HVT Injury Illness Prevention Plan 04.09hoopainsurance.com/documents/TSODraftIIPP0409.pdf · · 2009-04-20A periodic inspection system to identify workplace hazards. 3. Procedures

HVT Injury & Illness Prevention Plan (IIPP) Draft April 2009

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Hoopa Valley Tribe

Insurance Department ~ Tribal Safety Office

Injury & Illness Prevention Plan

(IIPP)

April 2009 DRAFT

Hoopa Valley Tribal Safety Office 103 Willow Street, Suite B

Hoopa, CA 95546 530.625.9200 x15 Fax 530.625.4269

Safety Officer, Pliny McCovey Jr. [email protected] www.hoopainsurance.com


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Page 3 of 20

Table of Contents

Introduction 5

Employee Wellness 5

Summary of Safety Officer’s Duties 6

Manager/Director Duties and Responsibilities 6

Supervisor Duties and Responsibilities 7

Employee Duties and Responsibilities 8

Safety Communications 8

Department Safety Meetings 9

Training and Safety Rules 9

General Safety Rules 9

Job-Specific Safety Rules 10

Hazard Identification and Inspection 11

Inspection Report Checklist 11

Reporting an Incident 12

To Promote Safety 12

Recordkeeping Reminders 13

IIPP Forms to Be Completed and Filed

Occupational Injury & Illness Logs (OSHA 300, 300A, & 301) 14

Incident Report Form 17

Employee Safety Information Form 18

Hazard Removal Form 19

Employee Training Logs 20

HVT Injury & Illness Prevention Plan (IIPP) Draft April 2009 Page 4 of 20


INTRODUCTION

An Injury and Illness Prevention Program (IIPP) is a proven method that protects employees,

lowers your costs and increases profitability. At the Hoopa Valley Tribe (HVT), the Hoopa

Office of Tribal Safety (TSO) has the goal is to make it easy for employees to read and utilize this

IIPP to improve workplace safety, boost employee morale and raise the efficient output of

services to our clients and membership.

Workplace accidents result in lost productivity, equipment damage, spoiled products and an

unproductive management time. They also drive up your workers' compensation premiums.

That's why it pays to implement an IIPP, and to have your employees adhere to its policies.

An effective IIPP includes these elements:

1. A written plan designating who's in charge of safety program implementation.

2. A periodic inspection system to identify workplace hazards.

3. Procedures for investigating the cause of accidents, illnesses or injuries.

4. Methods to ensure elimination of hazards once they're identified through inspections and

accident/incident investigations.

5. A safety and health training program specific to each job that's required for new

employees as well as whenever new substances, processes, procedures or equipment are

introduced to the workplace.

6. A system for employees to communicate safety concerns to employers without fear of

reprisal.

7. A system for ensuring employee compliance with safety and health practices.

8. Maintenance of appropriate records and steps taken to implement and maintain the

accident prevention program.

The TSO intends to implement the above elements in the following IIPP to help the HVT ensure

that it is taking every precaution to reduce and eliminate workplace hazards. This particular

prevention plan is included in the Hoopa Valley Tribe’s overall Safety Manual.

EMPLOYEE WELLNESS

All employees are allotted two 15 minute breaks for a total of 30 minutes for exercise and health

and wellness. Each department can set their own criteria for exercise and employee wellness,

however, there must be at least 30 minutes a day allotted for any employee who chooses to utilize

this time for stretching, walking, jogging, exercise, or any other form of injury and illness

prevention. This time is specifically set aside for injury and illness prevention and may not be

used as personal time for anything other than exercising, etc. Please refer to you departments

rules for exercise breaks as each department should have a policy in writing.


SUMMARY OF SAFETY OFFICER'S DUTIES

The Safety Officer has responsibility for planning, directing, monitoring and controlling the

HVT’s overall Safety Plan including this IIPP. The Safety Officer reports to the director of HVT

Insurance who reports directly to the HVT Chairman and HVT Council. The Safety Officer's

duties include:

1. Issuing a written statement of the HVT’s safety policy at least once a year that outlines the

Tribe's position on safety and includes updates on safety progress and accident prevention

goals.

