______ permanent beach play equipment (see “PLAYGROUND” checklist section);
______ benches;
______ fire-grates;
______ picnic tables;
______ dumpsters;
______ traffic, directional and informational signs;
______ rip rap;
______ security lighting;
______ lifesaving stations;
SECTION 5 - 40

State of West Virginia

Board of Risk and Insurance Management
______ retaining walls.
______ Are these miscellaneous structures and equipment included in the inspection
program?

INSPECTION COMMENTS/RECOMMENDATIONS
_______________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Equipment Inspections
BATTERY CHARGING AREA – see Vehicle Maintenance Area

COMPRESSED GAS CYLINDERS – see Welding, Cutting, and Brazing

COMPRESSORS/COMPRESSED AIR

______ Are compressors equipped with pressure relief valves, and pressure gauges?
______ Are compressor air intakes installed and equipped to ensure that only clean
uncontaminated air enters the compressor?
______ Are air filters installed on the compressor intake?
______ Are compressors operated and lubricated in accordance with the manufacture’s
recommendations?
______ Are safety devices on compressed air systems check frequently?
______ Before any repair work is done on the pressure system of a compressor, is the
pressure bled off and the system locked-out?
______ Are signs posted to warn of automatic starting feature of the compressor?
______ Is the belt drive system totally enclosed to provide protection for the front,
back, top, and sides?
______ Is it strictly prohibited to direct compressed air towards a person?
______ Are employees prohibited from using highly compressed air for cleaning
purposes?
______ If compressed air is used for cleaning off clothing; it’s the pressure reduced
to less than 10-psi?
______ When using compressed air for cleaning, do employees wear protective chip
guarding and personal protective equipment?
______ Are safety chains or other suitable locking devices used at couplings of
high pressure hose lines where a connection failure would create a hazard?
______ Before compressed air is used to empty containers of liquid, is the safe
working pressure of the container checked?
______ When compressed air is used with abrasive blast cleaning equipment, is the
operating valve a type that must be held open manually?
SECTION 5 - 41

State of West Virginia

Board of Risk and Insurance Management
______ When compressed air is used to inflate auto tires, is a clip-on chuck and an inline
regulator preset to 40 psi required?
______ Is it prohibited to use compressed air to clean up or move combustible dust if
such action could cause the dust to be suspended in the air and cause a fire or
explosion hazard?
______ Is every receiver equipped with a pressure gauge and with one or more
automatic, spring-loaded safety valves?
______ Is the total relieving capacity of the safety valve capable of preventing pressure
in the receiver from exceeding the maximum allowable working pressure of
the receiver by more than 10 percent?
______ Is every air receiver provided with a drainpipe and valve at the lowest point for
the removal of accumulated oil and water?
______ Are compressed air receivers periodically drained of moisture and oil?
______ Are all safety valves tested frequently and at regular intervals to determine
whether they are in good operating condition?
______ Is the inlet of air receivers and piping systems kept free of accumulated oil and
carbonaceous materials?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FALL PROTECTION

______ Are supervisors required to monitor and enforce the use of written fall
protection procedures?
______ Do workers know they are responsible to know and follow fall protection
procedures?
______ If standard fall protection is not feasible, are all workers required to tie off
with a full body harness and shock-absorbing lanyard equipped with double
locking snaps?
______ Is the use of body belts as part of a personal fall arrest system prohibited?
______ Are only locking type snap-hooks permitted for use in personal fall arrest
systems and positioning systems?
______ Is it required that the lanyard must be attached to the D-ring in the center of
the back and to a structural member capable of supporting a 5,000-pound
load in the event of a fall?
______ Are tie off points required to be above the head as high as possible?
______ Is it required that lanyards can be no longer than six feet?
______ Are employees working from swing scaffolds, boatswain chairs, spider
baskets, etc., required to be tied off to an independent lifeline which is
securely attached to a structural member?
______ Is each worker required to have a separate lifeline to themselves?

SECTION 5 - 42

State of West Virginia

Board of Risk and Insurance Management
______ Is it required that employees working near electrical equipment use nylon or
other non-conductive lanyards (steel slings prohibited)?
______ Are all fall protection equipment protected from damage and kept in good
repair?
______ Is any equipment subject to a fall (in-service loading) immediately removed
from service?
______ Are all employees that are exposed to fall hazards trained in fall protection
procedures, held accountable for compliance, and the training documented?

Is fall protection utilized at the following heights:

______ Commercial roofing – six feet or higher?

______ Residential roofing – 25 feet or higher?
______ General Industry – four feet or higher?
______ Grain handling facilities – six feet or higher where feasible?
______ Steel erection – 25 feet or higher?
______ Scaffolds - 10 feet or higher?
______ When scaffold is less than 45 inches – six feet or higher?
______ Fixed ladders – 25 feet or higher?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FISH CLEANING STATIONS

______ Are fish cleaning stations installed in accordance with manufacturers’

instructions?
______ Are instructions for use and appropriate warnings posted?
______ Are all guards in place?
______ Is all equipment functioning properly and in clean condition?
______ What was the date of the last inspection?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FORKLIFTS - INDUSTRIAL TRUCKS

Also see Material Handling

______ Are only employees who have been trained in the proper use of hoists allowed
to operate them?

SECTION 5 - 43

State of West Virginia

Board of Risk and Insurance Management
______ Is operator training documented?
______ Are only trained personnel allowed to operate industrial trucks?
______ Is substantial overhead protective equipment provided on high lift rider
equipment?
______ Is use of hard hats and appropriate foot protection required?
______ Are your forklifts, motorized vehicles and mechanized equipment inspected
daily or prior to use?
______ Are all industrial trucks not in safe operating condition removed from
service?
______ Are repairs to fuel and ignition systems conducted only in areas specifically
designed for them?
______ Is it prohibited to fuel an internal combustion engine with a flammable liquid
while the engine is running?
______ Are fueling operations done in such a manner that likelihood of spillage will be
minimal?
______ When spillage occurs during fueling operations is the spilled fuel washed away
completely, evaporated or other measures taken to control vapors before
restarting the engine?
______ Are the required lift trucks operating rules posted and enforced?
______ Is directional lighting provided on each industrial truck that operates in an area
with less than 2-foot candles per square foot of generated lighting?
______ Does each industrial truck have a warning horn, whistle, gong, or other device
which can clearly be heard above the normal noise in the areas where
operated?
______ Are the brakes on each industrial truck capable of bringing the vehicle to a
complete and safe stop when fully loaded?
______ Will the industrial truck’s parking brake effectively prevent the vehicle from
moving when unattended?
______ Are trucks shut off and breaks set prior to loading or unloading?
______ Are containers stored, stacked, blocked and limited in height so they are stable
and secure?
______ Are dock boards (bridge plates) used when loading or unloading operations are
taking place between vehicles and docks?
______ Are trucks and trailers secured from movement during loading and
unloading?
______ Are industrial trucks operating in areas where flammable gases or vapors, or
combustible dust or ignitable fibers may be present in the atmosphere,
approved for such locations?
______ Are motorized and hand/rider safety mechanism designed so that the brakes are
applied, and power to drive the motor shuts off when the operator releases his
or her grip on the device that controls the travel?
______ Are industrial trucks with internal combustion engine, operated in buildings or
enclosed areas, carefully checked to ensure operations do not cause harmful
concentration of dangerous gases or fumes?

SECTION 5 - 44

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

FUELING – See Vehicle Maintenance Area

GRINDERS - ABRASIVE WHEEL EQUIPMENT

______ Is the work rest used and kept adjusted to within 1/8 inch of the wheel.
______ Is the adjustable tongue on the top side of the grinder used and kept adjusted
to within ¼ inch of the wheel?
______ Do the guards cover the spindle, nut, and flange and 75 percent of the wheel
diameter?
______ Are bench and pedestal grinders permanently mounted?
______ Is there signage posted requiring the use of eye protection?
______ Are goggles or face shields always worn when grinding?
______ Is the maximum RPM rating of each abrasive wheel compatible with the
RPM rating of the grinder motor?
______ Are fixed or permanently mounted grinders connected to their electrical
supply system with metallic conduit or other permanent wiring method?
______ Does each grinder have an individual on and off control switch?
______ Is each electrically operated grinder effectively grounded?
______ Before new abrasive wheels are mounted, are they visually inspected and
ring tested?
______ Are dust collectors and powered exhausts provided on grinders used in
operations that produce large amounts of dust?
______ Are splashguards mounted on grinders that use coolant to prevent the coolant
reaching employees?
______ Is cleanliness maintained around grinders?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HAND/POWER TOOLS AND EQUIPMENT

______ Are all tools and equipment (both company and employee owned) used by
employees at their workplace in good condition?
______ Are hand tools such as chisels, punches, etc., which develop mushroomed
heads during use, reconditioned or replaced as necessary?

SECTION 5 - 45

State of West Virginia

Board of Risk and Insurance Management
______ Are broken or fracture handles on hammers, axes and similar equipment
replaced promptly?
______ Are worn or bent wrenches replaced regularly?
______ Are appropriate handles used on files and similar tools?
______ Are employees made aware of the hazards caused by faulty or improperly used
hand tools?
______ Are appropriate safety glasses, face shields, etc. used while using hand tools or
equipment which might produce flying materials or be subject to breakage?
______ Are jacks checked periodically to assure they are in good operating condition?
______ Are tool handles wedged tightly in the head of all tools?
______ Are tool cutting edges kept sharp so the tool will move smoothly without
binding or skipping?
______ Are tools stored in dry, secure location where they won’t be tampered with?
______ Is eye and face protection used when driving hardened or tempered studs or
nails?
______ Is it prohibited to fuel an internal combustion engine with a flammable liquid
while the engine is running?
______ Are fueling operations done in such a manner that likelihood of spillage will be
minimal?
______ When spillage occurs during fueling operations is the spilled fuel washed away
completely, evaporated, or other measures taken to control vapors before
restarting the engine?
______ Are fuel caps replaced and secured before starting the engine?
______ In fueling operations, is there always metal contact between the container and
the fuel tank?
______ Are fueling hoses of a type designed to handle the specific type of fuel?
______ Is it prohibited to handle or transfer gasoline in open containers?
______ Are open lights, open flames, or sparking, or arcing equipment prohibited near
fueling or transfer of fuel operations?
______ Is smoking prohibited in the vicinity of fueling operations?
______ Are fueling operators prohibited in building or other enclosed areas that are not
specifically ventilated for this purpose?
______ Where fueling or transfer of fuel is done through a gravity flow system, are the
nozzles of the self-closing type?
______ Are grinders, saws and similar equipment provided with appropriate safety
guards?
______ Are power tools used with the correct shield, guard, or attachment,
recommended by the manufacturer?
______ Are portable circular saws equipped with guards above and below the base
shoe?
______ Are circular saw guards checked to assure they are now wedged up, thus
leaving the lower portion of the blade unguarded?
______ Are rotating and moving parts of equipment guarded to prevent physical
contact?
______ Are all cords connected, electrically operated tools and equipment effectively
grounded or the approved double insulated type?
SECTION 5 - 46

State of West Virginia

Board of Risk and Insurance Management
______ Are effective guards in place over belts, pulleys, chains, sprockets, on
equipment such as concrete mixers, air compressors, etc.?
______ Are portable fans provided with full guards or screens having openings of ½
inch or less?
______ Is hoisting equipment available and used for lifting heavy objects, and are
hoist ratings and characteristics appropriate for the tasks?
______ Are ground-fault circuit interrupters provided on all temporary electrical 15
and 20-ampere circuits used during periods of construction?
______ Are pneumatic and hydraulic hoses on power-operated tools checked regularly
for deterioration or damage?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HOIST AND AUXILIARY EQUIPMENT

______ Is each overhead electric hoist equipped with a limit device to stop the hook
travel at its highest and lowest point of safe travel?
______ Will each hoist automatically stop and hold any load up to 125 percent of its
rated load, if its actuating force is removed?
______ Is the rated load of each hoist legibly marked and visible to the operator?
______ Are stops provided at the safe links of travel for trolley hoist?
______ Are the controls of hoist plainly marked to indicate the direction of travel or
motion?
______ Is each cage-controlled hoist equipped with an effective warning device?
______ Are close-fitting guards or other suitable devices installed on hoist to assure
hoist ropes will be maintained in the sheave groves?
______ Are all hoist chains or ropes of sufficient length to handle the full range of
movement of the application while still maintaining two full wraps on the
drum at all times?
______ Are nip points or contact points between hoist ropes and sheaves which are
permanently located within seven feet of the floor, ground or working
platform, guarded?
______ Is it prohibited to use chains or rope slings that are kinked or twisted?
______ Is it prohibited to use the hoist rope or chain wrapped around the load as a
substitute, for a sling?
______ Have slings been inspected and the inspection documented?
______ Is the operator instructed to avoid carrying loads over people?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 47

State of West Virginia

Board of Risk and Insurance Management
__________________________________________________________________

LADDERS – PORTABLE

______ Are all ladders maintaining in good condition, joints between steps and side
rails tight, all hardware and fittings securely attached and movable parts
operating freely without binding or undue play?
______ Are non-slip safety feet provided on each ladder?
______ Are non-slip safety feet provided on each metal or rung ladder?
______ Are ladder rungs and steps free of grease and oil?
______ Is it prohibited to place a ladder in front of doors opening toward the ladder
except when the door is blocked open, locked or guarded?
______ Is it prohibited to place ladders on boxes, barrels, or other unstable bases to
obtain additional height?
______ Are employees instructed to face the ladder when ascending or descending?
______ Are employees prohibited from using ladders that are broken, missing steps,
rungs, or cleats, broken side rails or other faulty equipment?
______ Are employees instructed not to use the top step of ordinary stepladders as a
step?
______ When portable rung ladders are used to gain access to elevated platforms,
roof, etc., does the ladder always extend at least 3 feet above the elevated
surface?
______ Is it required that when portable rung or cleat type ladders are used, the base
is so that slipping will not occur, or it is lashed or otherwise held in place?
______ Are portable metal ladders legibly marked with signs reading “CAUTION –
DO NOT USE AROUND ELECTRICAL EQUIPMENT” or equivalent
wording?
______ Are employees prohibited from using ladders as guys, braces, skids, gin
poles, or for other than their intended purpose?
______ Are employees instructed to only adjust extension ladders while standing at a
base (not while standing on the ladder or from a position above the ladder)?
______ Are metal ladders inspected for damage, sharp edges or splinters?
______ Are the rungs of ladders uniformly spaced?
______ Is the formula one-foot width for each four feet of height to calculate
separation for the base of the ladder from the structure it is leaning against?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 48

State of West Virginia

Board of Risk and Insurance Management
LOCK-OUT TAG-OUT PROCEDURES

______ Is all machinery or equipment capable of movement, required to be deenergized

or disengaged and blocked or locked out during cleaning,
servicing, adjusting or setting up operations, whenever required?
______ Where the power disconnecting means for the equipment does not also
disconnect the electrical control circuit?
______ Are the appropriate electrical enclosures identified?
______ Is a means provided to assure the control circuit can also be disconnected and
locked out?
______ Is the locking out of control circuits in lieu of locking out main power
disconnects prohibited?
______ Are all equipment control valve handles provided with a means for locking
out?
______ Does the lock out procedure require that stored energy (mechanical,
hydraulic, air, etc.) be released or blocked before equipment is locked out for
repairs?
______ Are appropriate employees provided with individually keyed personal safety
locks?
______ Are employees required to keep personal control of their key(s) while they
have safety locks in use?
______ If there is a master key, is access to it limited?
______ Is it required that only the employee exposed to the hazard place may remove
the safety lock?
______ Is it required that employees check the safety of the lock out by attempting a
start up after making sure no one is exposed?
______ Are employees instructed to always push the control circuit stop button prior
to re-engaging the main power switch?
______ Is there a means provided to identify any or all employees who are working
in locked-out equipment by their locks or accompanying tags?
______ Are sufficient number of accident preventative signs or tags and safety
padlocks provided for any reasonable foreseeable repair emergency?
______When machine operations, configuration or size requires the operator to
leave his or her control station to install tools or perform other operations,
and that part of the machine could move if accidentally activated, is such
element required to be separately locked or blocked out?
______ In the event that equipment or lines cannot be shut down, locked-out and
tagged, is a safe procedure established and rigidly followed?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SECTION 5 - 49

State of West Virginia

Board of Risk and Insurance Management
MACHINE GUARDING

______ Is there a training program to instruct employees on safe methods of machine

operation?
______ Is there adequate supervision to ensure that employees are following safe
machine operating procedures?
______ Is there a regular program of safety inspection of machinery and equipment?
______ Is all machinery and equipment kept clean and properly maintained?
______ Is sufficient clearance around and between machines to allow for safe
operations, set up and servicing, material handling and waste removal?
______ Is equipment and machinery securely placed and anchored, when necessary
to prevent tipping or other movement that could result in personal injury?
______ Is there a power shut off switch within reach of the operator’s position at each
machine?
______ Can electric power to each machine be locked out for maintenance, repair, or
security?
______ Are the non-current-carrying metal parts of electrically operated machines
bonded and grounded?
______ Are foot operated switches guarded or arranged to prevent accidental
actuation by personnel or falling objects?
______ Are manually operated valves and switches controlling the operation of
equipment and machines clearly identified and readily accessible?
______ Are all emergency stop buttons colored red?
______ Are all pulleys and belts that are within 7 feet of the floor or working level
properly guarded?
______ Are all moving chains and gears properly guarded?
______ Are splashguards mounted on machines that use coolant to prevent the
coolant from reaching employees?
______ Are methods provided to protect the operator and other employees in the
machine area from hazards created at the point of operation, in-going nip
points, rotating parts, flying chips, and sparks?
______ Are machinery guards secure and so arranged that they do not offer a hazard
in their use?
______ If special hand-tools are used for placing and removing material, do they
protect the operator’s hands?
______ Are revolving drums, barrels, and containers required to be guarded by an
enclosure that is interlocked with the drive mechanism, so that revolution
cannot occur unless the guard enclosures are in place, so guarded?
______ Do arbors and mandrels have firm and secure bearings and are they free from
play?
______ Are provisions made to prevent machines from automatically starting when
power is restored after a power failure or shutdown?
______ Are machines so constructed so as to be free from excessive vibration when
the largest tool is mounted and run at full speed?
______ If machinery is cleaned with compressed air, is air pressure controlled and
personal protective equipment or other safeguards utilized to protect
operators and other workers from eye and body injury?
SECTION 5 - 50

State of West Virginia

Board of Risk and Insurance Management
______ Are fan blades protected with a guard having opening no larger than ½ inch,
when operating within 7 feet of the floor?
______ Are saws used for ripping equipped with anti kick-back devices and
spreaders?
______ Are radial arm saws so arranged that the cutting head will gently return to the
back of the table when released?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

PLAYGROUNDS

Is the overall equipment properly maintained to ensure:

______ nuts, bolts, and screws are recessed, covered or sanded smooth and level
______ nuts and bolts are tight and not able to be loosened without tools
______ metal equipment is free of rust and chipping paint
______ wooden equipment is free of splinters and rough surfaces
______ equipment is free of sharp edges
______ ropes, chains, and cables have not frayed or worn out
______ equipment has not shifted or become bent
______ there are no open “V” entrapment angles on any part of the equipment
______ there are no holes in the equipment forming finger traps (e.g. at the ends of
the tubes)
______ there are no pinch, crush, and shear points
______ there is no corrosion or visible rotting at points where equipment comes into
contact with ground surfaces
______ no components are missing. All parts of the equipment are present
______ there are no head entrapment areas (spaces 3½” to 9”)
______ handgrips are between 1” and1.67” in diameter for playgrounds designed for
ages 6-12 and 1.25” for playgrounds designed for ages 2-5
______ footing for equipment is stable and buried below ground level or covered by
surfacing materials?

