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TRANSCRIPT
A Workplace Accident and
Injury Reduction Program
For
XYZ Company
Required for all Minnesota Businesses with 25 or More Employees
Incorporates Provisions of Minnesota Statutes Chapter 182.653, Subdivision 8
Americana Safety. All rights reserved.
Minnesota - A Workplace Accident and Injury Reduction Program
Americana Safety. All rights reserved.
Table of Contents
Section Description Page
1 Management Commitment 3
2 Assignment of Responsibilities 4
3 Safety Committees and Meetings 10
4 Hazard Identification and Analysis 13
5 Hazard Prevention and Control 23
6 Accident Investigation and Reporting 33
7 Emergency Planning 40
8 Safety and Health Training 49
9 Company Required Safety Programs 52
10 Company Required Safety Training Courses 53
11 Company Required Safety Forms & Checklists 55
12 Program Review 57
Appendices:
Appendix A List of Training Subjects 61
Appendix B Hazard Assessment Checklists 63
Appendix C Hazard Assessment and Correction Record 64
Appendix D Accident/Exposure Investigation Report 66
Appendix E Employee Training and Instruction Record 68
Appendix F Source of Information – MN OSHA 70
Appendix G Minnesota OSHA Area Offices 71
Appendix H Employee Acknowledgement Form 73
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 1
Management Commitment
Program Policy Statement
XYZ Company shall comply with all occupational safety and health laws of the State of
Minnesota.
To accomplish this, we must constantly be aware of unsafe acts and conditions in all work areas
that can produce injuries. No employee is required to work at a job they know is not safe or
healthful.
As employees of XYZ Company, your cooperation in detecting hazards and, in turn, controlling
them, is a condition of your employment. Inform your supervisor immediately of any situation
beyond your ability or authority to correct.
Program Requirement
This written program is required for all businesses within the State of Minnesota.
This program incorporates and complies with the provisions of Minnesota Statutes Chapter
182.653, Subdivision 8.
Proper use of this program requires the Program Administrator to carefully review the require-
ments for each of the program sections, appendices and to modify, where necessary, to accu-
rately reflect specific company requirements as it relates to its operation and workforce.
This program must be maintained by the employer in order to be effective.
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 2
Assignment of Responsibilities
1. Program Administrator
Written Safety and Health Program administrator, Program Administrator has the authority
and responsibility for implementing the provisions of this program.
DECISION POINT – Enter a name or position title (recommended)
The Program Administrator for XYZ Company is
_______________________________________.
Company Responsibilities
XYZ Company responsibilities shall including the following:
1. Provide support from the top level down to first line supervisors in terms of time, effort,
and money.
2. Resolve scheduling and personnel conflicts.
3. Provide realistic dates for correcting safety and health concerns.
4. Support training for safety committee members.
5. Provide leadership and direction.
6. Participate in safety committee meetings.
7. "Talk up" the positive effects of safety committee activities, on a one-on-one basis or in-
group meetings.
8. Respond to recommendations in a timely manner.
9. Ensure lines of communication are open and non-threatening.
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 3
Safety Committee and Meetings
DECISION POINT - If a Safety Committee is not established state reason.
1. Safety Committee
XYZ Company has formed a safety committee to help employees and management work togeth-
er to identify safety problems, develop solutions, review incident reports and evaluate the effec-
tiveness of our safety program. The committee is made up of management-designated repre-
sentatives and employee-elected representatives.
A. The committee shall:
1) Promote a safe and healthy work environment at all times.
2) Encourage communication between employees and management.
3) Serve as an oversight committee on all issues relative to safety and health.
4) Make recommendations to the Safety Representative.
B. Functions: The committee has four principal functions:
1) Identify potential hazards;
2) Evaluate these potential hazards;
3) Recommend corrective action; and
4) Follow up implemented recommendations.
To carry out its functions, the committee is required to hold meetings and carry out reg-
ular inspections of the workplace
C. Membership
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Section 4
Hazard Identification and Analysis
1. Recordkeeping and Review
A. Employees will:
Employees will report any injury or work-related illness to their immediate supervisor
regardless of how serious. Minor injuries such as cuts and scrapes can be entered on a
“Minor Injury Log” posted in a conspicuous location. The employee must use an “Em-
ployee’s Injury/Illness Report Form” to report more serious injuries.