2. Giving proper and prompt attention to safety recommendations requiring Tribal Council or

Tribal Chairman’s approval.

3. Educating and encouraging enforcement by managers and supervisors relating to safety

issues—and cooperating fully with them in all matters relating to safety.

4. Reviews all submitted safety performance results and recommendations from each

department.

5. Reviews all Incident Reports to ensure all causal factors have been identified and that

appropriate corrective actions are recommended and implemented.

6. Reviewing injury reports for causal factors and providing accident prevention measures to

managers and directors.

7. Tracking the status of safety recommendations submitted by the Tribal Council,

Chairman’s Office, supervisors and employees.

8. Ensuring that employees with jobs and tasks that require personal protective gear get the

equipment they need and use it properly.

9. Coordinating the safety committee, if deemed necessary to assemble such a committee by

the Tribal Council.

MANAGER/DIRECTOR DUTIES AND RESPONSIBILITIES

Managers and Directors of HVT entities must effectively execute these responsibilities to achieve

Hoopa Valley Tribal safety objectives. Many responsibilities can be worked on cooperatively

with the Hoopa Tribal Safety Office.

1. Familiarize yourself with the HVT Safety Program and its policies to ensure its effective

implementation.

2. Assess all safety considerations when introducing a new process, procedure, machine or

material into the workplace.

3. Support the Safety Manager and all programs and committees that promote safety and

health.


4. Conduct inspections with supervisors on a scheduled basis. Enforce good housekeeping

and take prompt corrective action to eliminate workplace hazards.

5. Provide complete safety training. Teach general safety regulations and job specific safety

rules to employees prior to assignment of duties. Follow up periodically to ensure they

follow safe work procedures.

6. Investigate or review supervisors' Incident Reports for all accidents resulting in employee

injury and property damage. Submit all Incident Reports to the Safety Officer.

7. Review Material Safety Data Sheets (MSDS) with employees working near or with

hazardous materials.

8. Maintain the Material Safety Data Sheet (MSDS) binder and update it whenever new

chemical hazards enter the workplace.

9. Take action, including disciplinary action as necessary, when employees perform unsafe

acts. If disciplinary action is warranted, write a description of action taken and distribute

to the Safety Manager. Refer to the HVT Personnel Policies for disciplinary guidelines.

SAFE WAY = RIGHT WAY SET A GOOD EXAMPLE

SUPERVISOR DUTIES AND RESPONSIBILITIES

Supervisors are the foundation of the Hoopa Tribe’s overall Safety Program as well as this IIPP.

Fulfilling your safety responsibilities is critical to our success.

1. Familiarize yourself with the HVT Safety Program and its policies to ensure its effective

implementation.

2. Assess all safety considerations when introducing a new process, procedure, machine or

material into the workplace.

3. Investigate all accidents resulting in employee injury and property damage. Ensure that

appropriate action is taken to prevent recurrence. Report all accidents, injuries and near

misses to the Hoopa Tribal Safety Office.

4. Provide complete safety training to new and transferred employees. Teach general safety

regulations and job-specific safety rules to employees prior to assignment of duties.

Follow up periodically to ensure they follow safe work procedures.

5. Conduct scheduled safety inspections. Take corrective action to eliminate or control an

unsafe condition or work practice immediately if within your area of authority.

6. Ensure all injuries are treated immediately. Report all injuries to Hoopa Tribal Insurance,

who is the Tribe’s workers' compensation insurance carrier.

7. Review MSDS’s with employees working near or with hazardous materials.


EMPLOYEE DUTIES AND RESPONSIBILITIES

All employees working for the HVT are required to comply with all written policies of the Tribe

as well as any directives from their supervisors including this IIPP as well as the Safety Manual,

of which this IIPP is a component. All Tribal Employees must:

1. Follow all safety rules and regulations.

2. Wear appropriate safety equipment as required by the job.

3. Report ALL injuries, unsafe conditions and practices to your supervisor.

4. Ask questions if there is a misunderstanding about how to perform a task. Do not attempt

to perform any job or operate any machinery that you have not been properly trained to

operate.