Is playground evaluated for general environmental hazards:

______ can be reached safely by children (on foot or on bicycle)

______ if needed, a suitable perimeter fence is provided for border hazards within
100’ of playground edge (streets with heavy traffic, railroad tracks, parking
lots, etc.)

SECTION 5 - 51

State of West Virginia

Board of Risk and Insurance Management
______ seating (benches, outdoor tables) is in good condition (free of splinters,
missing hardware or slats, protruding bolts, etc.)
______ signs to give information about where to seek help in case of emergency
______ signs to give information about regulations on the use of the playground
(hours, pets, age, etc.)
______ signs to give information of name and number of responsible authority (to
report hazards)
______ signs on all bordering roads advise motorists that a playground is nearby
______ trash receptacles are provided, located outside of the play area, and emptied
daily
______ poisonous plants are removed from play area
______ shaded area is provided
______ the play area is visible to deter inappropriate behavior?

Is equipment designed for appropriate age/size:

______ are the children who use the equipment of age/developmental level for which
the equipment was designed (i.e. ages 2-5 and 6-12)
______ the playground design separates younger users (2-5) through appropriately
selected equipment
______ the play area has signage that informs users of the intended user age group?

Is equipment designed for accessibility:

______ the playground is accessible to people with disabilities (access to playground

is at least 60” wide)
______ the playground use zone has an accessible safety surface
______ accessible restroom facilities are located nearby
______ accessible seating is located in the play area
______ an accessible source of drinking water is available in or near the play area

Is playground protective surface present to ensure:

______ all elevated play equipment (slides, swings, bridges, seesaws, climbing
apparatus, etc.) has 12” of loose fill or impact-absorbing material underneath
and extending a minimum of 6’ around the structure
______ surfacing materials, such as sand, pea gravel (round 1/8” pellets), wood
chips, or manufactured unitary surfaces pass the 200 G test from the highest
accessible part of the equipment
______ surfaces are checked at least weekly and raked to prevent them from
becoming packed down and to remove hidden hazards (e.g. litter, sharp
objects, animal feces)
______ loose materials are replenished as needed to maintain adequate depth and
coverage;
______ standing water is not found on the surface or inside the equipment?

SECTION 5 - 52

State of West Virginia

Board of Risk and Insurance Management
Are slides constructed to ensure:
______ they are no more than 8 feet high
______ the ladder to access the slide is angled at less than 75 degrees with handrails
on both sides, flat steps spaced less than 12” apart, and completely enclosed
risers
______ the flat surface at the top of the slide is a minimum of 22” long going back
from the slide bed-way and is the width of the slide
______ there is a barrier at the top of the slide to prevent falls with handholds to
assist in sitting
______ sides of the bed-ways are at least 4” high
______ the angle of the sliding surface averages less than or equal to 30 degrees
______ a flat sliding surface (run out zone) at the bottom of the slide is a minimum
of 11” long;
______ for slides taller than 4 feet high designed for school age children (5-12
years), the bottom of the slide does not exceed 15” above the protective
surface material
______ for slides 4’ high or less and designed for preschool ages (2-5 years), the
bottom of the slide does not exceed 11” above the protective surface
material
______ tube slides have a minimum diameter equal to or greater than 23”
______ there are no circular slides in the pre-school play area
______ the sliding surface is not made of wood or fiberglass
______ if the slide is made in several pieces, the sliding surface must have no gaps or
rough edges?
______ the sliding surface faces away from the s un or is located in the shade
______ steps are regularly spaced, less than or equal to 12” apart from top to bottom?

Are climbing devices constructed to ensure:

______ handholds stay in place when grasped

______ accessible equipment height (platform, deck, etc.) does not exceed 4’ for 2-5
year old users
______ children have a safe way to descend equipment when they have reached the
top
______ climbing bars and handrails are between 1” and 1.67” in diameter
______ there is a 29” (minimum protective perimeter barrier around pre-school (2-5)
equipment that is more than 30” above the underlying surface
______ 38” protective barriers are present when elevated surface exceeds 48” above
underlying surface for school age children’s (5-12) equipment
______ footholds are less than or equal to 12” apart from top to bottom
______ spaces between openings should not be between 3½” and 9” to avoid
entrapment hazards
______ guardrails are present for all elevated surfaces 30” above the underlying
surface for school age children’s (5-12) equipment. (Over 48” needs
protective barrier.)
______ guardrails or protective barriers are present on all elevated surfaces greater
than 20” above underlying surface for preschool age children (2-5).
SECTION 5 - 53

State of West Virginia

Board of Risk and Insurance Management
______ the center of the grasping device or horizontal ladders to the underlying
surface material is no greater than 84” on climbing devices designated to
children over the age of 5 years, 60” on devices for children from 2 to 5 years
of age?

Are swings constructed to ensure:

______ multiple occupancy swings with the exception of tire swings are not
recommended for use in public playgrounds and should be removed
______ animal figure swings are not recommended for use in public playgrounds and
should be removed
______ rope swings are not recommended for use in public playgrounds and should
be removed
______ swinging exercise rings and trapeze bars are not recommended for use in
public playgrounds and should be removed
______ swing seats are to be made of canvas, rubber or other lightweight material
______ lightweight bucket-type swing seats are available for toddlers and children
with disabilities and all openings meet entrapment criteria
______ the swing clearance in both directions must be 2 times the height of the
swing
______ the swing clearance is to be covered with impact absorbing surface material
______ swings are to be at least 24” from each other and 30” away from the frame
______ “S” hook openings are no greater than .04”
______ hanging rings are less the 3½” or more than 10” in diameter
______ chain link openings do not exceed 5/16” in diameter (4.0 chain)
______ when stationary, all seats are level
______ there are no two swings in any individual swing bay
______ preschool swing seats are at a maximum height of 18” and no occupied
swing seat is less than 12” from the protective surface
______ the swing set crossbar is not more than 8’ above the surface for tot-swings
and 10’ above the surface for school age children
______ for tire swings there is at least a 30” safety zone from the crossbeam support
structure and the furthest extensions of the swing, and each must have a
minimum clearance of 12” from the bottom of the tire to the protective
surface
______ for tire swings have drainage openings every 5” to 6” if conventional tires
are used
______ for tire swings not made of steel belted radial tires;
______ to-fro swings and rotating equipment are located away from circulation paths
(a distance at least equal to the equipment use zone and an additional safety
factor for circulation) and near the periphery of the playground?

Are seesaws constructed to ensure:

______ the maximum seat level does not reach more than 5’ above the ground
______ the fulcrum is enclosed or designed to prevent pinching
SECTION 5 - 54

State of West Virginia

Board of Risk and Insurance Management
______ handholds stay in place when grasped without turning or wobbling and do
not extend beyond seat width
______ a rubber tire segment is buried in the surfacing material under the seats?

Are sand play areas established to ensure:

______ located in a shaded area

______ inspected and raked at least every week for debris and to provide exposure to
air and sun
______ if in a box, cover at night to prevent animal excrement contamination
______ does not have standing water?

Is rocking equipment constructed to ensure:

______ seating surfaces are less than 30” above the protective surface
______ there are no equipment parts that could cause a pinching or crushing injury
______ handholds stay in place when grasped and pass the protrusion test
______ footrests stay in place and pass the protrusion test?

Is the crawl through tunnel constructed to ensure:

______ all components of the tunnels are secure and firmly fixed
______ the internal diameter of the tunnel is at least 40”
______ the tunnel has two safe, clear exits
______ the tunnel is designed to drain freely?

Are merry-go-rounds constructed to ensure:

______ rotating platform is continuous and approximately circular. The difference

between the minimum and maximum radii of a non-circular platform should
not exceed 2”
______ no components of the rotating equipment, including handrails, extend
beyond the platform perimeter
______ there are no openings in the surface of the platform that permit the
penetration of 5/16” rod through the surface
______ handrails should have a diameter between 1” and 1.67”
______ there are no accessible shearing or crushing mechanisms in the undercarriage
of the equipment
______ the platform does not provide up and down motion
______ The peripheral speed of the platform does not exceed 13 feet per second?

SECTION 5 - 55

State of West Virginia

Board of Risk and Insurance Management
INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

PORTABLE (POWER OPERATED) TOOLS AND EQUIPMENT – see Hand

Tools and Equipment

POWDER ACTUATED TOOLS

______ Are employees who operate powder-actuates tools trained in their use and
carry a valid operator’s card?
______ Is each powder-actuate tool stored in its own locked container when not
being used?
______ Is a sign at least 7 inches by 10 inches with bold type reading
“POWDERACTUATED TOOL IN USE” conspicuously posted when the tool is
being used?
______ Are powder-actuated tools left unloaded until they are actually ready to be
used?
______ Are powder-actuated tools inspected for obstructions or defects each day before
use?
______ Do powder-actuated tool operators have and use appropriate personal protective
equipment such as hard hats, safety goggles, safety shoes and ear protection?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SCAFFOLDS

______ Is it required that if the platform is not protected by standard handrails and
toe boards, a safety harness be used?
______ Are freestanding scaffolds stable; anchored if necessary?
______ Is the use of fiber rope prohibited if used around extreme heat, open flame,
or where burning, welding, or cutting is done?
______ Is there a pre-use inspection of scaffolding?
______ Has scaffolding been constructed, maintained, and placed in accordance with
structural manufacture’s specifications?

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INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

SPRAYING OPERATIONS

______ Is adequate ventilation assured before spray operations are started?

______ Is mechanical ventilation provided when spraying operations are done in
enclosed areas?
______ When mechanical ventilation is provided during spraying operations, is it so
arranged that it will not circulate the contaminated air?
______ Is the spray area free of hot surfaces?
______ Is the spray area at least 20 feet from flames, sparks, operating electrical
motors and the other ignition sources?
______ Are portable lamps used to illuminate spray areas suitable for use in a
hazardous location?
______ Is approved respiratory equipment provided and used when appropriate
during spraying operations?
______ Do solvents used for cleaning have a flash point of 100 degrees F or more?
______ Are fire control sprinkler heads kept clean?
______ Are “NO SMOKING” signs posted in spray areas, paint rooms, paint booths,
and paint storage areas?
______ Is the spray area kept clean of combustible residue?
______ Are spray booths constructed of metal, masonry, or other substantial
noncombustible material?
______ Are spray booth floors and baffles noncombustible and easily cleaned?
______ Is infrared drying apparatus kept out of the spray area during spray
operations?
______ Is the spray booth completely ventilated before using the drying apparatus?
______ Is the electric drying apparatus properly grounded?
______ Are lighting fixtures for spray booths located outside of the booth and the
interior lighted through sealed clear panels?
______ Are the electrical motors for exhaust fans placed outside the booths or ducts?
______ Are belts and pulleys inside the booth fully enclosed?
______ Do ducts have access doors to allow cleaning?
______ Do all drying spaces have adequate ventilation?
______ Is appropriate personal protective equipment provided and used?
______ Is the correct type of respirator being worn by personnel?
______ Are all chemicals used in spray painting operations correctly labeled?
______ Are MSDSs for all chemicals accessible and reviewed?
______ Are tools used for cleaning purposes made of non-sparking material?
______ Do electrical and fire suppression methods meet codes for Hazardous
Communications?

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INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

TIRE INFLATION see Vehicle Maintenance Area

WELDING, CUTTING, AND BRAZING

______ Are only authorized and trained personnel permitted to use welding, cutting
or brazing equipment?
______ Does each operator have a copy of the appropriate operating instructions and
are they directed to follow them?
______ Are employees exposed to the hazards created by welding, cutting, or
brazing operations protected with personal protective equipment and
clothing?
______ In addition to the appropriate personal protective equipment required, do the
eye protection helmets, hand shields and goggles used meet appropriate
welding operator equipment standards?
______ Are compressed gas cylinders regularly examined for obvious signs of
defects, deep rusting, or leakage?
______ Is care used in handling and storage of cylinders, safety valves, relief valves,
etc., to prevent damage?
______ If welding gases are stored, handled, and used in accordance with safe
practices and standards?
______ Are precautions taken to prevent the mixture of air or oxygen with
flammable gases, except at a burner or in a standard torch?
______ Are only approved apparatus (torches, regulators, pressure-reducing valves,
acetylene generators, manifolds) used?
______ Are cylinders kept away from heat sources?
______ Are the cylinders kept away from elevators, stairs, or gangways?
______ Is it prohibited to use cylinders as rollers or supports?
______ Are empty cylinders appropriately marked and their valves closed?
______ Are signs reading: DANGER – NO SMOKING, MATCHES, OR OPEN
FLAMES, or the equivalent, posted?
______ Are cylinders, cylinder valves, couplings, regulators, hoses, and apparatus
kept free of oily or greasy substances?
______ Are parallels lengths of oxygen and acetylene taped together for convenience
and to prevent tangling, covered by not more than 4 inches out of 12 inches?
______ Is care taken not to drop or strike cylinders?
______ Unless secured on special trucks, are regulators removed and valve
protection caps put in place before moving cylinders?
______ Do cylinders without fixed hand wheels have keys, handles or non-adjustable
wrenches on stem valves when in service?

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______ Are liquefied gases stored and shipped valve -end up with valve covers in
place?
______ Are provisions made to never crack a fuel-gas cylinder valve near a source of
ignition?
______ Before a regulator is removed, is the valve closed and gas released from the
regulator?
______ Is red used to identify the acetylene (and other fuel-gas) hose, green for
oxygen hose, and black for inert gas and air hose?
______ Are pressure-reducing regulators used only for the gas and pressures for
which they were intended?
______ Is open circuit (No Load) voltage or arc welding and cutting machines as low
as possible and not in excess of the recommended limits?
______ Under wet conditions, are automatic controls for reducing no load voltage
used?
______ Is grounding of the machine frame and safety ground connections of portable
machines checked periodically?
______ Are electrodes removed from the holders when not in use?
______ Is the required electric power to the welder shut off when no one is in
attendance?
______ Is suitable fire extinguisher equipment available for immediate use?
______ Is the welder forbidden to coil or loop welding electrode cable around his
body?
______ Are wet machines thoroughly dried and tested before being used?
______ Are work and electrode leads frequently inspected for wear and damage, and
replaced when needed?
______ Do means for connecting cable lengths have adequate insulation?
______ When the object to be welded cannot be moved and fire hazards cannot be
removed, are shields used to confine heat, sparks, and slag?
______ Are fire-watchers assigned when welding or cutting is performed in locations
where a serious fire might develop?
______ Are combustible floors kept wet, covered by damp sand, or protected by
fire resistant shields?
______ When floors are wet down, are personnel protected from possible electrical
shock?
______ When welding is done on metal walls, are precautions taken to protect
combustibles on the other side?
______ Before hot work is begun, are used drums, barrels, tanks, and other
containers so thoroughly cleaned that no substances remain that could
explode, ignite, or produce toxic vapors?
______ Is check made for adequate ventilation in and where welding or cutting is
performed?
______ When working in confined places, are environmental monitoring tests taken
and means provided for quick removal of welders in case of emergency?
______ Are cylinders with a water weight capacity over 30 pounds, equipped with
means for connecting a valve protector device or with a collar or recess to
protect the valve?
______ Are compressed gas cylinders legibly marked to clearly identify the gas
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 containment (generally by color code)?
______ Are compressed gas cylinders stored in areas which are protected from external
heat sources such as flame impingement, intense radiant heat, electric arcs, or
high temperature lines?
______ Are cylinders located in areas where they will not be damaged by passing or
falling objects or subject to tampering by unauthorized persons?
______ Are cylinders stored or transported in a manner to prevent them from creating
a hazard by tipping, falling or rolling?
______ Are cylinders containing liquefied fuel gas, stored or transported in a position
so that the safety relief device is always in direct contact with the vapor space
in the cylinder?
______ Are fuel gas cylinders and oxygen cylinders separated by distance, fire
resistant barriers, etc while in storage?
______ Are valve protectors always placed on cylinders when the cylinders are not in
use or connected for use?
______ Are all valves closed off before a cylinder is moved, when the cylinder empty,
and at the completion of each job?
______ Are low-pressure fuel-gas cylinders checked periodically for corrosion,
general distortion, cracks, or any other defects that might indicate a weakness
or render it unfit for service?
______ Does the periodic check of low-pressure fuel-gas cylinders include a close
inspection of the cylinders' bottom?