B. Supervisors will: DECISION POINT
a. Investigate a serious injury or illness using procedures in the “Incident Investigation”
section.
b. Complete an “Incident Investigation Report” form.
c. Give the “Employee’s Report” and “Incident Investigation Report” to the company
Safety Representative.
2. Hazard Recognition Methods
Hazard recognition is a vital element in the program. It is a system to identify any existing or
potential dangers in the workplace, then following through to eliminate or control them. If
dangers occur (or reoccur), there is a breakdown in the danger control system, and in turn
the safety and health program. The danger control system also serves as the basis for devel-
oping safe work procedures and safety and health training.
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Section 5
Hazard Prevention and Control
1. Eliminating Workplace Hazards
XYZ Company is committed to eliminating or controlling workplace hazards that could cause
injury or illness to our employees. We will meet the requirements of state safety standards
where there are specific rules about a hazard or potential hazard in our workplace. When-
ever possible we will design our facilities and equipment to eliminate employee exposure to
hazards. Where these engineering controls are not possible, we will write work rules that
effectively prevent employee exposure to the hazard. When the above methods of control
are not possible or are not fully effective we will require employees to use personal protec-
tive equipment (PPE) such as safety glasses, hearing protection, foot protection etc.
2. Safety Rules and Work Procedures
A. General Safety Rules
The XYZ Company Written Safety and Health Manual apply to all employees.
The rules may be very simple or extremely complex, depending on the nature of the
work processes and the number and kinds of employees involved. Some items that are
addressed by general safety rules are:
1) Personal protective equipment requirements;
2) Clothing appropriate for the work;
3) Behavior expected of all employees;
4) How to leave the workplace safely, with particular reference to emergency proce-
dures; and
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 6
Accident Investigation and Reporting
DECISION POINT - If this investigation system is not in place, it must be created.
Accident Investigation and Reporting
A system must be established for investigating all workplace accidents, near misses, injuries and
illnesses. Someone who can identify the causes and recommend corrective actions should com-
plete the investigation system. It is important to keep records of accident investigations. They
can help to determine the types of accidents that occur, where they happen, their causes and
any accident trends. Such information is invaluable in preventing future accidents and may also
help reveal flaws in operating procedures.
1. Program Introduction
At XYZ Company accident investigation is an integral part of our total occupational safety
and health program. It is especially important as a means to determine root causes, docu-
ment facts, provide information on costs, and promote safety.
All serious occupational injuries and illnesses shall be thoroughly investigated by the Safety
Representative with the underlying goal of preventing recurrence.
Whenever there is an incident that results in death or serious injuries that have immediate
symptoms, a preliminary investigation will be conducted by the immediate supervisor of the
injured person(s), a person designated by management, an employee representative of the
safety committee, and any other persons whose expertise would help the investigation.
The company investigation team will take written statements from witnesses, photograph
the incident scene and equipment involved. The team will also document as soon as possi-
ble after the incident, the condition of equipment and any anything else in the work area
that may be relevant.
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 7
Emergency Planning
DECISION POINT
1. Emergency Planning and Procedures
An evacuation map for the building is posted (Customize by adding location, if this applies
to your company). It shows the location of exits, fire extinguishers, first aid kits, and where
to assemble outside (Customize by adding meeting location for your location). A copy of
the map is attached to this program.
All XYZ Company employees will receive training on how to use a portable fire extinguisher
as part of their initial orientation. Buildings will display a map that shows the location of ex-
its, fire extinguishers, first aid kits, and where to assemble outside.
At XYZ Company, advance planning and preparation for emergencies is good insurance.
Some emergency planning is mandated by regulations, such as for first aid and fire evacua-
tion and for certain situations in specific industries or operations.
A list of possible emergencies shall be prepared and procedures established to respond to
those emergency situations.
Emergency plans shall be reviewed with individuals such as doctors, fire and explosives ex-
perts or special consultants where possible, and on an as needed basis.
Emergency procedures shall be updated whenever changes are made in materials, equip-
ment or building structures.
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 8
Safety and Health Training
Safety and health training at XYZ Company imparts knowledge, generates new ideas, reinforces
existing ideas and principles and puts the other three elements of the program into action.