5. Contribute ideas or suggestions to improve the safety program.

6. Attend safety meetings!

SAFETY BEGINS WITH YOU!

SAFETY COMMUNICATIONS

All HVT Employees need to know that we are serious about providing a safe and healthy

workplace. In order to ensure we are providing a safe working environment for our employees we

are encouraging effective communications in regards to safety between employees and their

supervisors, between supervisors and managers, and between managers and the TSO or Tribal

Government.

Effective ways to reinforce this message include:

1. Soliciting employee’s ideas for improving safety. Conduct monthly staff meetings with

Safety as a regular agenda item. Discuss with all staff members the importance of

reporting unsafe conditions and how to effectively report and avoid unhealthy conditions.

2. Forming committees or designating a Safety Officer within each department that address

different aspects of illness and injury prevention; and

3. Offering safety training. Training can be provided in house by the Tribal Safety Officer or

you may elect to hire outside consultants to provide job-specific training to any of your

employees. Contact the Hoopa Tribal Safety Officer for more information regarding free

employee training.


DEPARTMENTAL SAFETY MEETINGS

Department safety meetings can be brief huddles where supervisors create and maintain

employee safety awareness and solve safety-related problems. Safety meetings should be

conducted prior to undergoing any task of new nature or even prior to conducting day to day

tasks. During these 5-10 minute meetings, employees discuss the dangers posed by specific types

of machinery, tools, equipment and materials. Here's how to run an effective meeting:

1. Hold the meeting at the beginning of the work shift, just after lunch or after a break.

2. Choose a specific topic relating to health and safety. If you notice oil spills on the floor

that aren't cleaned promptly, explore why. If an accident or near-accident occurred on the

job, talk about it. What happened? Where? How can it be prevented in the future?

3. Choose a narrow topic. You can't cover "Hand Tool Safety" in a 5-10 minute meeting, but

you can address "Safe Use of Hand-Held Grinders."

TRAINING AND SAFETY RULES

Have all employees read this IIPP and any Job-Specific Safety Rules that apply to them. When

they've finished reading all the safety rules, discuss the importance of the rules with them and

answer their questions. Finally, have them sign the Employee Training Log (Attached). Submit

copies of the signed form to the Tribal Safety Office and Human Resources for inclusion in the

employee's personnel file. This way, an employee's subsequent failure to follow a safety rule or

procedure can trigger disciplinary action consistent with your company's personnel policies and

procedures.

GENERAL SAFETY RULES

The Hoopa Valley Tribe strives to provide a safe, healthful work environment. But safety begins

with YOU. You are responsible for reporting any hazards to your supervisor immediately and

following safe work procedures. Beware: Any violation of safety rules will result in disciplinary

action. The following list of safety rules is not complete. Your manager will provide you with

additional information and training as necessary.

1. Report all accidents, safety hazards including unsafe or broken tools or equipment to your

supervisor.

2. Observe all warning signs, safety bulletins and posters.

3. Before starting work, tuck in loose clothing.

4. Avoid ALL horseplay and never distract another worker.

5. Use protective clothing and equipment such as goggles, safety glasses, guards and other

protective equipment. It is mandatory that you use this equipment when required.

6. To lift heavy objects, squat down, keep your back straight and use the leg muscles when

lifting. Do not attempt to lift any object heavier than you can handle.


7. When using sharp-edged tools, cut away from your body.

8. Keep the floors, aisles and passageways clear of stock, materials, scrap, tools, oil and

equipment. You are responsible for keeping your work area clean and organized.

9. Do not undertake a job that appears to be unsafe.

10. Report any fire immediately to a manager or supervisor.

11. Do not block access to fire-fighting equipment, fire sprinklers or fire exits.

12. Learn the location of all fire exits and fire extinguishers. In case of fire, turn off all

electrical equipment and walk quietly to the nearest exit. Follow your manager's direction.

JOB-SPECIFIC SAFETY RULES

Each job comes with its own hazards and safety rules. Each department is responsible for

identifying and outlining safety rules for job-specific duties. These job-specific rules will

supplement this IIPP as well as the HVT’s Safety Manual. Your job may consist of other

potentially risky activities, from working above or below ground to handling hazardous materials.