INSPECTION COMMENTS/RECOMMENDATIONS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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Emergency Management
Plan
 Emergency Management Plan

Emergency Plans and Procedures

Having plans in place for dealing with unexpected emergencies is critically important to
preventing the loss of life and controlling injury to people and damage to property. There
is no substitute for being prepared when an emergency situation arises. This section
outlines the steps for establishing emergency and evacuation plans including instructions
for the evacuation of persons with disabilities. Information on specific emergencies
including fire, natural disaster/severe weather, hazmat emergencies, technological, bomb
threats, and workplace violence are covered. Also covered is contingency planning in
case of business interruption.

It is extremely important that all personnel know exactly what to do in the event of an
emergency. Established emergency plans should be periodically communicated to all
employees, tested by actual drills and updated whenever necessary.

There is no single emergency plan that is adaptable to all situations. To develop specific
plans each entity will need to draw upon any expertise that is available from their police
departments, government agencies, and security specialists. (See Appendix 1 Sample
Emergency Plan Template and Appendix 2 Stanford University Campus Emergency
Plan)

Emergency Planning Process

Step 1 -- Establish a Planning Team

Step 2 -- Analyze Capabilities and Hazards
Step 3 -- Develop the Plan
Step 4 -- Implement the Plan

STEP 1 – Establish a Planning Team

Determine who is in charge of developing the emergency management plan. The
following is guidance for making the appointment.

1. Form the Team - the size of the planning team will depend on the facility's
operations, requirements and resources. Usually involving a group of people is
best because:
a. It encourages participation and gets more people invested in the
process.

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 b. It increases the amount of time and energy participants are able to give.
c. It enhances the visibility and stature of the planning process.
d. It provides for a broad perspective on the issues.

Determine who can be an active member and who can serve in an advisory
capacity. In most cases, one or two people will be doing the bulk of the work. At
the very least, you should obtain input from all functional areas.

2. Establish Authority - demonstrate management's commitment and promote an

atmosphere of cooperation by "authorizing" the planning group to take the steps
necessary to develop a plan. The group should be led by the chief executive or
entity manager. Establish a clear line of authority between group members and the
group leader, though not so rigid as to prevent the free flow of ideas.

3. Issue a Mission Statement - have the chief executive issue a mission statement
to demonstrate the entity's commitment to emergency management. The statement
should:
a. Define the purpose of the plan and indicate that it will involve the entire
organization
b. Define the authority and structure of the planning group

4. Establish a Schedule and Budget - establish a work schedule and planning

deadlines. Timelines can be modified as priorities become more clearly defined.

Develop an initial budget for such things as research, printing, seminars,

consulting services and other expenses that may be necessary during the
development process.

STEP 2 -- ANALYZE CAPABILITIES AND HAZARDS

This step entails gathering information about current capabilities and about possible
hazards and emergencies, and then determining the facility's capabilities for handling
emergencies.

1. Where do you stand right now?

Review Internal Plans and Policies

Documents to look for include:

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Board of Risk and Insurance Management
 a. Evacuation plan
b. Fire protection plan
c. Safety and health program
d. Environmental policies
e. Security procedures
f. Insurance programs
g. Employee manuals
h. Hazardous materials plan
i. Process safety assessment
j. Risk management plan

2. Meet with Outside Groups

Meet with government agencies, community organizations and utilities. Ask

about potential emergencies and about plans and available resources for
responding to them. Sources of information include:

a. Community emergency management office

b. Mayor or Community Administrator's office
c. Local Emergency Planning Committee (LEPC)
d. Fire Department
e. Police Department
f. Emergency Medical Services organizations
g. American Red Cross
h. National Weather Service
i. Public Works Department
j. Planning Commission
k. Telephone companies
l. Electric utilities

3. Identify Codes and Regulations

Identify applicable Federal, State and local regulations such as:

a. Occupational safety and health regulations

b. Environmental regulations
c. Fire codes
d. Transportation regulations
e. Zoning regulations
f. Corporate policies

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4. Identify Critical Products, Services and Operations

You'll need this information to assess the impact of potential emergencies and to
determine the need for backup systems. Areas to review include:

a. Entity products and services and the equipment needed to produce them
b. Products and services provided by suppliers, especially sole source
vendors
c. Lifeline services such as electrical power, water, sewer, gas,
telecommunications and transportation
d. Operations, equipment and personnel vital to the continued functioning
of the entity

5. Identify Internal Resources and Capabilities

Resources and capabilities that could be needed in an emergency include:

a. Personnel -- fire brigade, hazardous materials response team,

emergency medical services, security, emergency management
group, evacuation team, public information officer
b. Equipment -- fire protection and suppression equipment, communications
equipment, first aid supplies, emergency supplies, warning systems,
emergency power equipment, decontamination equipment
c. Facilities -- emergency operating center, media briefing area,
shelter areas, first-aid stations, sanitation facilities
d. Organizational capabilities -- training, evacuation plan,
employee support system
e. Backup systems -- arrangements with other facilities to provide for:

1. Payroll
2. Communications
3. Customer services
4. Shipping and receiving
5. Information systems support
6. Emergency power
7. Recovery support

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6. Identify External Resources

There are many external resources that could be needed in an emergency. In some
cases, formal agreements may be necessary to define the facility's relationship
with the following:

a. Local emergency management office

b. Fire Department
c. Hazardous materials response organization
d. Emergency medical services
e. Hospitals
f. Local and State Police
g. Community service organizations
h. Utilities
i. Contractors
j. Suppliers of emergency equipment

7. List Potential Emergencies

List all emergencies that could affect your facility, including those identified by
your local emergency management office. Consider both:

a. Emergencies that could occur within your facility

b. Emergencies that could occur in your community

Below are some other factors to consider:

Historical -- What types of emergencies have occurred in the community,

at this facility and at other facilities in the area?
1. Fires
2. Severe weather
3. Hazardous material spills
4. Transportation accidents
5. Earthquakes
6. Tornadoes
7. Terrorism
8. Utility outages
9. Flooding

Geographic -- What can happen as a result of the entity's location? Keep

in mind:

1. Proximity to flood plains, seismic faults and dams

2. Proximity to companies that produce, store, use or transport
hazardous materials

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 3. Proximity to major transportation routes and airports
4. Proximity to nuclear power plants

Technological -- What could result from a process or system failure?

Possibilities include:

1. Fire, explosion, hazardous materials incident

2. Safety system failure
3. Telecommunications failure
4. Computer system failure
5. Power failure
6. Heating/cooling system failure
7. Emergency notification system failure

Human Error -- What emergencies can be caused by employee error?

Are employees trained to work safely? Do they know what to do in an
emergency? Human error is the single largest cause of workplace
emergencies and can result from:

1. Poor training
2. Poor maintenance
3. Carelessness
4. Misconduct
5. Substance abuse
6. Fatigue

Physical -- What types of emergencies could result from the design or

construction of the entity’s facility? Does the physical facility enhance
safety? Consider:

1. The physical construction of the facility

2. Hazardous processes or byproducts
3. Facilities for storing combustibles
4. Layout of equipment
5. Lighting
6. Evacuation routes and exits
7. Proximity of shelter areas

Regulatory -- What emergencies or hazards are you regulated to deal

with?
Analyze each potential emergency from beginning to end. Consider what
could happen as a result of:

1. Prohibited access to the facility

2. Loss of electric power
3. Communication lines down

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 4. Ruptured gas mains
5. Water damage
6. Smoke damage
7. Structural damage
8. Air or water contamination
9. Explosion
10. Building collapse
11. Trapped persons
12. Chemical release

8. Assess the Potential Human Impact

Analyze the potential human impact of each emergency -- the possibility of death
or injury.

9. Assess the Potential Property Impact

Consider the potential property for losses and damages.

Consider:

a. Cost to replace
b. Cost to set up temporary replacement
c. Cost to repair

10. Assess the Potential Business Impact

Assess the impact of:

a. Business interruption
b. Employees unable to report to work
c. Contractual agreements
d. Interruption of critical supplies
e. Interruption of product distribution

11. Assess Internal and External Resources

Next assess your resources and ability to respond. To help you do this, consider
each potential emergency from beginning to end and each resource that would be
needed to respond. For each emergency ask these questions:

a. Do we have the needed resources and capabilities to respond?

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 b. Will external resources be able to respond to us for this emergency as
quickly as we may need them, or will they have other priority areas to
serve?
c. If the answers are yes, move on to the next assessment. If the answers are
no, identify what can be done to correct the problem. For example, you
may need to:
1. Develop additional emergency procedures
2. Conduct additional training
3. Acquire additional equipment
4. Establish mutual aid agreements
5. Establish agreements with specialized contractors

STEP 3 -- DEVELOP THE PLAN

You are now ready to develop an emergency management plan. This section describes
how.

PLAN COMPONENTS

Your plan should include the following basic components.

1. Executive Summary

The executive summary gives management a brief overview of: the

purpose of the plan; the facility's emergency management policy;
authorities and responsibilities of key personnel; the types of emergencies
that could occur; and where response operations will be managed.

2. Emergency Management Elements

This section of the plan briefly describes the entity's approach to the core
elements of emergency management, which are:

a. Direction and control

b. Communications
c. Life safety
d. Property protection
e. Community outreach
f. Recovery and restoration
g. Administration and logistics.

These elements, which are described in detail in Section 2, are the

foundation for the emergency procedures that your entity will follow to
protect personnel and equipment and resume operations.

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3. Emergency Response Procedures

The procedures spell out how the entity will respond to emergencies.
Whenever possible, develop them as a series of checklists that can be
quickly accessed by senior management, department heads, response
personnel and employees.

Determine what actions would be necessary to:

a. Assess the situation

b. Protect employees, customers, visitors, equipment, vital records
and other assets, particularly during the first three days
c. Get the business back up and running.

Specific procedures might be needed for any number of situations such as

bomb threats or tornadoes, and for such functions as:

a. Warning employees and customers

b. Communicating with personnel and community responders
c. Conducting an evacuation and accounting for all persons in the
entity’s facility
d. Managing response activities
e. Activating and operating an emergency operations center
f. Fighting fires
g. Shutting down operations
h. Protecting vital records
i. Restoring operations

4. Support Documents

Documents that could be needed in an emergency include:

Emergency call lists -- lists (wallet size if possible) of all persons on and
off site who would be involved in responding to an emergency, their
responsibilities and their 24-hour telephone numbers.

Building and site maps that indicate:

a. Utility shutoffs
b. Water hydrants
c. Water main valves
d. Water lines
e. Gas main valves
f. Gas lines
g. Electrical cutoffs
h. Electrical substations
i. Storm drains

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 j. Sewer lines
k. Location of each building (include name of building, street name
and number)
l. Floor plans
m. Alarm and enunciators
n. Fire extinguishers
o. Fire suppression systems
p. Exits
q. Stairways
r. Designated escape routes
s. Restricted areas
t. Hazardous materials (including cleaning supplies and chemicals)
u. High-value items

Resource lists -- lists of major resources (equipment, supplies, services)

that could be needed in an emergency; mutual aid agreements with local
companies and other government agencies.

Some entity facilities may be required to develop:

1. Emergency escape procedures and routes

2. Procedures for employees who perform or shut down critical
operations before an evacuation
3. Procedures to account for all employees, visitors and contractors
after an evacuation is completed
4. Rescue and medical duties for assigned employees
5. Procedures for reporting emergencies
6. Names of persons or departments to be contacted for information
regarding the plan

THE DEVELOPMENT PROCESS

The following is guidance for developing the plan.

1. Identify Challenges and Prioritize Activities

Make a list of tasks to be performed, by whom and when. Determine how

you will address the problem areas and resource shortfalls that were
identified in the planning process.

2. Write the Plan

Assign each member of the planning group a section to write. Determine

the most appropriate format for each section.

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 Establish an aggressive timeline with specific goals. Provide enough time
for completion of work, but not so much as to allow assignments to linger.
Establish a schedule for:

a. First draft
b. Review
c. Second draft
d. Tabletop exercise
e. Final draft
f. Printing
g. Distribution

3. Establish a Training Schedule

Have one person or department responsible for developing a training

schedule for your entity. For specific ideas about training, refer to Step 4.

4. Coordinate with Outside Organizations

Meet periodically with local government agencies and community

organizations. Inform appropriate government agencies that you are
creating an emergency management plan. While their official approval
may not be required, they will likely have valuable insights and
information to offer.

Determine State and local requirements for reporting emergencies, and

incorporate them into your procedures.

Determine protocols for turning control of a response over to outside

agencies. Some details that may need to be worked out are:

a. Which entrance will responding units use?

b. Where and to whom will they report?
c. How will they be identified?
d. How will entity personnel communicate with outside
responders?
e. Who will be in charge of response activities?

Determine what kind of identification authorities will require to allow key

personnel into entity facilities during an emergency.

5. Contact other offices and divisions to learn:

a. Their emergency notification requirements

b. The conditions where mutual assistance would be necessary

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 c. How offices will support each other in an emergency
d. Names, telephone numbers and pager numbers of key personnel

6. Review, Conduct Training and Revise

Distribute the first draft to group members for review. Revise as needed.

For a second review, conduct a tabletop exercise with management and

personnel who have a key emergency management responsibility. In a
conference room setting, describe an emergency scenario and have
participants discuss their responsibilities and how they would react to the
situation. Based on this discussion, identify areas of confusion and
overlap, and modify the plan accordingly.

7. Seek Final Approval

Arrange a briefing for the chief executive officer and senior management
and obtain written approval.

8. Distribute the Plan

Place the final plan in three-ring binders and number all copies and pages.
Each individual who receives a copy should be required to sign for it and
be responsible for posting subsequent changes.
Determine which sections of the plan would be appropriate to show to
government agencies (some sections may include private listings of
names, telephone numbers or radio frequencies). Distribute the final plan
to:

a. Chief executive and senior managers

b. Members of the emergency response team
c. Community emergency response agencies
(appropriate sections)

Have key personnel keep a copy of the plan in their homes. Inform
employees about the plan and training schedule.

STEP 4 -- IMPLEMENT THE PLAN

Implementation means more than simply exercising the plan during an emergency. It
means acting on recommendations made during the vulnerability analysis, integrating the
plan into company operations, training employees and evaluating the plan.

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INTEGRATE THE PLAN INTO OPERATIONS

Look for opportunities to build awareness; to educate and train personnel;

to test procedures; to involve all levels of management, all departments
and the community in the planning process; and to make emergency
management part of what personnel do on a day-to-day basis.

Test How Completely The Plan Has Been Integrated By Asking:

a. How well does senior management support the responsibilities

outlined in the plan?
b. Have emergency planning concepts been fully incorporated into
the entity's accounting, personnel and financial procedures?
c. How can the entity's processes for evaluating employees and
defining job classifications better address emergency
management responsibilities?
d. Are there opportunities for distributing emergency preparedness
information through corporate newsletters, employee manuals or
employee mailings?
e. What kinds of safety posters or other visible reminders would be
helpful?
f. Do personnel know what they should do in an emergency?
g. How can all levels of the organization be involved in evaluating
and updating the plan?

CONDUCT TRAINING, DRILLS AND EXERCISES

Everyone who works at or visits the entity should be required to take part
in some form of training. This could include periodic employee discussion
sessions to review procedures, technical training in equipment use for
emergency responders, evacuation drills and full-scale exercises. Below
are basic considerations for developing a training plan.

1. Planning Considerations

Assign responsibility for developing a training plan. Consider the

training and information needs for employees, contractors, visitors,
managers and those with an emergency response role identified in
the plan.
Determine for a 12-month period:

a. Who will be trained?

b. Who will do the training?
c. What training activities will be used?
d. When and where each session will take place?

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 e. How the session will be evaluated and documented?

Consider how to involve community responders in training

activities.
Conduct reviews after each training activity. Involve both
personnel and community responders in the evaluation process.

2. Training Activities

Training can take many forms:

a. Orientation and Education Sessions -- These are

regularly scheduled discussion sessions to provide
information, answer questions and identify needs
and concerns.

b. Tabletop Exercise -- Members of the emergency

management group meet in a conference room
setting to discuss their responsibilities and how they
would react to emergency scenarios.

c. Walk-through Drill -- The emergency management

group and response teams actually perform their
emergency response functions. This activity
generally involves more people and is more
thorough than a tabletop exercise.

d. Functional Drills -- These drills test specific

functions such as medical response, emergency
notifications, warning and communications
procedures and equipment, though not necessarily
at the same time. Personnel are asked to evaluate
the systems and identify problem areas.

e. Evacuation Drill -- Personnel walk the evacuation

route to a designated area where procedures for
accounting for all personnel are tested. Participants
are asked to make notes as they go along of what
might become a hazard during an emergency, e.g.,
stairways cluttered with debris, smoke in the
hallways. Plans are modified accordingly.

f. Full-scale Exercise -- A real-life emergency

situation is simulated as closely as possible. This

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 exercise involves emergency response personnel,
employees, management and community response
organizations.

3. Employee Training

General training for all employees should address:

a. Individual roles and responsibilities

b. Information about threats, hazards and protective actions
c. Notification, warning and communications procedures
d. Means for locating family members in an emergency
e. Emergency response procedures
f. Evacuation, shelter and accountability procedures
g. Location and use of common emergency equipment
h. Emergency shutdown procedures

4. Evaluate and Modify the Plan

Conduct a formal audit of the entire plan at least once a year.

Among the issues to consider are:

a. How can you involve all levels of management in

evaluating and updating the plan?

b. Are the problem areas and resource shortfalls identified

in the vulnerability analysis being sufficiently addressed?

c. Does the plan reflect lessons learned from drills and

actual events?

d. Do members of the emergency management group and

emergency response team understand their respective
responsibilities? Have new members been trained?

e. Does the plan reflect changes in the physical layout of

the facility? Does it reflect new facility processes?

f. Are photographs and other records of facility assets up to

date?

g. Is the entity attaining its training objectives?

h. Have the hazards in the facility changed?

i. Are the names, titles and telephone numbers in the plan

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 current?

j. Are steps being taken to incorporate emergency

management into other entity processes?