The answer to the question, “How do I get new employees into the mainstream and build
productivity?” is “Training!” On-the-job or through formal classroom instruction, training is a
necessity for improving performance. As time passes and processes or product lines change,
employees must be retrained.
Safety and health training implies training on specific job procedures. It can be given separately,
but it is better combined with regularly scheduled job-related training. Such training benefits
the employee through fewer work-related injuries and illness reduced stress, and worry caused
by exposure to dangers. Training must also be provided for supervisors.
1. Supervisor and Employee Safety Training
Supervisory Training
XYZ Company supervisory training is a logical first step since supervisors will help in training
the other employees. Supervisors are key figures in the implementation and overall success
of the safety and health program. As a minimum, our supervisors shall be trained in the fol-
lowing areas:
a. The need to establish and maintain safe and healthful working conditions;
b. The dangers associated with a job, the potential effect on employees, and the rules,
procedures and work practices for control of these dangers;
c. How to relate this information by example and instruction to employees, to ensure that
they understand and follow safe procedures; and
Minnesota - A Workplace Accident and Injury Reduction Program
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Section 9
Company Required Safety Programs
Due to the nature of work and operations performed by XYZ Company, it is necessary that the
following regulatory programs are included in our Injury and Illness Prevention Program:
For convenience, programs listed in the table below are alpha sorted.
DECISION POINT – Review and select those programs that apply or included others not listed
Company Required Safety and Health Plans & Programs
Accident Prevention Program Forklift Safety Program
Asbestos Management Plan Hazard Communication Program
Bloodborne Pathogens Program Hearing Conservation Program
Chemical Hygiene Plan Hot Work Permit Program
Confined Space Entry Program Ladders and Stairways Work Plan
Control of Hazardous Energy Program Laser Safety Program
Cranes and Derricks Safety Program Lead Safety Program
Electrical Safety Program Personal Protective Equipment Plan
Emergency Action Plan Powered Industrial Truck Program
Excavation and Trenching Program Radiation Protection Program
Fall Protection Program Respiratory Protection Program
Fire Prevention Work Plan Scaffolding Safety Program
Flammable Storage / Compressed Gas Welding Safety Program
Table 1
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Section 10
Company Required
Safety Training Courses
Due to the nature of work and operations performed by XYZ Company, it is necessary that the
following safety training courses are included in our Injury and Illness Prevention Program:
For convenience, courses listed in the 3 tables below are alpha sorted.
DECISION POINT – Review and select those courses that apply or included others not listed
Company Required Safety Training Courses – Sorted A-E
Accident Investigation Construction Safety Management
Accident Prevention Signs & Tags Crane Safety – Refresher
Asbestos Safety Cranes & Derricks in Construction
Bloodborne Pathogens – Initial/Refresher Electrical Safety
Bloodborne Pathogens – Train-the-Trainer Emergency Exit Routes
Chemical Spills Emergency Response Team
Competent Persons Ergonomics – Basic Human Factors
Compressed Gas Cylinder Ergonomics – Advanced Human Factors
Concrete & Masonry Excavation Safety
Confined Space Entry Eye & Face Protection
Table 2
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Company Required Safety Training Courses – Sorted F-L
Fall Protection Hexavalent Chromium
Portable Fire Extinguisher Hot Work Permit Safety
Flammable & Combustible Liquids Indoor Air Quality
Forklift Safety – Classroom (English) Introduction to OSHA
Forklift Safety – Classroom (Spanish) Job Hazard Analysis
Hand & Power Tools Laser Safety
Hazard Communication Lead Exposure
Hazard Vulnerability Liquid Nitrogen
Hazardous Materials Management Lockout-Tagout
Hearing Protection
Table 3
Company Required Safety Training Courses – Sorted M-W
Machine Guarding Safety Representative Training
Material Handling Safety Supervisor Training
Office Safety Awareness Scaffolding
Pandemic Preparedness Slip, Trip & Fall Prevention
Personal Protective Equipment Stairway & Ladder Safety
Powered Industrial Truck TB Respiratory Protection
Radiation Safety Walking & Working Surfaces
Respirator Protection Warehouse Safety
Safe Lifting Awareness – Back Safety Workplace Violence Prevention - Healthcare
Safety Audit Training Workplace Violence Prevention - Retail
Table 4
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Section 11
Company Required
Safety Forms & Checklists
Due to the nature of work and operations performed by XYZ Company, it is necessary that the
following safety forms and checklists are included in our Injury and Illness Prevention Program:
For convenience, forms listed below are subject sorted.