You may need to create your own job-specific safety rules based on the unique nature of your job.

A list of job-specific rules should be in writing and submitted to the TSO for review prior to

implementation. I have included one example below related to Tools and Machinery.

TOOLS AND MACHINES 1. Use safe hand tools only. Worn or defective tools should always be replaced or tagged

out of service until repaired.

2. Use the correct tool for the job. Think about doing the job the safest way before you start

work.

3. Keep tools clean and free from defects. Make sure hammers, chisels and other striking

tools are free of mushroomed or burred heads.

4. Use safety glasses, goggles or face shields while working with grinders, buffers, saws or

any activity exposing you to possible eye injury.

5. Wear helmets or well-fitted face shields when engaged in electric arc welding and cutting,

hydrogen welding and similar operations.

6. Focus on the job! Do not distract any employee operating a machine or tool. If someone

starts talking to you, discontinue your work and stop the machine when you respond.

SAFE OPERATION OF EQUIPMENT REQUIRES CONCENTRATION.


HAZARD IDENTIFICATION & INSPECTION

It is the responsibility of the employee and supervisor to inspect your employees' work area

thoroughly every month to identify and correct problems or unsafe work practices before an

accident occurs. As part of this monthly inspection, you should:

• take immediate action to fix any unsafe condition or activity; or

• take steps to correct unsafe conditions if you cannot fix them immediately (such as

promptly completing a work order or notifying a repair technician).

Always write a report of the hazard and what steps you've taken to address it--and give it to the

Safety Officer. If you identify an imminent hazard that cannot be eliminated without

endangering employees and/or property, then evacuate all exposed employees except those

needed to fix the problem. Make sure the remaining employees use appropriate gear and other

safeguards when removing the hazard.

Most accidents result when someone fails to follow safety procedures and rules. Such unsafe acts

usually occur quickly, for short periods of time. When you see an unsafe act, alert the employee

immediately. Explain what you observed and how it could cause injury. Then show the

employee the correct way of doing the job and ask for a demonstration to confirm understanding.

INSPECTION REPORT CHECKLIST

Please use this checklist to identify safety issues that may need attention. Inspect each of the

following:

Housekeeping

Material handling methods and hazards

Electrical hazards (open switches and boxes, machine grounding, defective wiring, etc.)

Uncluttered aisles, work space and overhead clearances

Maintenance of equipment, furnishings and facilities

Physical condition of offices, platforms, stairs, railings and steel shelving

Hand tools (condition, properly stored, ground, etc.)

Lighting in work, storage and toilet areas

Ventilation of work, storage and toilet areas

Fire hazards and protective devices

Ladders and portable steps

Chemical hazards and protective equipment

Overhead equipment and doors to ensure that tracks and pulleys are working properly

First-aid kits, eye wash stations, supplies and equipment

Complete the Hazard Removal Form (Attached) upon identification of any workplace hazards

identified during any routine inspection or after any report of a workplace hazard. Submit the

completed forms to the TSO for filing.


REPORTING AN INCIDENT

Upon first learning of an injury, illness or major equipment breakdown, you should investigate

what happened, complete an Incident Report (Attached) and give a copy to the Safety Officer.

Investigate and complete an Incident Report for all incidents that result in injury, first aid or

doctor treatment.

The purpose of an accident investigation is to prevent similar accidents, not to place blame. But if

the injured employee or someone else contributed to the accident by failing to follow safety rules,

then disciplinary action may be appropriate.

The following procedures will help you perform a successful investigation:

1. Visit the incident scene as soon as possible while facts are fresh and before witnesses

forget important details.

2. If possible, interview the injured worker at the scene of the incident and "walk" him or her

through a re-enactment.

3. Conduct all interviews in private. Interview witnesses one at a time. Talk with anyone

who has knowledge of the equipment or circumstances contributing to an accident, even if

they did not witness it firsthand.

4. Interview witnesses and have them complete the Incident Report.

5. Document details graphically. For some incidents, you may need to preserve the scene by

cordoning the area until the investigation ends; otherwise, use sketches, diagrams and

photos and take measurements when appropriate.