Have community agencies and organizations been briefed on the plan?

Are they involved in evaluating the plan?

In addition to a yearly audit, evaluate and modify the plan at these

times:

a. After each training drill or exercise

b. After each emergency
c. When personnel or their responsibilities change
d. When the layout or design of the facility changes
e. When policies or procedures change
f. Remember to brief personnel on changes to the plan.

Evacuation of Disabled Persons Planning

The Americans with Disabilities Act (ADA) defines a disabled person as anyone who has
a physical or mental impairment that substantially limits one or more major life activities,
such as seeing, hearing, walking, breathing, performing manual tasks, learning, caring for
oneself or working (See Appendix 3 Evacuation of Disabled Persons)

The purpose of this section is to identify the unique problems associated with emergency
evacuation of persons with limiting disabilities from a facility. Since facility emergency
planning must be site specific, it would be impossible to provide specific information and
guidance for all instances. This guide may be used by facility directors and managers to
familiarize themselves and employees with the basic techniques of emergency evacuation
planning for the disabled.

Emergency Evacuation

It is essential for facilities that provide services to the general public have a pre-planned
procedure for evacuation of the disabled.

Management Responsibility

Management has a responsibility to provide emergency plans for their facilities. This
includes having the proper immediate emergency equipment, emergency & evacuation
plans and a properly trained staff. Additionally, to provide the required assistance, the
facility employees must know where these people are and how to evacuate them safely
without increasing the danger to them or to the people they are trying to assist.

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Employees Role in an Emergency

For employees to provide proper direction and leadership in an emergency they must
have had proper training in the procedures to be followed.

The Elderly & Children

While many elderly people may have no impairments, many will be limited by the
natural and normal restrictions associated with the aging process. During a situation that
requires emergency evacuation, children cannot be expected to understand or comply
with directions designed for adults. If they have become separated from their caregivers,
they will require special assistance.

Hearing Impaired

The most significant problem during emergencies for the hearing impaired is immediate
notification of the emergency. Emergency alarms should incorporate a distinct visual
signal as well as audible signal to alert persons with hearing difficulties. Another problem
encountered by the hearing impaired is their inability to ensure their communication of an
emergency has been received. Special procedures should be implemented to allow the
hearing impaired to communicate that an emergency situation exists and/or obtain
assistance.

Speech Impaired

In emergency situations persons with speech impairments are not only limited by their
own disability but also limited by the inability of others to recognize they are trying to
communicate non-verbally. In emergencies employees must be trained to take the
necessary time to understand the ideas being communicated.

Visually Impaired

For those people with significant reduction in visual acuity, being in an unfamiliar
environment causes them difficulty in navigating their surroundings. In an emergency
they would be at a significant disadvantage unless aided. To assist persons with limited
sight ability the following techniques will be helpful: (See also Signage and
Communicating an Emergency)

• Install phones with large button faces and numbers. Numbers should be of a
significant contrast to the button face to facilitate recognition.
• Signs and emergency directions should be large print and in colors that do not
preclude recognition by persons with color blindness.
• Install Braille imprints on all doors.
• Provide Braille or verbal emergency instructions for visually impaired employees
and guests.
• Provide familiarization tours for the visually impaired.

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Mobility Impaired

Mobility impairment has a wide range. These restrictions may include conditions that
require the use of crutches, canes, walkers, and people with motor dysfunction and health
problems that limit mobility. Employees need to be trained in techniques for assisting the
mobility impaired.

Mentally Impaired

Again, as with all the previous disabilities discussed, mental impairment may range from
slightly diminished abilities to total incapacitation. Employees should be trained to
handle unexpected behavior and provide the proper assistance attention to these people
during evacuation. Additionally, they should be trained to be sensitive to mentally
impaired persons attempts to communicate information or questions.

Evacuation Pre-Planning

Pre-planning and preparation will increase the margin of safety, save lives and property
when an emergency arises. Evacuation of the disabled can be carried out successfully if
proper policies and techniques are implemented to:

• Train employees in methods of assisting the disabled

• Train employees how to effectively communicate an emergency
• Assign specific tasks during an emergency
• Identify specific needs of the disabled
• Provide a facility specific response plan

Audible Alarms

Audible emergency signals must have an intensity and frequency that can attract the
attention of individuals who have partial hearing loss. Select a signal that has a sound
characterized by three or four clear tones without a great deal of "noise" in between.

Visual Alarms

Visual alarms, to be effective, must be located and oriented so that they will spread
signals and reflections throughout a space or raise the overall light level sharply.

Signage

There are several methods that can be employed to assist the visually impaired person in
navigating unfamiliar surroundings.

• Tactile maps that depict facility layout (including emergency routes and
instructions)
• Auditory-recorded instructions.

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 • Raised and Brailed characters and pictorial symbols
• Signage with sufficient contrast and size.

Areas of Rescue Assistance

Areas of rescue assistance are areas, which have direct access to an exit, where people
who are unable to use stairs may remain temporarily in safety to await further instructions
or assistance during emergency conditions. These areas should be clearly marked and
identified to persons with disabilities.

Employee Training

The purpose of employee training in this area is three-fold. First they should be provided
an appreciation for the limitations of the disabled to be better able to provide the proper
assistance in each case. Second, through proper training, they will understand their own
limitations in providing assistance and be able to maximize their abilities in this area.
Third, employees should be trained that disabled people are not all alike. Each disabled
persons has different personal means of physically and psychologically handling their
disabilities.

Emergency Drills

Each facility should conduct routine drills to ensure that employees can perform assigned
functions and that the plan actually works. These drills can be used to finely tune the
facility's response to emergencies and greatly reduce the possibility of inappropriate
actions that could lead to unnecessary endangerment of people and property. Training
drills should include briefs to employees on the expected response from emergency
personnel from both on-site and off.

Fire Emergency Planning Guide

Fire is the most common of all the hazards. Every year fires cause thousands of deaths
and injuries and billions of dollars in property damage.

Planning Considerations

1. Meet with the fire department to talk about the community's fire response
capabilities. Talk about entity operations. Identify processes and materials that
could cause or fuel a fire, or contaminate the environment in a fire.

2. Have the entity facility inspected for fire hazards. Ask about fire codes and
regulations.

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3. Ask the entity insurance carrier to recommend fire prevention and protection
measures. The carrier may also offer training.

4. Distribute fire safety information to employees: how to prevent fires in the

workplace, how to contain a fire, how to evacuate entity facilities, where to report
a fire.

5. Instruct personnel to use the stairs -- not elevators -- in a fire. Instruct them to
crawl on their hands and knees when escaping a hot or smoke-filled area.

6. Conduct evacuation drills. Post maps of evacuation routes in prominent places.

Keep evacuation routes including stairways and doorways clear of debris.

7. Assign fire wardens for each area to monitor shutdown and evacuation
procedures.

8. Establish procedures for the safe handling and storage of flammable liquids and
gases.

9. Establish procedures to prevent the accumulation of combustible materials.

10. Provide for the safe disposal of smoking materials.

11. Establish a preventive maintenance schedule to keep equipment operating safely.

12. Place fire extinguishers in appropriate locations.

13. Train employees in use of fire extinguishers.

14. Install smoke detectors. Check smoke detectors once a month, change batteries at
least once a year.

15. Establish a system for warning personnel of a fire. Consider installing a fire alarm
with automatic notification to the fire department.

16. Consider installing a sprinkler system, fire hoses and fire-resistant walls and
doors.

17. Ensure that key personnel are familiar with all fire safety systems.

18. Identify and mark all utility shutoffs so that electrical power, gas or water can be
shut off quickly by fire wardens or responding personnel.

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 Natural Disaster/Severe Weather Emergency Planning
FLOODS AND FLASH FLOODS

Floods are the most common and widespread of all natural disasters. Most communities
in the United States can experience some degree of flooding after spring rains, heavy
thunderstorms or winter snow thaws.

Most floods develop slowly over a period of days. Flash floods, however, are like walls
of water that develop in a matter of minutes. Flash floods can be caused by intense storms
or dam failure.

Planning Considerations

1. Ask local emergency management office whether entity facilities are located in a
flood plain. Learn the history of flooding in the area. Learn the elevation of entity
facilities in relation to steams, rivers and dams.

2. Review the community's emergency plan. Learn the community's evacuation

routes. Know where to find higher ground in case of a flood.

3. Establish warning and evacuation procedures for the facility. Make plans for
assisting employees who may need transportation.

4. Inspect areas in the entity facilities, which are subject to flooding. Identify records
and equipment that can be moved to a higher location. Make plans to move
records and equipment in case of flood.

5. Purchase a NOAA Weather Radio with a warning alarm tone and battery backup.
Listen for flood watches and warnings.

6. Flood Watch -- Flooding is possible. Stay tuned to NOAA radio. Be prepared to

evacuate. Tune to local radio and television stations for additional information.

7. Flood Warning -- Flooding is already occurring or will occur soon. Take

precautions at once. Be prepared to go to higher ground. If advised, evacuate
immediately.

8. Ask your insurance carrier for information about flood insurance. Regular
property and casualty insurance does not cover flooding.

9. Consider the feasibility of flood-proofing entity facilities.

SEVERE WINTER STORMS

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Severe winter storms bring heavy snow, ice, strong winds and freezing rain. Winter
storms can prevent employees and customers from reaching the entity facilities, leading
to a temporary shutdown until roads are cleared. Heavy snow and ice can also cause
structural damage and power outages.

Planning Considerations

1. Listen to NOAA Weather Radio and local radio and television stations for
weather information:
a. Winter Storm Watch -- Severe winter weather is possible.

b. Winter Storm Warning -- Severe winter weather is expected.

c. Blizzard Warning -- Severe winter weather with sustained winds of at

least 35 mph is expected.

d. Traveler's Advisory -- Severe winter conditions may make driving

difficult or dangerous.

2. Establish procedures for entity shutdown and early release of employees.

3. Store food, water, blankets, battery-powered radios with extra batteries and other
emergency supplies for employees who become stranded at the entity facilities.

4. Provide a backup power source for critical operations.

5. Arrange for snow and ice removal from parking lots, walkways, loading docks,
etc.

TORNADOES

Tornadoes are incredibly violent local storms that extend to the ground with whirling
winds that can reach 300 mph.

Spawned from powerful thunderstorms, tornadoes can uproot trees and buildings and turn
harmless objects into deadly missiles in a matter of seconds. Damage paths can be in
excess of one mile wide and 50 miles long.

Tornadoes can occur in any state but occur more frequently in the Midwest, Southeast
and Southwest. They occur with little or no warning.

Planning Considerations

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1. Ask local emergency management office about the community's tornado warning
system.
2. Purchase a NOAA Weather Radio with a warning alarm tone and battery backup.
Listen for tornado watches and warnings:

a. Tornado Watch -- Tornadoes are likely. Be ready to take shelter. Stay

tuned to radio and television stations for additional information.

b. Tornado Warning -- A tornado has been sighted in the area or is indicated

by radar. Take shelter immediately.

3. Establish procedures to inform personnel when tornado warnings are posted.

Consider the need for spotters to be responsible for looking out for approaching
storms.

4. Work with a structural engineer or architect to designate shelter areas in the entity
facilities. Ask local emergency management office or National Weather Service
office for guidance.

5. Consider the amount of space you will need.

6. The best protection in a tornado is usually an underground area. If an underground

area is not available, consider:

a. Small interior rooms on the lowest floor and without windows

b. Hallways on the lowest floor away from doors and windows
c. Rooms constructed with reinforced concrete, brick or block with no
windows and a heavy concrete floor or roof system overhead
d. Protected areas away from doors and windows

7. Make plans for evacuating personnel away from lightweight modular offices or
mobile home-size buildings. These structures offer no protection from tornadoes.

8. Conduct tornado drills.

9. Once in the shelter, personnel should protect their heads with their arms and
crouch down.

HAZARDOUS MATERIALS Emergency Planning

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Hazardous materials are substances that are either flammable or combustible, explosive,
toxic, noxious, corrosive, oxidizable, an irritant or radioactive.

There are a number of Federal laws that regulate hazardous materials, including: the
Superfund Amendments and Reauthorization Act of 1986 (SARA), the Resource
Conservation and Recovery Act of 1976 (RCRA), the Hazardous Materials
Transportation Act (HMTA), the Occupational Safety and Health Act (OSHA), the Toxic
Substances Control Act (TSCA) and the Clean Air Act.

In addition to on-site hazards, be aware of the potential for an off-site incident affecting
entity operations.

Planning Considerations:

1. Identify and label all hazardous materials stored, handled, produced and disposed
of by the entity. Follow government regulations that apply. Obtain material safety
data sheets (MSDS) for all hazardous materials at each entity location.

2. Ask the local fire department for assistance in developing appropriate response
procedures.

3. Train employees to recognize and report hazardous material spills and releases.
Train employees in proper handling and storage.

4. Establish a hazardous material response plan:

a. Establish procedures to notify management and emergency response
organizations of an incident.
b. Establish procedures to warn employees of an incident.
c. Establish evacuation procedures.

5. Depending on entity operations, organize and train an emergency response team

to confine and control hazardous material spills in accordance with applicable
regulations.

6. Identify facilities in the area near the entity that use hazardous materials.
Determine whether an incident could affect entity operations.

7. Identify highways, railroads and waterways near the entity used for the
transportation of hazardous materials. Determine how a transportation accident
near the entity could affect operations.

Emergency Response Team (ERT)

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Emergency Response Team (ERT) staffing requirements and responsibilities include the
following:

1. Safety/Loss Control Officer

2. Operations Manager
3. First Responders
4. Support Personnel

Description of Duties

Safety/Loss Control Officer

The Safety Loss Control Officer is the key coordinator for members of the Emergency
Response Team This position has overall responsibility and authority for every action of
the ERT.

The Safety/Loss Control Officer must establish an overall plan, assign team members to
specific tasks, and assist team members in achieving their tasks by using effective
direction of the operations. The goal is to get the maximum productivity from all
available resources.

Operations Manager

The Operations Manager will relay and carry out the decisions of action, made by the
Emergency Response Team. The Operations Manager will also relay information back to
the Safety/Loss Control Officer concerning action taken and incident developments. The
Operations Manager also shall coordinate efforts of the Support Personnel and First
Responders.

First Responders

Responders will perform the actual tasks of rescue and containment of a leak or spill.
Teams will not enter a contaminated area unless Back-up Responders are available.
Trained Company personnel will use self-contained breathing apparatus (SCBA) with
total encapsulated Chemical Responder Suits.

Initially, First Responders will enter the Hot Zone (hazardous area) to collect air sample
readings to assess the severity of the release. However, if the release can be safely
terminated by closing shutoff valves, this shall be directed by the Safety/Loss Control
Officer as a primary action to provide for quicker rescue action. The air sample readings
will be relayed back to the Safety/Loss Control Officer and decisions for action to contain
the leak will be made once all data is gathered. Any action taken after this point will
depend upon the incident and its severity.

Support Personnel

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Support personnel provide services for the Safety/Loss Control Officer and First
Responders. These activities include, but are not limited to:

• Perimeter Air/Water/Soil Sampling

• Equipment Issue and Control
• Assistance with security and medical efforts

Training for Emergency Response Teams

The Plant Manager has the responsibility to ensure all employees, supervisors and
Emergency Response Team Members are trained and have a level of competence to the
degree that they are affected by or must respond to as assigned under the Emergency
Response Program.

TECHNOLOGICAL Emergency Planning

Technological emergencies include any interruption or loss of a utility service, power
source, life support system, information system or equipment needed to keep the entity in
operation.

Planning Considerations

Identify all critical operations, including:

1. Utilities including electric power, gas, water, hydraulics, compressed air,

municipal and internal sewer systems, wastewater treatment services

2. Security and alarm systems, elevators, lighting, life support systems, heating,
ventilation and air conditioning systems, electrical distribution system.

3. Manufacturing equipment, pollution control equipment

4. Communication systems, both data and voice computer networks

5. Transportation systems including air, highway, railroad and waterway

6. Determine the impact of service disruption.

7. Ensure that key safety and maintenance personnel are thoroughly familiar with all
building systems.

8. Establish procedures for restoring systems. Determine need for backup systems.

9. Establish preventive maintenance schedules for all systems and equipment.

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 Man-Made Disaster Emergency Planning
Bomb Threat & Physical Security Planning

In preparing to cope with a bomb incident, it is necessary to develop two separate but
interdependent plans, namely a physical security plan and a bomb incident plan.

The physical security plan deals with prevention and control of access to the facility. The
bomb incident plan provides detailed procedures to be implemented when a bombing
attack is executed or threatened.

In planning, a command center should be designated to be focal point of telephone or

radio communications. The management personnel assigned to operate the center should
have the authority to decide whatever action should be taken during the threat. Obtain an
updated blueprint or floor plan of the entity building and maintain it in the command
center.

Contact the police department, fire department, or local government agencies to

determine if any assistance is available for developing a physical security plan or bomb
incident plan. If possible, have police and/or fire department representatives and
members of entity staff inspect each entity building for areas where explosives are likely
to be concealed.

Training is essential to properly deal with a bomb threat incident. Instruct all personnel,
in what to do if a bomb threat is received. It is very important to organize and train an
evacuation unit which will be responsive to the command center and has a clear
understanding of the importance of its role.

Security Against Bomb Incidents

In considering measures to increase security for each entity building or office, it is highly
recommended that you contact the local police department for guidance regarding a
specific plan for your entity.

The exterior configuration of a building or facility is very important. By the addition of

fencing and lighting, and by controlling access, the vulnerability of an entity and its’
facilities to a bomb attack can be reduced significantly.