DECISION POINT – Review and select those forms that apply or included others not listed
CONFINED SPACE
Confined Space Entry Permit Confined Space – Class A & B Permit Confined Space – Class C Permit List of Authorized Entrants Permit Required Confined Space – Inventory Log
CONSTRUCTION INDUSTRY - SAFETY MANAGEMENT
Construction Industry Inspection Checklist Job Start-Up Checklist Contractors Job Site Checklist Contractor Safety Performance Report Construction Equipment Checklist Forklift Service Checklist Operator Performance Evaluation Checklist Safety Nets Inspection Checklist Body Harness & Lanyard Inspection Report Competent Person Evaluation – Fall Protection
CRANE OPERATIONS
Cranes, Derricks or Material Handling Devices Worksheet Crane Inspection Checklist Crane Pre-Lift Checklist Sling (Chain) Inspection Report Monthly Hoist Rope Inspection Report Monthly Hoist Hook Inspection Report
EMERGENCY ACTION AND RESPONSE Crisis Management Response Team - Contact Log Safety Representatives - Contact Log External Resources – Contact Log Vulnerability Analysis Chart Bomb Threat Checklist Employee Evacuation - Accounting Log Physically Challenged – Employee List Command Post Equipment Inventory Log Press Information Log Post Exercise Evaluation Report
Minnesota - A Workplace Accident and Injury Reduction Program
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EMPLOYEE SAFETY RECORDS
Employee Acknowledgement Form Employee Orientation Checklist – Construction Employee PPE Assessment Form Employee PPE Issue Form Employee Safety Training Record Ergonomic Workstation Analysis Form Employee Ergonomic Workstation Questionnaire Employee Safety Suggestion Form
EXCAVATION OPERATIONS
Pre-Excavation Checklist Trenching Design Checklist Trench Safety – Daily Field Report Competent Person Evaluation – Excavation
FIRE PREVENTION Hot Work Permit Fire Safety Inspection Checklist Fire Drill Post Response Report Emergency HAZMAT Inventory Log Hazardous Waste Disposal Request Form
GENERAL INDUSTRY – SAFETY MANAGEMENT
General Industry Safety Inspection Checklist Office Safety Inspection Checklist Job Safety Analysis Worksheet & Instructions Accident Prevention Program Analysis Forklift Service Checklist Hearing Conservation Program Log Scaffolding Safety Checklist Site Safety Meeting Record Supervisors Monthly Meeting Record Report of Safety Hazard Form Property Security Survey
INCIDENT REPORTING FORMS
OSHA 300 Log Employee Injury & Illness Report Employee Injury Cost Accounting Matrix Vehicle Accident & Property Damage Report Compiling Direct and Indirect Costs
OCCUPATIONAL HEALTH FORMS
Medical Evaluation Questionnaire – Respirator Use Respirator Fit Testing Record Hepatitis B Vaccine - Accept/Decline Form Bloodborne Pathogens Risk Classification Flowchart BBP Employee Annual Training Record BBP Source Patient Consent Form
RADIATION PROGRAM FORMS
Radioactive Material Use Log Pregnancy Declaration Form Laboratory Contamination Survey Record Radiation Producing Device - Authorization Form Training Guide for Radiation Workers Training Guide for Ancillary Radiation Works
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Section 12
Program Review
The AWAIR Act requires employers to review the entire program at least annually and document
the findings. Program review is vital, because it serves as a check to see if the organization is
making progress towards its goal of creating a safer, healthier workplace for all employees.
The second reason for conducting a review or audit of the workplace safety and health program
is to determine whether the procedures used in the facility are consistent with those described
in the program and if they are effective. For example, if the audit shows there are injuries and
illnesses occurring from hazards that have not been identified or controlled through the meth-
ods described in the safety and health program, the auditor needs to determine if the methods
are being used in the facility correctly and as described in the program. If the methods are not
being used or are used incorrectly, the auditor needs to determine what barriers are present
that prevent the correct application of the methods (e.g., production demands, supervisor work-
loads or lack of training). If the hazard identification and control techniques are being applied
correctly, then the organization needs to further review the techniques and, perhaps, modify
them or adopt new ones.
