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Written Safety and Health Program

For

XYZ Company

Required for all Hawaii Businesses with 25 or More Employees Incorporates Provisions of Hawaii Administrative Rules

Title 12, Subtitle 8, Part 2, Chapter 60

Hawaii - Written Safety and Health Program


Table of Contents

Section Description Page

1 Management Commitment 3

2 Assignment of Responsibilities 4

3 Employee Participation 10

4 Hazard Recognition 13

5 Hazard Prevention and Control 23

6 Emergency Planning 33

7 Safety and Health Training 42

8 Company Required Safety Programs 46

9 Company Required Safety Training Courses 47

10 Company Required Safety Forms & Checklists 49

Appendices

Appendix A List of Training Subjects 51

Appendix B Hazard Assessment Checklist (Alpha sorted) 53

Appendix C Hazard Assessment and Correction Record 54

Appendix D Accident/Exposure Investigation Report 56

Appendix E Employee Training and Instruction Record 58

Appendix F Employee Acknowledgement Form 60



Section 1

Management Commitment

Program Policy Statement

XYZ Company shall comply with all occupational safety and health laws of the State of Hawaii.

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 with 25 or more employees within the State

of Hawaii.

This program incorporates and complies with Hawaii Administrative Rules Title 12, Subtitle 8,

Part 2, Chapter 60

Proper use of this program requires the Program Administrator to carefully review the

requirements for each of the program sections, appendices and to modify, where necessary, to

accurately 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.



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 _______________________________________.

2. Company Responsibilities

XYZ Company responsibilities shall including the following:

a. Provide support from the top level down to first line supervisors in terms of time, effort,

and money.

b. Resolve scheduling and personnel conflicts.

c. Provide realistic dates for correcting safety and health concerns.

d. Support training for safety committee members.

e. Provide leadership and direction.

f. Participate in safety committee meetings.

g. "Talk up" the positive effects of safety committee activities, on a one-on-one basis or in-

group meetings.

h. Respond to recommendations in a timely manner.

i. Ensure lines of communication are open and non-threatening.

j. Consider expanding the safety committee's responsibilities and authority to better serve

the company.



Section 3

Employee Participation

DECISION POINT - If one is not established, state reason and/or justification, then edit the

text in this section as appropriate to your business.

1. Occupational Safety and Health Committee

XYZ Company has formed a safety committee to help employees and management work

together to identify safety problems, develop solutions, review incident reports and evaluate

the effectiveness of our safety program. The committee is made up of management-designated

representatives 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 regular

inspections of the workplace.



Section 4

Hazard Recognition

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

“Employee’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

developing safe work procedures and safety and health training.



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.

Whenever 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 protective 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 Program 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

procedures; and

5) Danger areas that are: “off-limits” for employees.



Section 6

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

exits, 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

evacuation 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

experts or special consultants where possible, and on an as needed basis.

Emergency procedures shall be updated whenever changes are made in materials,

equipment or building structures.



Section 7

Safety and Health Training

Training at XYZ Company is an essential part of our plan to provide a safe work place.

Training Administrator

Written Safety and Health Program training administrator, Training Administrator has the

authority and responsibility for implementing the provisions of this program.

DECISION POINT – Enter a name or position title (recommended)

The Training Administrator for XYZ Company is _______________________________________.

The Training Administrator is responsible to verify that each employee has received an initial

safety orientation by their supervisor, has received any training needed to do the job safely and

that the employee file documents the training. This administrator will make sure that an outline

and materials list is available for each training course we provide:

1. New-Hire Employee Orientation

A. All XYZ Company employees will attend the new-hire employee orientation prior to

commencing employment. New-hires shall receive occupational health and safety

training in the following subject areas:

1) XYZ Company Safety Philosophy and Policy

2) Disciplinary procedures for non-compliance

3) Employee Danger Reporting System

4) Accident Reporting System

5) Personal Protective Equipment (when applicable)

6) Fall Protection -100% tie-off (when applicable)



Section 8

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



Section 9

Company Required

Safety Training Courses


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



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



Section 10

Company Required

Safety Forms & Checklists


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



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

TRAINING RECOGNITION CERTIFICATE

Certificate of Completion



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

equipment.

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.

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

communication.

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 ___________________________________________



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

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