Parking should be restricted, if possible, to 300 feet from each entity building. If
restricted parking is not feasible, properly identified employee vehicles should be parked
closest to the entity facilities and visitor vehicles parked at a distance.

Heavy shrubs and vines should be kept close to the ground to reduce their potential to
conceal criminals or bombs. Unless there is an absolute requirement for such

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ornamentation, window boxes and planters are better removed. If they must remain, a
security patrol should be employed to check them regularly.

A highly visible security patrol can be a significant deterrent. Even if this ''patrol'' is only
one security guard/night guard, he/she is optimally utilized outside the building. If an
interior guard is utilized, consider the installation of closed-circuit television cameras that
cover exterior building perimeters.

Have an adequate burglar alarm system installed by a reputable company that can service
and properly maintain the equipment. Post signs indicating that such a system is in place.

Entrance/exit doors with hinges and hinge pins on the inside to prevent removal should
be installed.

Controls should be established for positively identifying personnel who have

authorization to access critical areas and for denying access to unauthorized personnel.
These controls should extend to the inspection of all packages and materials being taken
into critical areas.

Doors or access ways to areas such as boiler rooms, mail rooms, computer areas,
switchboards, and elevator control rooms should remain locked when not in use. It is
important to establish a procedure for the accountability of keys. If keys cannot be
accounted for, locks should be changed.

Good housekeeping is also vital. Trash or dumpsite areas should remain free of debris. A
bomb or device can easily be concealed in the trash. Combustible materials should be
properly disposed of, or protected if further use is anticipated.

Perhaps entrances and exits can be modified with a minimal expenditure to channel all
visitors through someone at a reception desk. Individuals entering the facility would be
required to sign a register indicating the name, building, and room number of the person
whom they wish to visit. Employees at these reception desks could contact the person to
be visited and advise him/her that a visitor, by name, is in the lobby. The person to be
visited may decide to come to the lobby to see that the purpose of the visit is valid. A
system for signing out when the individual departs could be integrated into this
procedure.

Responding to Bomb Threats

Instruct all personnel, especially those at the telephone switchboard, in what to do if a

bomb threat call is received.

A calm response to the bomb threat caller could result in obtaining additional
information. (See Bomb Threat checklist in Appendix 4)

When a bomb threat is called in:

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 a. Keep the caller on the line as long as possible. Ask him/her to repeat the message.
Record every word spoken by the person.
b. If the caller does not indicate the location of the bomb or the time of possible
detonation, ask him/her for this information.
c. Inform the caller that the building is occupied and the detonation of a bomb could
result in death or serious injury to many innocent people.
d. Pay particular attention to background noises, such as motors running, music
playing, and any other noise, which may give a clue as to the location of the
caller.
e. Listen closely to the voice (male, female), voice quality (calm, excited), accents,
and speech impediments. Immediately after the caller hangs up, report the threat
to the person designated by management to receive such information.
f. Report the information immediately to the police department, fire department,
ATF, FBI, and other appropriate agencies. The sequence of notification should be
established in the bomb incident plan.

When a written threat is received, save all materials, including any envelope or container.
Once the message is recognized as a bomb threat, further unnecessary handling should be
avoided. Every possible effort must be made to retain evidence such as fingerprints,
handwriting or typewriting, paper, and postal marks.

Evacuation

An evacuation unit consisting of management personnel should be organized and trained.

The organization and training of this unit should be coordinated with the development of
the bomb incident plan, as well as with all tenants of an entity building or facility.

When police officers or firefighters arrive at the entity facility, the contents and the floor
plans will be unfamiliar to them if they have not previously inspected the facility. Thus, it
is extremely important that the evacuation or search unit be thoroughly trained and
familiar with the floor plans of the buildings and immediate outside areas.

The evacuation or search unit should be trained only in evacuation and search techniques
and not in the techniques of neutralizing, removing or otherwise having contact with the
device. If a device is located, it should not be disturbed. However, its location should be
well marked and a route back to the device noted.

Search Teams

It is advisable to use more than one individual to search any area or room, no matter how
small. Searches can be conducted by supervisory personnel, area occupants or trained
explosive search teams.

The search conducted by a trained team is the best for safety, morale and thoroughness,
though it does take the most time. The decision as to who should conduct searches lies

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with management, and should be considered and incorporated into the bomb incident
plan.

Suspicious Object Located

It is imperative that personnel be instructed to report suspicious objects. Under no

circumstances should anyone move, jar or touch a suspicious object or anything attached
to it. The removal or disarming of a bomb must be left to the professionals in explosive
ordnance disposal. When a suspicious object is discovered, the following procedures are
recommended:

1. Report the location and an accurate description of the object to the appropriate
warden. This information should be relayed immediately to the command center,
which will notify the police and fire departments, and rescue squad. These
officers should be met and escorted to the scene.
2. Identify the danger area, and block it off with a clear zone of at least 300 feet,
including floors below and above the object.
3. Evacuate the building.
4. Do not re-enter the building until the device has been removed/disarmed, and
the building declared safe for re-entry by authorized personnel.

Bomb Incident Plan

1. Designate a chain of command.

2. Establish a command center.
3. Decide what primary and alternate communications will be used.
4. Establish clearly how and by whom a bomb threat will be evaluated.
5. Decide what procedures will be followed when a bomb threat is received or
device discovered.
6. Determine to what extent the available bomb squad will assist and at what point
the squad will respond.
7. Provide an evacuation plan with enough flexibility to avoid a suspected danger
area.
8. Designate search teams.
9. Designate areas to be searched.
10. Establish techniques to be utilized during search.
11. Establish a procedure to report and track progress of the search and a method to
lead qualified bomb technicians to a suspicious package.
12. Have a contingency plan available if a bomb should go off.
13. Establish a simple-to-follow procedure for the person receiving the bomb threat.
14. Review your physical security plan in conjunction with the development of your
bomb incident plan.

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Command Center

1. Designate a primary location and an alternate location.

2. Assign personnel and designate decision-making authority.
3. Establish a method for tracking search teams.
4. Maintain a list of likely target areas.
5. Maintain a blueprint of floor diagrams in the center.
6. Establish primary and secondary methods of communication. (Caution the use of
two-way radios during a search because they can possibly cause the premature
detonation of an electric blasting cap.)
7. Formulate a plan for establishing a command center, if a threat is received after
normal work hours.
8. Maintain a roster of all necessary telephone numbers.

Workplace Violence Prevention

The goal of this section is to assist each entity in implementing programs to identify the
potential risks of workplace violence and institute corrective measures. No single strategy
is appropriate for all entities. Risk factors for workplace violence differ widely among
workplaces. Each entity may use a combination of strategies recommended in this
section, as appropriate, for their particular workplace. (See Appendix 5 Sample Workplace
Violence Program)

These guidelines consist of the basic elements from which an entity can construct a
violence prevention program tailored to meet the specific needs of their workplace. An
effective approach to preventing workplace violence includes five key components: (1)
management commitment and employee involvement, (2) worksite analysis, (3) hazard
prevention and control, (4) safety and health training, and (5) evaluation. Using these
basic elements, an entity can fashion prevention plans that are appropriate for their needs,
based upon the hazards and circumstances of their particular situation.

Management Commitment

Management provides the motivation and resources to deal effectively with workplace
violence. The visible commitment of management to worker and visitor safety and health
is an essential precondition for its success. Management can demonstrate its commitment
to violence prevention through the following actions:

• Create and disseminate a policy to managers and employees that expressly

disapproves of workplace violence, verbal and nonverbal threats, and related
actions.
• Take all violent and threatening incidents seriously, investigate them, and take
appropriate corrective action.
• Outline a comprehensive plan for maintaining security in the workplace.
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 • Assign responsibility and authority for the program to individuals or teams with
appropriate training and skills. This means ensuring that all managers and
employees understand their obligations.
• Provide necessary authority and resources for staff to carry out violence
prevention responsibilities.
• Hold managers and employees accountable for their performance. Stating
expectations means little if management does not track performance, reward it
when competent, and correct it when it is not.
• Take appropriate action to ensure that managers and employees follow the
administrative controls or work practices.
• Institute procedures for prompt reporting and tracking of violent incidents that
occur in and near the establishment.
• Encourage employees to suggest ways to reduce risks, and implement appropriate
recommendations from employees and others.
• Ensure that employees who report or experience workplace violence are not
punished or otherwise suffer discrimination.
• Work constructively with other parties such as landlords, lessees, local police,
and other public safety agencies to improve the security of the premises.

Employee Involvement

Management commitment and employee involvement are complementary elements of an

effective safety and loss control program. To ensure an effective program, management,
front-line employees, and employee representatives need to work together in the structure
and operation of their violence prevention program.

Employee involvement is important for several reasons. First, front-line employees are an
important source of information about the operations of the entity and the environment in
which the entity operates. This may be particularly true for employees working at night
when higher level managers may not routinely be on duty. Second, inclusion of a broad
range of employees in the violence prevention program has the advantage of harnessing a
wider range of experience and insight than that of management alone. Third, front-line
workers can be very valuable problem solvers, as their personal experience often enables
them to identify practical solutions to problems and to perceive hidden impediments to
proposed changes. Finally, employees who have a role in developing prevention
programs are more likely to support and carry out those programs.

Employees and employee representatives can be usefully involved in nearly every aspect
of a violence prevention program. Their involvement may include the following:

• Participate in surveys and offer suggestions about safety and security issues.
• Participate in developing and revising procedures to minimize the risk of violence
in daily business operations.
• Assist in the security analysis of the entity.
• Participate in performing routine security inspections of the entity facilities.

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 • Participate in the evaluation of prevention and control measures.
• Participate in training current and new employees.
• Share on-the-job experiences to help other employees recognize and respond to
escalating agitation, assaultive behavior, or criminal intent, and discuss
appropriate responses.

Workplace Hazard Analysis

A worksite hazard analysis involves a step-by-step, common-sense look at the workplace

to find existing and potential hazards for workplace violence. This entails the following
steps: (1) review records and past experiences, (2) conduct an initial worksite inspection
and analysis, and (3) perform periodic safety audits.

Because the hazard analysis is the foundation for the violence prevention program, it is
important to select carefully the person(s) who will perform this step. Management can
delegate the responsibility to one person or a team of employees. If a large entity uses a
team approach, it may wish to draw the team members from different parts of the entity,
such as representatives from senior management, operations, employee assistance,
security, occupational safety and health, legal, human resources staff, or employee
representatives. Small entities might assign the responsibility to a single staff member or
a consultant.

Prevention Strategies

After assessing violence hazards, the next step is to develop measures to protect
employees and visitors from the identified risks of injury and violent acts. Workplace
violence prevention and control programs include specific engineering and work practice
controls to address identified hazards. The tools listed in this section are not intended to
be a "one-size-fits-all" prescription. No single control will protect employees and visitors.
To provide effective deterrents to violence, the entity may wish to use a combination of
controls in relation to the hazards identified through the hazard analysis.

Training and Education

Training and education ensure that all staff are aware of potential security hazards and the
procedures for protecting themselves, their co-workers, and visitors. Employees with
different roles in the entity may need different types and levels of training.

General Training

Employees need instruction on the specific hazards associated with their job and worksite
to help them minimize their risk of assault and injury. Such training would include
information on potential hazards identified in the entity, and the methods to control those
hazards. Topics may include the following:
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 • An overview of the potential risk of assault.
• Operational procedures, such as cash handling rules, that are designed to reduce
risk.
• Proper use of security measures and engineering controls that have been adopted
in the workplace.
• Behavioral strategies to defuse tense situations and reduce the likelihood of a
violent outcome, such as techniques of conflict resolution and aggression
management.
• Specific instructions on how to respond to a robbery (such as the instruction to
turn over money or valuables without resistance) and how to respond to attempted
shoplifting.
• Emergency action procedures to be followed in the event of a violent incident.

Training should be conducted by persons who have a demonstrated knowledge of the

subject and should be presented in language appropriate for the individuals being trained.
Oral quizzes or written tests can ensure that the employees have actually understood the
training that they received. An employee's understanding also can be verified by
observing the employee at work.

The need to repeat training varies with the circumstances. Retraining should be
considered for employees who violate or forget safety measures. Similarly, employees
who are transferred to new job assignments or locations may need training even though
they may already have received some training in their former position.

Training for Supervisors, Managers, and Security Personnel

To recognize whether employees are following safe practices, management personnel

should undergo training comparable to that of the employees and additional training to
enable them to recognize, analyze, and establish violence prevention controls. Knowing
how to ensure sensitive handling of traumatized employees also is an important skill for
management. Training for managers also could address any specific duties and
responsibilities they have that could increase their risk of assault. Security personnel need
specific training about their roles, including the psychological components of handling
aggressive and abusive customers and ways to handle aggression and defuse hostile
situations.

The team or coordinator responsible for implementation of the program should review
and evaluate annually the content, methods, and frequency of training. Program
evaluation can involve interviewing supervisors and employees, testing and observing
employees, and reviewing responses of employees to workplace violence incidents.

Recordkeeping

Good records help employers determine the severity of the risks, evaluate the methods of
hazard control, and identify training needs. An effective violence prevention program
will use records of injuries, illnesses, incidents, hazards, corrective actions, and training
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Board of Risk and Insurance Management
to help identify problems and solutions for a safe and healthful workplace. Each entity
can tailor their recordkeeping practices to the needs of their violence prevention program.
The purpose of maintaining records is to enable the entity to monitor its on-going efforts,
to determine if the violence prevention program is working, and to identify ways to
improve it. An Entity may find the following types of records useful for this purpose:

• Records of employee and other injuries and illnesses at the establishment.

• Records describing incidents involving violent acts and threats of such acts, even
if the incident did not involve an injury or a criminal act. Records of events
involving abuse, verbal attacks, or aggressive behavior can help identify patterns
and risks that are not evident from the smaller set of cases that actually result in
injury or crime.
• Written hazard analyses.
• Recommendations of police advisors, employees, or consultants.
• Up-to-date records of actions taken to deter violence, including work practice
controls and other corrective steps.
• Notes of safety meetings and training records.

Prevention Programs

Violence prevention programs benefit greatly from periodic evaluation. The evaluation
process could involve the following:

• Review the results of periodic safety audits.

• Review post-incident reports. In analyzing incidents, the entity should pay
attention not just to what went wrong, but also to actions taken by employees that
avoided further harm, such as handling an incident in such a way as to avoid
escalation to violence.
• Examine reports and minutes from staff meetings on safety and security issues.
• Analyze trends and rates in illnesses, injuries or fatalities caused by violence
relative to initial or "baseline" rates.
• Consult with employees before and after making job or worksite changes to
determine the effectiveness of the interventions.
• Keep abreast of new strategies to deal with workplace violence.

Management should communicate any lessons learned from evaluating the workplace
violence prevention program to all employees. Management could discuss changes in the
program during regular meetings of the safety/Loss Control Committee or other
employee groups.

Disaster Recovery/ Business Continuation Planning

A business continuation, or disaster recovery plan, is an important component of an
entity’s overall business plan. Designed to restore the entity to normal operations after a

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catastrophic loss, this plan considers events that could have a potentially devastating
effects. Business continuation planning can significantly minimize the duration of an
interruption and lessen the recovery costs for damages or loss to the entity.

The Planning Process

Business continuation planning has two phases: 1) analyzing the current state of disaster
preparedness and 2) developing the plan. Every entity must analyze its risks and
determine the importance of the plan in its operations and how much time and resources
will be allocated.

Analyzing the Risk

In analyzing those potential threats that an entity might experience, some questions to
consider are:

• Could the entity survive an extended failure of its facilities?

• Are vital business records properly inventoried and managed?
• Would business records be accessible or restorable after a disaster?
• Are the entity’s facilities physically secured?
• What losses is the entity insured for, is the coverage adequate, and
• What is the entity’s source of revenue and how could the cash flow
be interrupted?

The answers to these question and many others should be derived through a
comprehensive risk analysis that, at minimum, includes:

• An analysis of physical hazards

• A service utility reliability study that looks at the company furnishing power to
the entity’s systems to determine reliability and emergency back-up sources
• A review of the administration of vital business records
• A security analysis
• An examination of insurance coverages
• An analysis of revenue

While every operation of an entity should be considered in business

continuation planning, special emphasis should be placed on data processing and
information systems. Critical to successful recovery are the backup and restoration of
data.

Once the entity has identified its vulnerable areas, it can begin to develop
a strategic plan that addresses potential causes of business interruption.

Developing the Plan

Business interruption can be controlled in several ways. Consider the

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Board of Risk and Insurance Management
amount of time the entity needs to recover and the amount of money
available for allocation to the recovery plan.

A well-developed and organized strategic plan will detail cost-effective

steps to avoid the disaster, allocate the entity’s valuable resources
properly, and restore the entity and its critical operations quickly.

The Contingency Plan does not plan for the immediate or even eventual
replacement of all existing resources at an alternate site. Rather, it is
intended to implement a viable and effective office in an alternate location
for an undetermined period of time to perform only those functions
essential to keeping the entity viable.

Key Plan Components

The plan should contain these key components:

Disaster Avoidance

Avoiding interruption through prevention measures and back-up systems is

the true goal of business continuation planning. Entity systems should
have appropriate protection devices, systems redundancies, and
administrative controls in place.

Emergency Preparedness

Unexpected events can happen no matter how many and what kind of prevention
measures are in place. Defining an effective way to deal with these events can reduce
their impact and minimize the interruption potential.

Identification of Essential Functions

Each entity should identify its essential functions as the basis for
contingency planning. Essential functions are those functions that enable
entities to provide vital services in a catastrophe.

Alternate Facilities

Each entity should designate alternate operating facilities as part of its Contingency
Plans, and prepare its personnel for the possibility of unannounced relocation of essential
functions and/or Contingency Plan “core” staff to these facilities.

Interoperable Communications
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Board of Risk and Insurance Management
The success of entity operations at an alternate facility is dependent upon
the availability of critical communications systems to support connectivity
to internal organizations, other entities, and the public.