The primary focus of the evaluation effort should be whether the organization has made pro-
gress in achieving the AWAIR program’s goals and objectives within the past year and, if so,
whether the progress made actually improved worker safety and health. If an organization has
achieved the goals and objectives described in its safety and health program, it should set new
goals and objectives for the coming year to motivate managers and employees to work to fur-
ther improve safety and health on the job. The organization, its management and its employees
should continually work to improve workplace safety, just as they do to improve quality, cost
effectiveness and other facets of the business.
Minnesota - A Workplace Accident and Injury Reduction Program
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Appendix A
List of Training Subjects
DECISION POINT – Select applicable training subjects - Strikethrough/delete those that do not
XYZ Company trains our workers about the following selected training subjects:
1. The employer's Code of Safe Practices.
2. Confined spaces.
3. Safe practices for operating any agricultural equipment.
4. Good housekeeping, fire prevention, safe practices for operating any construction equip-
ment.
5. Safe procedures for cleaning, repairing, servicing and adjusting equipment and machinery.
6. Safe access to working areas.
7. Protection from falls.
8. Electrical hazards, including working around high voltage lines.
9. Crane operations.
10. Trenching and excavation work.
11. Proper use of powered tools.
12. Guarding of belts and pulleys, gears and sprockets, and conveyor nip points.
13. Machine, machine parts, and prime movers guarding.
14. Lock-out/tag-out procedures.
15. Materials handling.
16. Chainsaw and other power tool operation.
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17. Tree falling/bucking procedures and precautions, including procedures for recognizing and
working with hazard trees, snags, lodged trees, and unsafe weather conditions.
18. Yarding operations, including skidding, running lines, unstable logs, rigging and communi-
cation.
19. Landing and loading areas, including release of rigging, landing layout, moving vehicles
and equipment, and log truck locating, loading and wrapping.
20. Fall protection from elevated locations.
21. Use of elevated platforms, including condors and scissor lifts.
22. Safe use of explosives.
23. Driver safety.
24. Slips, falls, and back injuries.
25. Ergonomic hazards, including proper lifting techniques and working on ladders or in a
stooped posture for prolonged periods at one time.
26. Personal protective equipment.
27. Respiratory Equipment.
28. Hazardous chemical exposures.
29. Hazard communication.
30. Physical hazards, such as heat/cold stress, noise, and ionizing and non-ionizing radiation.
31. Laboratory safety.
32. Bloodborne pathogens and other biological hazards.
33. Other job-specific hazards, such as _____________________________________________
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Appendix B
Hazard Assessment Checklist
DECISION POINT – Determine which checklists apply to your operation and delete all others
XYZ Company has determined the following hazard assessment checklists apply to its operations
1. Abrasive Wheel Equipment Grinders
2. Compressed Air Receivers
3. Compressed Gas & Cylinders
4. Compressors & Compressed Air
5. Confined Spaces
6. Control of Harmful Substances by
Ventilation
7. Crane Checklist
8. Electrical
9. Elevated Surfaces
10. Emergency Action Plan
11. Environmental Controls
12. Ergonomics
13. Exit Doors
14. Exiting or Egress
15. Fire Protection
16. Flammable & Combustible Materials
17. Floor & Wall Openings
18. Fueling
19. General Work Environment
20. Hand Tools & Equipment
21. Hazardous Chemical Exposures
22. Hazardous Substances Communication
23. Hoist & Auxiliary Equipment
24. Identification of Piping Systems
25. Industrial Trucks – Forklifts
26. Infection Control
27. Lockout-Tagout Procedures
28. Machine Guarding
29. Material Handling
30. Noise
31. Personal Protective Equipment & Clothing
32. Portable (Power Operated) Tools &
Equipment
33. Portable Ladders
34. Powder Actuated Tools
35. Sanitizing Equipment & Clothing
36. Spraying Operations
37. Stairs and Stairways
38. Tire Inflation
39. Transporting Employees & Materials
40. Ventilation for Indoor Air Quality
41. Walkways
42. Welding, Cutting & Brazing