Vital Records and Databases

The protection and ready availability of electronic and hardcopy

documents, references, records, and information systems needed to support
essential functions under the full spectrum of emergencies is another
critical element of a successful Contingency Plan.

Recovery Methods

Recovery after an interruption is facilitated by knowledge of an entity’s

critical operations and the business functions that must be maintained. An entity’s
immediate goal after an interruption is to recover vital business functions — those
operations whose cessation would cause a severe decrease in revenue or service.
Customers should experience few, if any, negative effects from the
interruption.

Restoration Procedures

Rebuilding an entity’s physical facilities, reestablishing business

operations, and restoring revenue to pre-disaster levels must be done
concurrently with its recovery. The objective is to restore everything to
normal, or even better than normal.

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Board of Risk and Insurance Management
Funding

Any plan requires the allocation of resources. The plan should detail the
sources and allocation of revenue to fund disaster avoidance and restoration
measures. Having the proper types and amounts of insurance, along with an
arrangement to receive a timely and accurate settlement, will round out an
entity’s business continuation planning.

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Board of Risk and Insurance Management
 BRIM – APPENDIX 1

Appendix 1

Sample Emergency Plan Template

 BRIM – APPENDIX 1

Sample Emergency Plan Template

(a template for developing your emergency plan)
This Integrated Contingency Plan has been developed in accordance with the
guidelines and requirements published in the Federal Register, Vol. 61, No. 109.

Section I: Plan Introduction Elements

1. Purpose and Scope
This Emergency Plan has been developed for the (Company). This plan provides core
guidance on actions necessary for all emergency situations with could cause hazard to life
or property from accidental or natural causes.
Facility Overview: The facility covered in this plan is a (type of industry) plant
situated in (CITY - STATE). A ___ shift operation the facility is occupied
____hours per day with a maintenance group on site on weekends. The facility
employees security personnel on a round the clock basis.
Emergency Plan Coverage:
• Planning Guidelines
• Fire Prevention Plan
• Notification Procedures
• Emergency Evacuation
• Tornado & High Winds
• Fire/Explosion
• Hazardous Chemical Release
• Medical Emergencies
• Bomb Threat
• Emergency Response Team SOP
Regulations Addressed:
• General Industry Emergency Response (29 CFR
1910 pub.3122)
• Emergency Action Plan (29 CFR 1910.38)
 BRIM – APPENDIX 1

• Chemical Process Safety Management (29 CFR

1910.119)
• Risk Management Program (EPA: 40 CFR, Part 68)
2. Table of Contents
Emergency Response Planning Guidelines
• Responsibilities
• Training
• Emergency Response Planning
• Emergency Response Progression and Priorities
• Fire Fighting Restrictions
• Areas of Planning & Development
Emergency Action Plan
• Background
• Responsibilities
• References
• Priorities
• Fire Prevention Plan
• Standard Operating Procedures
SOP: Management Notification
SOP: Notification of Emergency Response Team
SOP: Notification of Employees
SOP: Notification of Local Emergency Groups
SOP: Corporate Notification
SOP: Emergency Evacuation
Emergency Assembly Areas
Evacuation Routes
SOP: Tornadoes & High Winds
SOP: Fire/Explosion
SOP: Hazardous Chemical Release
SOP: Medical Emergencies
SOP: Bomb Threat
Emergency Response Team SOP
• ERT Staffing
 BRIM – APPENDIX 1

• Description of Duties
• Training for ERT
• Assignment of Positions
• Checklists
Incident Commander
Operations Manager
Safety Officer
3. Current Revision Date: ___ _____ 199__
4. General Facility Identification Information
Facility Name: Company Name
Owner: Company, Inc.
PO Box XXX
CITY, State XXXXX-XXXX
(555)321-6789
Facility Location: (Shipping address)
Mailing Address: (This address of the location if different from corporate office)
Company
PO Box XXX
City, State, ZIP
Key Contacts: Senior Managers Name & Title
Facility Phone Number: (555)321-4567
Facility Fax Number: (555)321-1111
Key Personnel: _____________, Plant Manager
_______________, Maintenance Manager
_______________, Production Manager
_______________, Safety Manager

Section II: Core Plan Elements

1. Discovery
Initial actions the person(s) discovering an incident are detailed in the Standard Operating
Procedure (SOP) for Notification and the attached SOPs for various event covered by this
plan.
2. Initial Response
 BRIM – APPENDIX 1

A. Procedures for internal and external notification are contained in the Notification SOP
B. Objective and Protocols for establishing goals, planning, are contained
throughout the plan as it addresses various events. Planning and priorities are
outlined in the section titled Emergency Response Planning Guidelines.

Emergency Response Planning Guidelines

General
The (Company & Facility) has developed an Emergency Action Plan and Emergency
Response Team Standard Operating Procedures in order to:
a. protect life & property
b. minimize severity of emergency situations
c. comply with OSHA PSM Standard 29 CFR 1910.119
d. comply with EPA RMP regulation 40 CFR, Part 68
This facility has chosen to have an Emergency Response Team (ERT) to control and
abate accidental releases of hazardous material. The ERT would coordinate efforts with
local emergency agencies and organizations to mitigate peripheral emergency issues
within and beyond the facility fence lines.

References
The information and guides of this plan have been developed from the following sources:
General Industry Emergency Response (29 CFR 1910 pub.3122)
Emergency Management Guide-ARC (FEMA)
Accident Prevention for Industrial Operations (NSC)
Emergency Action Plan (29 CFR 1910.38)
Medical Services and First Aid (29 CFR 1910.151)
Confined Space Entry (29 CFR 1910.146)
Chemical Process Safety Management (29 CFR 1910.119)
Risk Management Program (EPA: 40 CFR, Part 68)
Responsibilities
Facility Management:
• evaluate the number and types of hazards expected based on past
experience and general knowledge to plan and develop Emergency
Response Plan specifics.
 BRIM – APPENDIX 1

• provide training to all employees for their roles in all emergency

plans
• quarterly conduct necessary drills to exercise the emergency
response plans
• annually conduct emergency rescue from confined space drill
• conduct all other actions required in this planning guide to
implement, develop and maintain an effective Emergency
Response Plan
• make assignments for all Emergency Response Team positions
Maintenance Manager shall:
• maintain sufficient inventory of equipment for the ERT
• provide maintenance and inspection of ERT response equipment
• participate in training of the ERT
40 Hour HAZMAT trained personnel:
• Assist in training of the ERT as directed by the Plant Manager
• normally be assigned to active positions on the ERT
Safety Manager:
• provide technical assistance in development and execution of
emergency response plans

Training
All Emergency Response Plans must be written in concise terms and made available to
all Employees through additions to personnel handbooks, operation manuals, and posting
on company bulletin boards. Training and annual re-training programs should be
conducted to assure an adequate level of knowledge.

For the Plan to be effective, training must cover:

1. Reporting emergencies
2. Evacuation routes and meeting places
3. Alarm or warning systems
4. Specific assigned actions
Periodic drills are required to assure that the Employees know what to do in case of an
emergency. Persons with specific duties require additional training and frequent exercise
drills. Security must not be over-looked in the Emergency Response Plan. It may be
 BRIM – APPENDIX 1

necessary to control access of unauthorized personnel, media and onlookers; direct

outside Emergency Response vehicles and control looting. Local Emergency Services
should be contacted and invited to train in conjunction with company drills.

Emergency Response Planning

When planning for emergencies, the following areas should be considered for each
hazard:
1. How will that hazard affect Employees, operations and facilities
2. How can this hazard be avoided
3. If the hazard can not be avoided, how can the hazard be minimized

Staffing of Emergency Teams

Number of employees
Training requirements
Equipment Requirements
Personal protective equipment
Air quality monitoring equipment
Spill containment materials
Associated emergency response equipment
Development of Standard Operating Procedures
Emergency escape procedures & escape route assignments
Procedures for accounting for Employees after evacuation
Rescue and Medical Duties for assigned Employees
Procedure for Employees who operate critical equipment prior to evacuation
Preferred means of reporting fires and other emergencies
Job Titles of persons to be contacted for information about the plan/procedures

Emergency Response Progression and Priorities

In order of importance
1. Evacuation and accounting for all Employees and Visitors
2. Contact local Emergency Services to report emergency
3. Assemble the Emergency Response Team, access the emergency, implement response
plan and provide for Emergency Responder Team safety
4. Notify Regulatory Agencies (OSHA, EPA, LEPC, etc.) where applicable to file
initial report.
5. Control the emergency through planned responses when safe; such as:
conduct search and rescue, turn off utilities, back-up and valve-off (SPECIFY
GENERAL SYSTEMS), control hazardous chemical spill/releases, man fire
pumps/sprinkler control valves to assure proper operation and prevent premature shut-off
6. Protect property from further damage by removal or physical protection
7. Initiate clean-up and salvage operations
 BRIM – APPENDIX 1

8. Conduct post-emergency evaluation and critique

9. File written reports to Regulatory Agencies where applicable
Fire Fighting Restrictions
Because of the danger associated, equipment required and training required. Emergency
Response Plans should not include fighting fires beyond the incipient stage (able to put
out with a fire extinguisher), entering a facility on fire to conduct search and rescue or
providing advanced medical care or treatment. Those areas are best left to Emergency
Response Professionals who have the skill, knowledge, training and equipment required
to control those events safely.

Training
Before implementing the Emergency Action Plan, a sufficient number of persons are to
be designated and trained to assist in the safe and orderly emergency evacuation of
employees.
Additionally, a review of the plan will be conducted:
• for all Employees initially when the plan is developed
• whenever an Associate's responsibilities or designated actions
under the plan change
• whenever the plan is changed
• for all new Employees as part of the New Hire Safety Training
The written plan shall be maintained in the workplace and made available for employee
review.

Maintenance
Written procedures have been developed to properly maintain equipment and systems
installed on heat producing equipment to prevent accidental ignition of combustible
materials.

Areas of Planning & Development

Required Information
1. Detailed current floor plans that indicate:
a. Evacuation routes and meeting areas
b. Location of utility shut-off
c. Location of hazardous chemical storage
d. Location of emergency response equipment
e. Location of water supplies, electrical supplies and communication equipment
 BRIM – APPENDIX 1

2. Resource materials available for quick reference

a. MSDSs, emergency response resource materials, etc.
b. Emergency. response check lists and appropriate contacts/telephone numbers
c. Vendor/Contractor lists for:
Emergency power generation, boilers, etc.
Emergency response equipment
Environmental abatement
Heavy equipment rentals and operators
Construction and building materials
3. List of the major fire hazards, handing and storage procedures,
potential ignition sources (such as boilers, gas fired equipment, welding,
smoking and other) and their control procedures, and the type of fire
protection equipment or systems installed to prevent or control ignitions or
fires.
4. List of Job Positions of those personnel responsible for control of
fuel source hazards.
5. Housekeeping procedures to prevent and control accumulations of
flammable and combustible waste material and residues so that they do
not contribute to a fire emergency.

Emergency Assembly Areas

Department Assembly Area
List each Department and the location you have selected that is a safe distance away from
affected buildings. You will need a separate list for each building
Attach a copy of building floor plans and grounds plan showing
• Exit Routes
• Fire Extinguisher Locations
• Utility Shutoff Locations
• Assembly Areas
• External Sprinkler Control Valves
• On-site Fire Hydrants
• Emergency Command Center Locati
 BRIM – APPENDIX 1

Emergency Assembly Areas

Department Assembly Area
List each Department and the location you have selected that is a safe distance away from
affected buildings. You will need a separate list for each building
Attach a copy of building floor plans and grounds plan showing
• Exit Routes
• Fire Extinguisher Locations
• Utility Shutoff Locations
• Assembly Areas
• External Sprinkler Control Valves
• On-site Fire Hydrants
• Emergency Command Center Location

Bomb Threat Phone Checklist

Your Name:___________________________
Time:__________
Date:__________

Caller's Identity: Male Female

Approximate Age: Years:__________

Origin of Call: Local Long Distance Phone Booth Internal

CALLERS VOICE IS
Slow Fast Loud Foreign Calm
High Pitch Distinct Raspy Stutter Foul
Drunk Slurred Deliberate Deep Distorted
Angry Nasal Irrational Laughing Emotional

BACKGROUND NOISE
Office Factory Animals Traffic Music
Airplanes Party Quiet Train Other Voices
 BRIM – APPENDIX 1

BOMB FACTS
KEEP CALLER TALKING. If caller seems agreeable to further conversation, ask
questions like:
1. When is the bomb going to explode?
What hour:__________ Time Remaining:__________
2. Where is the bomb?
Building:_____________ Area:_____________
3. What kind of bomb is it? What does it look like? Do you know who placed the
bomb?
4. Where are you now?
5. What is your name and address?
Did the caller appear familiar with the plant or building by description of the bomb
location?
Write out the message in its entirety and any other comments on reverse side.
Call the following people immediately after the bomb threat call
_______________________
_______________________
________________________

Emergency Operating Procedures

EOP: Management Notification
In the event of an emergency or a situation that could evolve into an emergency,
management must be informed immediately. The following individuals shall be notified
for events concerning the processing plant:
___________ maintains an updated Emergency Notification List and
Procedure.
Plant Manager
Production Manager
Maintenance Manager
Security
 BRIM – APPENDIX 1

Safety Coordinator

EOP: Emergency Response Team Notification

This procedure applies to situations that require implementing the Emergency Response
Plan for release of hazardous substances or immediate notification of management team
of a significant emergency event.

Here is where you describe How you will contact your Emergency Response
Team

EOP: Employees Notification

Employees may be notified of emergencies by the installed alarm system, public address
system or by supervisors. After initial notification, employees will be provided direction
by on scene supervisors

EOP: External Notification

The preferred method for contacting local Emergency Response Assistance is to call
911, this will provide initial notification to Law Enforcement, Fire Department and _____
County EMA/LEPC.

EOP: Corporate Notification

If any media interest is expected, contact Corporate Public Relations for assistance.
Reporting Losses:
In the following cases, the Corporate Office will be notified in a timely manner:
• Fire/Explosion Damage
• Flood Damage
• Tornado/High Wind Damage
• Theft
• Cargo Losses
Corporate Contact List:

List Corporate Names and Phone Numbers

 BRIM – APPENDIX 1

EOP: Emergency Evacuation

Background
Need for evacuation can be for many reasons. The keys to a successful evacuation are:
• Supervisor coordination and control, and
• Pre-determined routes and assembly areas
Management Action
1. After the Senior Manager on scene determines the need for an emergency
evacuation exists, the evacuation alarm will be activated (describe sound of your
alarm) and announcements & instructions will be issued over the public address
system.
2. Management will immediately start actions, taking into consideration the nature
and extent of the emergency.
Specific Responsibilities & Assigned Actions
1. Production Supervisors
A. Lead Employees from work areas when evacuation alarm is sounded.
B. Provide necessary assistance to any Employees with disabilities.
B. Escort Employees to the designated assembly area.
C. Account for Employees at the designated assembly area.
D. Notify Human Resource of any Employees that are not accounted for.
E. Provide control of Employees at assembly areas
2. Maintenance Supervisors Actions
3. List other actions to be taken by specific persons

EOP: Tornado and High Winds

Background
Tornadoes develop from powerful thunderstorms. They are incredibly violent local
storms that extend to the ground with winds that can reach 300 mph. They can uproot
trees, destroy buildings and turn harmless objects into deadly missiles in a matter of
seconds. Damage paths can exceed one mile wide and 50 miles long.

Definitions
Tornado Watch - Be ready to take shelter. Tornadoes are likely.
 BRIM – APPENDIX 1

Tornado Warning - Take shelter immediately. A tornado has been sighted in the area.

Types of Shelter Areas

The best protection in a tornado is usually an underground area. The best above
ground areas in a building are:
• Small interior rooms on the lowest floor without
windows
• Hallways on lowest floor away from outside doors
and windows
• Rooms constructed of reinforced concrete, brick or
block with no windows and a heavy concrete floor
or roof system.
Buildings with flat, wide-span roofs are not considered safe.

Management Pre-Action
1. During Thunderstorm season ensure NOAA Weather Radio (with warning
alarm & battery backup) is functioning properly. During Tornado Watches, assign
a specific person to monitor the radio.
2. During high probability periods or during Tornado Watches, consider placing
spotters to warn of approaching systems.
3. Pre-alert supervisors concerning the possibility of the need for directing
Employees to emergency shelter.
4. During Tornado Watches, place a sign at the main entrance & exit to notify
people of the potential hazardous condition.

Management Immediate Action

1. After the need to take shelter has been established announcements shall be
made to take shelter.
2. Immediately initiate sheltering action.
• Direct all Employees to move from their
workstation to along the nearest interior wall.
• Assume the lowest position possible and protect the
head area with arms.
3. After the threat has passed, initiate a head count and return to work or as
directed by plant management.
 BRIM – APPENDIX 1

EOP: Fire / Explosion

Background
Fires can have several causes and sources of fuel. Most deaths in a fire are caused by
smoke inhalation. It is important to remember that the normal evacuation path could be
towards the fire. In these cases, alternate routes, away from the fire are to be used. At no
time will employees attempt to contain a fire that has progressed past the initial small
stage. Explosions can have numerous causes. The results of explosions can range from
fires to weakened or collapsed structures.

Management Action
1. After it is established that there is a fire or explosion on the premises, the Management
will be notified immediately and the fire alarm sounded. The evacuation alarm shall also
be sounded.
2. Management will immediately initiate action, taking into consideration changes that
might become necessary according to the situation.
3. Management will establish a command post at _________
4. The Maintenance Manager will
• assign competent Employees to monitor the
sprinkler risers to assure normal operation.
• direct emergency shut down of utilities (power and
gas) and backup/valve off ammonia refrigeration
systems, and other actions as the situation requires.
• provide liaison with emergency response units
5. Security will call 911 and provide initial details of the fire and/or explosion to
emergency response units.

EOP: Bomb Threat

Follow the BOMB THREAT CALL REPORT Guide

1. Do not hang up phone.

2. Get all information: location, size, appearance, time the bomb will
explode, etc.
3. Alert another staff member to call the phone company to attempt a
trace on the call. (Dial "O" for Operator)
 BRIM – APPENDIX 1

4. Get the caller to talk as long as possible.

5. Notify the Management of the threat.
6. Management shall:
• Call Police Department & request assistance.
• Make decision concerning evacuation.
IF EVACUATION HAS BEEN DECIDED, NO ONE SHALL ENTER
THE PLANT UNTIL THE POLICE DEPARTMENT HAS GIVEN AN
ALL CLEAR TO PLANT MANAGER OR MANAGEMENT
MEMBER IN CHARGE.

EOP: Hazardous Chemical Release

See Also: Emergency Response Team SOP and
Spill Prevention Control & Countermeasures Plan
In the event of an accidental release of hazardous chemicals, an evacuation would be
required if the release is in a significant amount to cause, or have potential to cause,
harm to employees.
1. After it is determined that there is a hazardous chemical emergency, the Management
Team will be notified and make the decision whether to evacuate any areas. All
unqualified Employees should remain clear of any spill or release of any hazardous
material. If evacuation procedures have been initiated, ALL EMPLOYEES MUST
LEAVE THE PLANT and proceed to the designated meeting area
(see Emergency Evacuation SOP).
• NO ONE MAY ENTER THE
RELEASE/SPILL/AFFECTED AREAS
WITHOUT PROPER PERSONAL PROTECTIVE
EQUIPMENT AND MANAGEMENT
PERMISSION.
• PPE is required at all times until the hazard has
been dissipated with proof by proper testing
procedures.
2. Maintenance Manager will proceed directly to the emergency area to determine if
evacuation or outside help is necessary.
 BRIM – APPENDIX 1

3. Management will activate the Emergency Response Team if required.

4. Management will implement the Emergency Spill Procedures of the Spill Prevention
Control & Countermeasures Plan if any hazardous material is released.
Notification of State Department of Environmental Monitoring and EPA is
required if spilled oil material discharges or threatens to discharge into a
waterway of the State causing a visible sheen on or a discoloration of the surface
water or shorelines, or if a reportable quantity for a hazardous substance is
discharged or may unavoidably be discharged to a waterway of the State.

EOP: Medical Emergencies

All Medical Treatment provided by OHCP employed by Company shall follow the
Medical Directives and Nursing Procedures for Emergency Care
1. After a medical emergency has been identified, the Assigned Manager,
Occupational Health Care Professional or Senior Management Team Member and
Area Supervisor should be notified immediately. The Area Supervisor has the
responsibility to assure that the Assigned Manager, OHCP or Senior Management
Team Member has been notified.
2. The severity of the medical emergency and level of action required will be
determined by the on-site OHCP.
3. All Medical Emergency Care Providers will use the proper PPEs as outlined in
the Control of Blood-borne Pathogens Program and will follow the proper
standards of care.
4. All injured or ill Employees requiring emergency medical care for life/death
medical emergencies will be transported by local Emergency Medical Services
(EMS) to the nearest local Hospital.
5. All non-life/death medical emergencies will be managed by the OHCP and
Company Physician following proper standards of care.
6. All Employees who are involved in an injury or accident shall be screened for
drugs and alcohol as prescribed by company policy.
7. During any emergency, the OHCP or Assigned Manager will have the
responsibility to set-up the emergency medical care station at a location directed
by the Senior Management Team Member depending on the emergency and
relevant conditions.
 BRIM – APPENDIX 2

Appendix 2

Evacuation Planning & The ADA

Evacuation of Disabled Persons Planning Guide

 BRIM – APPENDIX 2

Evacuation Planning & the ADA

Evacuation of Disabled Persons Planning Guide
Contents
Introduction
Section 1: Need for Planning
Section 2: Disabilities and Evacuation Problems
Section 3: Evacuation Pre-Planning
Section 4: Alarm Systems
Section 5: Signage
Section 6: Areas of Rescue Assistance
Section 7: Employee Training

Introduction
Purpose
The purpose of this guide is to identify the unique problems associated with emergency
evacuation of persons with limiting disabilities from a facility. Additionally, we have
provided some examples of techniques that can be used for pre-planning and executing
emergency evacuation of disabled persons. Since facility emergency planning must be
site specific, it would be impossible to provide specific information and guidance for all
instances. This guide may be used by facility owners, directors and managers to
familiarize themselves and employees with the basic techniques of emergency evacuation
planning for the disabled.

ADA and Emergency Evacuation

The Americans With Disabilities Act (ADA) legislated equal access to facilities. One
segment of the intent of the ADA that has been overlooked is equal exit during
emergencies. It is essential that facilities that provide services to the general public such
as hotels, motels, restaurants, nursing homes, hospitals, retirement centers and recreation
facilities have a pre-planned procedure for evacuation of the disabled.
 BRIM – APPENDIX 2

The Elderly & Children

In this manual we have included two groups that are not normally associated with the
disabled: the elderly and children. As the average age of the population increases, the size
of elderly clientele is also increasing. While many of these people may have no
impairments, many will be limited by the natural and normal restrictions associated with
the aging process. These limitations include, but are not limited to, mobility impairment,
hearing and visual difficulties, speech problems, and reduced mental capabilities.
Children pose different problems in emergency evacuation procedures. They are
normally provided close supervision by parents, or other responsible adults, who provide
explicit direction for their daily activities. During a situation that requires emergency
evacuation, children cannot be expected to understand or comply with directions
designed for adults. If they have become separated from their caregivers, their link to
appropriate action has been severed and they will require special assistance.

Section 1- Need for Planning

Over 49 Million People are Disabled
Significant challenges can be expected during emergencies that require evacuation of a
facility and these will be compounded when dealing with the special problems associated
with the disabled, the elderly and children. A large reduction in these problems can be
achieved through pre-planning, employee training, proper equipment staging and liaison
with emergency professionals such as local Rescue & Assistance Squads, Fire and Police
Departments.

Management Responsibility
Owners and managers have the legal and moral responsibility to provide emergency plans
for their facilities. This includes having the proper immediate emergency equipment,
emergency & evacuation plans and a properly trained staff. While most facilities have
some sort of plan, either formal or informal, most do not provide for the special needs
that will arise during evacuation of the disabled, elderly and children. Under the ADA,
architectural barriers must be removed or redesigned to accommodate access for the
disabled. Unfortunately, emergency routes have, in many cases, been neglected. While
the use of elevators in multi-storied buildings are not safe emergency exit routes,
stairwells and ladders cannot be navigated by many elderly and disabled people without
assistance. Additionally, to provide the required assistance, the facility employees must
know where these people are and how to evacuate them safely without increasing the
danger to them or to the people they are trying to assist.

Employees Role in an Emergency

 BRIM – APPENDIX 2

During emergencies people generally look to authority figures for direction. The general
public normally expects this direction to come from facility employees and will, in most
cases, comply adequately. For employees to provide proper direction and leadership in an
emergency they must have had proper training in the procedures to be followed and this
implies that management has a detailed plan for them to implement. In the absence of an
effective plan and training, employees are left to their own choices in a crises. This can
result in abandonment of responsibility, counter productive actions, and even increase the
severity of the emergency situation. Employees must be trained to act in concert with
each other and in accordance with the facility's policies and emergency plan. While no
plan can cover all contingencies, the absence of a formal program and continuing
employee training will result in unnecessary endangerment of people and property.

Section 2 - Disabilities and Evacuation Problems

Hearing Impaired
The most significant problem during emergencies for the hearing impaired is immediate
notification of the emergency. Emergency alarms should incorporate a distinct visual
signal as well as audible signal to alert persons with hearing difficulties. Hearing
impairment covers a wide range, from loss of high frequency hearing to total loss of
auditory perception. Many people who augment their hearing with electronic aids often
remove them at night and in an emergency might not hear the audible alarms designed to
warn them of danger. Even after they become aware of the emergency they may forget to
install their hearing aids in a crisis. People with no hearing disability can temporarily lose
their hearing if a loud sharp noise occurs such as an explosion. Designing alarm systems
and search & notification procedures with the idea that normal communication
modes might not be effective will provide a facility the means of communicating
danger and necessary actions to the hearing impaired. Another problem encountered
by the hearing impaired is their inability to ensure their communication of an emergency
has been received. When using telephones or other communication devices they cannot
see the intended recipient. Special procedures should be implemented to allow the
hearing impaired to communicate that an emergency situation exists and/or obtain
assistance.

Speech Impaired
In emergency situations persons with speech impairments are not only limited by their
own disability but also limited by the inability of others to recognize they are trying
to communicate non-verbally. Under normal circumstances the techniques employed by
speech impaired persons to communicate their needs, wants and desires are effective
when the recipient provides adequate focus on the communication. In emergencies
employees must be trained to take the necessary time to understand the ideas being
communicated. As an example: During an evacuation of a facility due to fire an employee
encounters a guest that is exhibiting the need to communicate but is not coherent. This
person is motioning and possibly making sounds. The employee knows that this person
 BRIM – APPENDIX 2

must leave the area by the emergency route and tries to communicate this necessity. The
person resists. In this and similar cases, the employee must be trained to take the few
seconds required to calmly attempt to receive the communication. The disabled person
may have knowledge of a hazardous condition or location of persons needing assistance.
Training employees to communicate with speech-impaired persons is not difficult and
does not require the learning of the American Sign Language. The idea here, as in the
above case of communicating with hearing impaired persons, is to provide the disabled
person an opportunity to communicate.

Visually Impaired
As with hearing and speech-impaired persons, visual impairment runs a wide spectrum.
For those people with significant reduction in visual acuity, being in an unfamiliar
environment causes them difficulty in navigating their surroundings. In an emergency
they would be at a significant disadvantage unless aided. To assist persons with limited
sight ability the following techniques will be helpful: (See also Signage and
Communicating an Emergency)
• Install phones with large button faces and numbers. Numbers should be of
a significant contrast to the button face to facilitate recognition.
• Signs and emergency directions should be large print and in colors that do
not preclude recognition by persons with color blindness.
• Install Braille imprints on all doors.
• Provide Braille or verbal emergency instructions for visually impaired
employees and guests.
• Provide familiarization tours for the visually impaired.
Providing proper sensitivity training for employees can prevent
inappropriate behavior. It has been noted that some people have a
tendency to speak louder and more slowly to visually impaired persons.
This is an inappropriate reaction on their part in their attempt to deal with
their misconception of visual impairment.

Mobility Impaired
When most people think of disabled persons they have a mental picture of someone in a
wheelchair. Mobility impairment however also has a wide range. While persons restricted
to wheelchairs may be the most limited, accommodations must be made for all types of
mobility restrictions. These restrictions may include conditions that require the use of
crutches, canes, walkers, and people with motor dysfunction and health problems that
limit mobility. Evacuation of people with mobility impairment is compounded by the
nature of emergency route design. Stairwells used in lieu of elevators present the largest
obstruction for evacuation. Employees need to be trained in techniques for assisting the
mobility impaired. This includes knowing their own physical limitations and ascertaining
the mobility impaired person’s condition and preferences by asking them. Disabled
 BRIM – APPENDIX 2

people live with their disability every day and probably know the best methods for
assistance. Adequate and proper emergency equipment should be staged at strategic
locations throughout the facility to enable not only employees to assist the disabled but
also for use by emergency professionals that may respond to the scene.

Mentally Impaired
Again, as with all the previous disabilities discussed, mental impairment may range from
slightly diminished abilities to total incapacitation. Effective communication of the need
to evacuate may be hampered if employees are not calm and persistent in their efforts to
assist the mentally impaired. Though it is not always the case, some mentally impaired
people may react to an emergency in an unexpected manner. Employees should be
trained to handle unexpected behavior and provide the proper assistance attention to these
people during evacuation. Additionally, they should be trained to be sensitive to mentally
impaired persons attempts to communicate information or questions.

Elderly Persons
Determining the limitations of an elderly person is sometimes difficult. The normal aging
process causes diminished physical and mental abilities. These may occur sooner for
some, later for others, all to varying degrees. Elderly persons may have all or some of the
impairments discussed earlier. Accommodations that are designed for the disabled may
be used successfully for the elderly. It should be noted that the percentage of elderly
persons in the United States is growing dramatically larger. This trend will continue for
the next 50 years.

Children
As stated earlier, children are normally provided close supervision by parents, or other
responsible adults, who provide explicit direction for their daily activities. During a
situation that requires emergency evacuation, children cannot be expected to understand
or comply with directions designed for adults. If they have become separated from their
caregivers, their link to appropriate action has been severed and they will require special
assistance. As the number of facilities that provide on-site childcare rises, facility
planning for emergency evacuation of children has become more important. Childcare
areas should be located and designed to allow close and unrestricted access to emergency
exits.

Section 3 - Evacuation Pre-Planning

Increase Margin of Safety
 BRIM – APPENDIX 2

Pre-planning and preparation will increase the margin of safety, save lives and property
when an emergency arises. Evacuation of the disabled can be carried out successfully if
proper policies and techniques are implemented to:
· Train employees in methods of assisting the disabled
· Train employees how to effectively communicate an emergency
· Assign specific tasks during an emergency
· Identify specific needs of the disabled
· Provide a facility specific response plan

Facility Emergency Coordinator

Adequate management of any emergency plan relies on coordination and planning.
Assigning a management level individual the responsibility for emergency planning will
allow development of a resident expert who will be able to monitor policies, procedures
and employee training. This person could also be assigned as the facility ADA
Coordinator. The designated person should be familiar with the facility emergency plans,
types of rescue and assistance available from local fire departments & police, the Life
Safety Code, applicable local regulations, and ADA requirements for facility
accommodations.

Identification of People and Needs

For facilities that provide lodging, special care must be taken to provide adequate
measures to identify the specific needs of disabled persons. The following list provides
some procedures that would assist facility staff.
1) Provide a means of communicating the facility's understanding of the
special needs of the disabled. This can be achieved through several means.
· Signage at registration desks that provides a policy statement in
brief.
· Training counter persons to tactfully express the facility's desire to
be helpful.
· Space on registration cards to provide annotation for special needs
by the disabled.
2) Color Coding for identification of room locations. This technique has
numerous applications beyond identification of the location of disabled
persons for emergency evacuation. Procedures for color-coding should be
simple and easy to update. A single color should be assigned to each
specific type of disability. When more than one disability is involved the
most limiting one can be applied or a multi-colored system may be used.
 BRIM – APPENDIX 2

· Color-coding of room assignments at the registration desk alerts

desk staff when they receive a call from a guest that a special need
may exist.
· Color coding of room doors, by means of a small colored card (no
writing) inserted in a card holder on each door will alert the service
staff of possible special needs
· Color-coding of floor plans provides means of identifying guests
that may need evacuation assistance. These floor plans can also be
use to provide emergency response personnel locations of persons
needing extra assistance. These floor plans should show
emergency routes, stairwells, balconies, areas of rescue assistance
(discussed later in this chapter) rest rooms, major assembly areas
and room numbers as a minimum. These floor plans should,
however be simple to read and provide for quick understanding of
the facility layout. They should also be easily transportable by one
person to facilitate removal to a safe area for review by
management and emergency response units.

Communicating an Emergency
Communication of an emergency situation must be provided such that not only can the
facility alert guests but also so that guests can alert facility staff. Simple procedures can
be implemented to provide the hearing or speech impaired person the opportunity to
communicate by phone with the front desk. These procedures can be provided to guests
upon registration. As an example, the international symbol of access for hearing loss
could be displayed with an appropriate message that provides the type of assistance
available, such as:
· Infrared Assistive Listening System
· Audio Loop in Use, Turn T-Switch for Better Listening
· FM Assistive Listening System
· Real Time Captioning
· Captioned Note Taking
· Oral Interpreters
· Sign Language Interpreters

Section 4 - Alarm Systems

Audible Alarms
 BRIM – APPENDIX 2

Audible emergency signals must have an intensity and frequency that can attract the
attention of individuals who have partial hearing loss. People over 60 years of age
generally have difficulty perceiving frequencies higher than 10,00 Hz. An alarm signal,
which has a periodic element to its signal, such as single stroke bells, hi-low and fast
whoop are best. Avoid continuous or reverberating tones. Select a signal that has a sound
characterized by three or four clear tones without a great deal of "noise" in between.

Visual Alarms
Visual alarms, to be effective, must be located and oriented so that they will spread
signals and reflections throughout a space or raise the overall light level sharply.

Tactile Alarms
For hotel rooms and other rooms where people are likely to be asleep, a signal-activated
vibrator placed between mattress and box spring or under a pillow has been found by
Underwriters Laboratory to be effective in alerting sleepers. Many available devices are
sound activated so that they could respond to an alarm clock, clock radio, wake-up
telephone call or room smoke detector or general alarm.

Section 5 - Signage
There are several methods that can be employed to assist the visually impaired person in
navigating unfamiliar surroundings.
• Tactile maps that depict facility layout (including emergency routes and
instructions)
• Auditory-recorded instructions.
• Positioning of signs perpendicular to the path of travel.
• Raised and Brailed characters and pictorial symbols
• Signage with sufficient contrast and size.
The best readability is achieved through the use of light colored characters or
symbols on a dark background.

Section 6 - Areas of Rescue Assistance

The Following requirements are derived from the Federal Register and
are provided here for guidance and understanding. They are not all
inclusive and do not consider substantial local regulations and codes that
may exist.
 BRIM – APPENDIX 2

Areas of rescue assistance are areas, which have direct access to an exit, where people
who are unable to use stairs may remain temporarily in safety to await further instructions
or assistance during emergency conditions. These areas should be clearly marked and
identified to persons with disabilities that might limit their ability to use emergency
routes unassisted.
Consistent with local codes, areas of rescue assistance can be any one
of the following:
• A portion of a stairway landing within a smoke proof enclosure.
• A portion of an exterior exit balcony located immediately adjacent to an
exit stairway. Note that openings to the interior of the building located
within 20 feet of the area of rescue assistance must be protected with fire
assemblies having a 3/4-hour fire protection rating.
• A portion of a one-hour fire-resistive corridor located immediately
adjacent to an exit enclosure.
• A vestibule located immediately adjacent to an exit enclosure and
constructed to the same fire-resistive standards as required for corridors
and openings.
• A portion of a stairway landing within a exit enclosure which is vented to
the exterior of the structure and is separated from the interior of the
building with not less than one-hour fire-resistive doors.
• Other areas as described and designated by local codes and regulations

Size of Areas of Rescue and Assistance

Each Area of Rescue Assistance must provide at least two accessible areas each being not
less than 30 inches by 48 of inches horizontal surface. The area of rescue assistance
cannot encroach on any required exit width. The total number of areas should not be less
than one for every 200 persons of calculated occupant load served by the area of rescue
assistance.

Stairway Width
Each Stairway adjacent to an area of rescue assistance shall have a minimum width of 48
inches between the inner sides of the handrails.

Communication with areas of rescue assistance

A method of two-way communication, with both a visual and audible signal, must be
provided between each area of rescue assistance and the primary entry to the building.
The fire department or appropriate local authority may approve a location other than the
primary entry.
 BRIM – APPENDIX 2

Identification of areas of rescue assistance

Each area of rescue assistance shall be identified by a sign that states:
Area of Rescue Assistance
and displays the international symbol of accessibility. The sign must be illuminated when
exit sign illumination is required. Signage must also be installed at all inaccessible exits
and where otherwise necessary to clearly indicate the direction to areas of rescue
assistance. In each area of rescue assistance, instructions on the use of the area under
emergency conditions shall be posted adjoining the two-way communication system.

Section 7 - Employee Training

The purpose of employee training in this area is three-fold. First they should be provided
an appreciation for the limitations of the disabled to be better able to provide the proper
assistance in each case. Second, through proper training, they will understand their own
limitations in providing assistance and be able to maximize their abilities in this area.
Third, employees should be trained that disabled people are not all alike. Each disabled
persons has different personal means of physically and psychologically handling their
disabilities.

Equal Service
Management personnel should be trained in the provisions of the ADA that deal with the
facility's responsibility toward the disabled public. Equal service is required to be
available to all patrons.

Sensitivity Training
Employees should be trained to not only understand the limitations imposed by
disabilities but also their own misconceptions concerning the limitations of these patrons.
Service and assistance should always be provided with dignity and understanding.

Emergency Training
Facility Management should conduct coordinated emergency training on a frequent basis
to ensure employees can carry out assigned duties. Some specifics as they pertain to the
subject of this guide are:
 BRIM – APPENDIX 2

· Initial notification of Emergency Response Units (ERU), via 911, that

some disabled patrons will need evacuation assistance and the on-site
location where ERUs may contact management personnel.
· Sending employees to areas where disabled persons may be located to
assist in their notification and evacuation.
· Staging employees at Areas of Rescue Assistance.
• Use of Areas of Rescue Assistance communication equipment.
• Transporting color-coded floor plans, facility emergency information and
communication equipment to a safe, designated area.

Emergency Drills
Each facility should conduct routine drills to ensure that employees can perform assigned
functions and that the plan actually works. These drills can be used to finely tune the
facility's response to emergencies and greatly reduce the possibility of inappropriate
actions that could lead to unnecessary endangerment of people and property. Training
drills should include briefs to employees on the expected response from emergency
personnel from both on-site and off.

Types of danger and graduated response

Each facility emergency response plan should define the levels of danger to both people
and property. Management should train employees how and why these various levels are
activated by management and what their specific actions should be. Evacuation response
actions should be tailored to the situation and type of danger that exists or could possibly
exist. These types of dangers, from least severe to most severe, are categorized as:
· Possible Danger
· Imminent Danger
· Immediate Danger
· Life Threatening Danger

Employee Actions
All employee actions during emergencies should be directed to:
• Actions to notify Emergency Response Units
• Action to facilitate orderly and timely evacuation if necessary, this
includes notifying and assisting the disabled.
• Actions to limit the severity of the emergency
• Actions to assist Emergency Response Units and personnel
 BRIM – APPENDIX 2

Employees should be cautioned not to attempt any actions for which they are not trained
unless inaction would result in a Life Threatening Danger. Employees should not be
expected to unnecessarily endanger themselves while carrying out their assigned duties.

Additional training
Additional employee emergency training can be obtained through local Fire Departments,
The American Red Cross, Search and Rescue Units and similar organizations.
 BRIM – APPENDIX 3

APPENDIX 3

Sample Bomb Threat Checklist

 BRIM – APPENDIX 3

BOMB THREAT CHECKLIST

Exact time of call _______________

Exact words of caller _________________________________________________________________

__________________________________________________________________________________

QUESTIONS TO ASK (ask questions to keep caller on the line)

1. When is bomb going to explode? ___________________________________

2. Where is the bomb? ______________________________________________

3. What does it look like? ____________________________________________

4. What will cause it to explode? _______________________________________

5. Did you place the bomb? __________________________________________

6. Why? __________________________________________________________

7. Where are you calling from? ________________________________________

8. What is your name? _______________________________________________

CALLER'S VOICE (circle)

Calm Disguised Nasal Angry Broken

Stutter Slow Sincere Lisp Rapid

Giggling Deep Crying Squeaky Excited

Stressed Accent Loud Slurred Normal

Were there any background noises? __________________________________________

Remarks: _______________________________________________________________

Person receiving call: _____________________________________________________

Telephone number call received at: __________________________________________

Date: _________________________________________________________________

Report call immediately to: _______________________________________________

 BRIM – APPENDIX 4

Appendix 4

Sample Workplace Violence Program

 BRIM – APPENDIX 4

Workplace Violence Prevention Program

Workplace violence has emerged as an important safety and health issue in today's
workplace. The circumstances of workplace violence vary and may include robbery-
associated violence; violence by disgruntled clients, customers, patients, inmates, etc.;
violence by coworkers, employees, or employers; and domestic violence that finds its
way into the workplace.
1.0 Purpose
The purpose of this safety policy and program is to establish guidelines
and procedures for taking preventive measures to minimize the potential
workplace violence.
(Enter Entity Name Here) recognizes that workplace violence is an
occupational hazard and that a proactive approach in preventing
workplace violence is necessary. This includes provisions for management
and employee training, outlines prohibited behavior, and reporting and
investigation procedures. This safety policy also provides for
confidentiality, discipline, and anti-retaliation requirements.
2.0 Policy

It is the policy of (Enter Entity Name Here) to provide a place of

employment that is free from recognized hazards that cause or are likely to
cause death or serious physical harm to employees or the public. (Enter
Entity Name Here) is committed to maintaining a safe, healthful, and
efficient working environment where employees and the public are free
from the threat of workplace violence. When these workplace violence
hazards are recognized and identified then proper training and appropriate
security measures will be implemented.

3.0 Responsibilities

It is the responsibility of each manager/unit head, supervisor, and

employee to ensure implementation of (Enter Entity Name Here)'s safety
policy and procedure regarding Violence in the Workplace. It is also the
responsibility of each (Enter Entity Name Here) employee to report
immediately any unsafe act or condition to his or her supervisor.

Management
 BRIM – APPENDIX 4

• Provide support to all investigations of instances of violence in the

workplace

• Responsible for identifying the vulnerable locations and work

activities most susceptible to workplace violence

• Provide training for Managers, Supervisors and Employees

• Ensure compliance with this safety policy and procedure through

the auditing process
Supervisors

• Assist managers in the identification of vulnerable locations and

work activities within their organization.

• Report all instances of workplace violence

• Assist employees in reporting workplace violence

• Assist in all investigations

Employees

• Report any acts of violence or threatening behaviors to supervisors,

or their Personnel Representative

• Participate in training required by this policy and procedure.

Safety/Loss Control Officer

• Assist managers, supervisors, or others as necessary on any matter

concerning this safety policy and procedure.

• Provide consultative and audit assistance to ensure effective

implementation of this safety policy and procedure.

• Develop and provide training to (Enter Entity Name Here)

employees on workplace violence.

• Provide consultative and audit assistance to ensure effective

implementation of this safety policy and procedure.

• Identify and apply resources for Employee Assistance Programs

4.0 Training

All employees, including supervisors and managers will receive annual

awareness training. These sessions will explain (Enter Entity Name
Here)’s safety policy and procedure on workplace violence, as well as
 BRIM – APPENDIX 4

cover procedures for reporting and investigating threats, violent acts, and
unsafe workplace conditions. In addition, employees will be informed of
their responsibilities and of the measures they can take to protect
themselves and their co-workers from workplace violence.
Supervisor and Manager Training

When employees are respected and their concerns are addressed in a fair
and timely manner, they are far less likely to resort to violence as a way of
responding to conflicts. Creating this type of caring work environment
requires that supervisors and managers:

• Treat all employees fairly and respectfully.

• Are clear and consistent in their expectations.

• Involve employees in the decision-making process.

• Set realistic workloads, deadlines, and performance standards.

• Ensure employees have the resources they need to complete

assignments.

• Permit flexibility in working conditions for employees

experiencing difficult times.

• Acknowledge and follow-through on employee requests and

concerns.

• Provide regular and constructive feedback.

• Keep employees informed of what is going on in the organization.

To help supervisors and managers improve their overall effectiveness in
these areas, they will receive periodic training on the following
management skills:

• Communication

• Team building

• Mentoring

• Problem solving

• Counseling
Despite (Enter Entity Name Here)’s best efforts to create a healthy work
atmosphere, there are bound to be some performance- and behavior-
related problems. To keep these problems from spiraling out of control,
 BRIM – APPENDIX 4

supervisors and managers should be trained to recognize and handle them

at the lowest possible level. This can be accomplished by providing
training on:

• Conflict resolution

• Non-violent responses

• Disciplinary procedures

• Crisis management
Employee Training

Incidents of workplace violence can also be reduced if employees are

effective in their interactions with customers, visitors and co-workers.
Since not all employees join the workforce with the necessary "people
skills," the following skills will be taught to each employee:

• Customer service

• Communication

• Team building

• Problem solving

• Conflict resolution

• Non-violent response
It is also important that employees receive "awareness training" which
addresses:

• (Enter Entity Name Here)'s position on workplace violence

• Behaviors that are prohibited by (Enter Entity Name Here) policy.

• Disciplinary action that will result from policy violations.

• Procedures for reporting and investigating threats, violent acts, and

unsafe conditions.

• Measures that will be taken to ensure confidentiality.

• Steps (Enter Entity Name Here) has taken to increase security.

5.0 Prohibited Behavior
 BRIM – APPENDIX 4

Prohibited behaviors are those behaviors that are defined in this program
and behaviors that:

• Threaten the safety of an employee and/or customer.

• Affect the health, life, or well-being of an employee and/or

customer.

• Result in damage to company, employee, or public property

(excluding vehicle and equipment accidents).
Such acts include, but are not limited to:

• Threatening, intimidating, coercing, harassing, or assaulting an

employee or the public.

• Sexually harassing an employee or the public.

• Allowing unauthorized persons access to buildings without

management permission.

• Using, duplicating, or possessing keys to buildings or offices

within the building without authorization.

• Damaging, or attempting to damage, property of (Enter Entity

Name Here), an employee, or the public.

• Carrying unauthorized weapons (concealed or exposed) on (Enter

Entity Name Here) property.
6.0 Workplace Security Analysis
The Safety/Loss Control Committee should conduct a thorough initial risk assessment to
identify hazards, conditions, operations, and situations that could lead to violence. The
initial risk assessment includes a walkthrough survey to provide the data for risk
identification and the development of a comprehensive workplace violence prevention
program. The assessment process includes the following:

• Analyze incidents, including the characteristics of assailants and victims. Give an

account of what happened before and during the incident, and note the relevant
details of the situation and its outcome.

• Identify any apparent trends in injuries or incidents relating to a particular

worksite, job title, activity, or time of day or week. The Committee should
identify specific tasks that may be associated with increased risk.

• Identify factors that may make the risk of violence more likely, such as physical
features of the building and environment, lighting deficiencies, lack of tele-
 BRIM – APPENDIX 4

phones and other communication devices, areas of unsecured access, and areas
with known security problems.

• Evaluate the effectiveness of existing security measures. Assess whether those

control measures are being properly used and whether employees have been
adequately trained in their use.
7.0 Engineering Controls and Workplace Adaptation
Engineering controls remove the hazard from the workplace or create a barrier between
the worker and the hazard. The following physical changes in the workplace can help
reduce violence-related risks or hazards:

• Maintain adequate lighting within and outside the facility. The parking area and
the approach to the facility should be well lit during nighttime hours of operation.
Exterior illumination may need upgrading in order to allow employees to see what
is occurring outside the facility.

• Use fences and other structures to direct the flow of customer traffic to areas of
greater visibility.

• Install video surveillance equipment and closed circuit TV (CCTV). This may
include interactive video equipment. The video recorder for the CCTV should be
secure and out of sight. Posting signs that surveillance equipment is in use may
increase the effectiveness of the deterrence.

• Put height markers on exit doors to help witnesses provide more complete
descriptions of assailants.

• Use door detectors to alert employees when persons enter a building.

• Control access to buildings with door buzzers.

• Use silent and personal alarms to notify police or management in the event of a
problem.

• Install physical barriers such as bullet-resistant enclosures with pass-through

windows between customers and employees to protect employees from assaults in
locations with a history of robberies or assaults.
8.0 Administrative and Work Practice Controls
Administrative and work practice controls affect the way employees perform jobs or
specific tasks. The following examples illustrate work practices and administrative
procedures that can help prevent incidents of workplace violence:

• Integrate violence prevention activities into daily procedures, such as checking

lighting, locks, and security cameras, to help maintain worksite readiness.
 BRIM – APPENDIX 4

• Adopt proper emergency procedures for employees to use in case of a security

breach.

• Establish systems of communication in the event of emergencies. Employees

should have access to working telephones in each work area, and emergency
telephone numbers should be posted by the phones.

• Adopt procedures for the correct use of physical barriers, such as enclosures and
pass-through windows.

• Increase staffing levels at night at facilities located in high-crime areas.

• Lock doors used for deliveries when not in use. Also, do not unlock delivery
doors until the delivery person identifies himself or herself. Take care not to block
emergency exits–doors must open from the inside without a key to allow persons
to exit in case of fire or other emergency.

• Establish rules to ensure that employees or visitors can walk to outdoor areas
without increasing their risk of assault. The key is to have good visibility, thereby
eliminating potential hiding places for assailants near these areas. In some
locations, going to outside during daylight may be safer than doing so at night.

• Keep doors locked before business officially opens and after closing time.
Establish procedures to assure the security of employees who open and close the
facility, when staffing levels may be low.

• Limit or restrict areas of visitor access or close portions of the facility to limit
risk.

• Adopt safety procedures and policies for off-site work, such as deliveries.
Administrative controls are effective only if they are followed and used properly. Regular
monitoring helps ensure that employees continue to use proper work practices. Giving
periodic, constructive feed-back to employees helps to ensure that they understand these
procedures and their importance.

9.0 Periodic Safety Audits

Hazard analysis is an ongoing process. The Safety/Loss Control Committee will conduct
periodic safety audits to review workplace hazards and the effectiveness of the control
measures that have been implemented. These audits also can evaluate the impact of other
operational changes that were adopted. A safety audit is important in the aftermath of a
violent incident or other serious event for reassessing the effectiveness of the violence
prevention program.
 BRIM – APPENDIX 4

Prevention Programs
Violence prevention programs benefit greatly from periodic evaluation. The evaluation
process could involve the following:

• Review the results of periodic safety audits.

• Review post-incident reports.

• Examine reports and minutes from staff meetings on safety and security issues.

• Keep abreast of new strategies to deal with violence in various types industry.
10.0 Reporting & Investigation

Any employee (including a supervisor or manager) who has been

threatened, is a victim of a violent act, witnesses any threats or violent
acts, or learns of any threats or violent acts, is to report immediately such
activity to their supervisor or the Safety/Loss Control Officer. Each report
will be promptly evaluated and investigated by the management to
determine what follow-up actions are necessary. Management has the
authority and responsibility to request law enforcement intervention if it is
thought to be necessary.

Confidentiality

Information about an incident or threat will be disclosed only on a needs-

to-know basis, so that a fair and thorough investigation can be conducted
and appropriate corrective action can be taken. (Enter Entity Name Here)
will make every effort to ensure the safety and privacy of the individuals
involved.
Discipline

An employee who engages in prohibited behavior will be subject to

appropriate disciplinary action, as determined by the findings of the
investigation. Such discipline may include warnings, demotion,
suspension, or immediate dismissal. In addition, certain actions may cause
the employee to be held legally liable under state or federal law.
Retaliation

Episodes of workplace violence can only be eliminated if employees are

willing and able to report threats, violent acts and other unsafe conditions.
 BRIM – APPENDIX 4

To encourage employees to come forward without the fear of retaliation,

(Enter Entity Name Here) promises to promptly investigate all complaints
of retaliation and impose appropriate disciplinary action, up to and
including dismissal.
Counseling

Dealing with or being exposed to a violent or abusive situation can be

emotionally unsettling. (Enter Entity Name Here) will provide for
appropriate counseling to reduce tension and stress. Follow-up counseling
services may be provided and arranged by employee’s supervisors as
requested to affected employees.

11.0 Recordkeeping
Good records help determine the severity of the risks, evaluate the methods of hazard
control to protect property and create a safe and healthful facility for workers and
visitors. This violence prevention program will use the following types of records for this
purpose:

• Notes of safety meetings and training records.

• Records of property damages or losses, employee and third party injuries and
illnesses at the facility.

• Records describing incidents involving violent acts and threats including events
involving abuse, verbal attacks, or aggressive behavior

• Written hazard analyses.

• Recommendations of police advisors, employees, or consultants.

• Up-to-date records of actions taken to deter violence, including work practice

controls and other corrective steps.