6. Focus on causes and hazards. Describe what happened, how it happened and why it

happened. Determine the cause(s) of the accident.

7. Include a plan for preventing similar accidents in the future. Corrective actions usually

involve employee training or re-training, changing processes or procedures, correcting

unsafe conditions, or a combination of the above.

8. If a third party or defective product contributed to the accident, save any evidence. It

could lead to the recovery of claim costs.

TO PROMOTE SAFETY

Although safety promotion does not guarantee accidents will be prevented, it achieves the next

best thing by increasing employee safety awareness. Help managers and supervisors promote safe

workplace practices by:

1. Screening safety films to assist in educational training. Contact the Hoopa Tribal Safety

Office for more information.

2. Conducting safety training sessions.


3. Acquainting families of employees with the Hoopa Valley Tribe’s IIPP by sending them a

letter at home explaining the program and its goals.

4. Distributing safety pamphlets and handbooks to employees.

5. Placing safety posters in each department.

6. Posting a safety board in each department showing number of days worked without lost

time to injury.

7. Asking the Hoopa Tribal Safety Officer to conduct periodic free safety inspections and

accident investigations.

RECORDKEEPING REMINDERS

One of the most important aspects of the Safety Program and providing a safe working

environment is recordkeeping, as this provides a paper trail for any and all accidents, injuries, and

even near-misses. This written record enables the departments and the TSO to identify unsafe

conditions to reduce or eliminate the possibility of a re-occurring accident in the future. Without

proper documentation and recordkeeping, it is very plausible that the same accident will occur

again in the future without proper remediation measures in place. Again the overall goal of this

Prevention Plan is to reduce lost work time, increase productivity, ensure high morale and security

amongst employees, and to reduce equipment damage, all in an effort to lower the Insurance

premiums for the Hoopa Valley Tribe. Managers, Directors, and Supervisors should follow these

steps to ensure effective tracking of safety issues:

You should maintain safety records/reports, including:

1. Occupational Injury & Illness Log (attached)

2. Supervisor's Report of Injury - Incident Reports (attached)

3. Employee Safety Information Forms (attached)

4. Hazard Removal Form along with associated Inspection Checklist if any (attached)

5. Employee Safety Training Log or Record for all Tribal Employees (attached)

6. Employee Medical and Exposure Records from Medical Records Department (to be kept

in confidential personnel files)

7. Material Safety Data Sheets (Keep on file at each department)


OCCUPATIONAL INJURY & ILLNESS LOG

The following OSHA Work Related Injury and Illnesses Logs are included to provide a usable template for filling out and documenting any on the

job injuries or work-related illnesses. This form can be downloaded as an editable .pdf or .xls format from the OSHA website as well.

Year

City State

(A) (B) (C) (D) (E) (F)

(M)

(G) (H) (I) (J) (K) (L) (1) (2) (3) (4) (5) (6)

Page totals 0 0 0 0 0 0 0 0 0 0 0 0

Page 1 of 1 (1) (2) (3) (4) (5) (6)

You must record information about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment

beyond first aid. You must also record significant work-relate

OSHA's Form 300 (Rev. 01/2004)

Job Title (e.g.,

Welder)

Where the event occurred (e.g.

Loading dock north end)

Describe injury or illness, parts of body affected,

and object/substance that directly injured or

made person ill (e.g. Second degree burns on

right forearm from acetylene torch)

Classify the case

Check the "injury" column or choose one type

of illness:

Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time

to review the instruction, search and gather the data needed, and complete and review the collection of information.

Persons are no

Log of Work-Related Injuries and Illnesses

Employee's Name

Attention: This form contains information relating

to employee health and must be used in a manner

that protects the confidentiality of employees to the

extent possible while the information is being used

for occupational safety and health purposes. U.S. Department of LaborOccupational Safety and Health Administration

Respirato

ry

Conditio

n

Respirato

ry

Conditio

n

On job

transfer or

restriction

(days)Job transfer

or restriction

(mo./day)

Pois

onin

gP

ois

onin

g

Hearing L

oss

Inju

ry

Skin

Dis

ord

er

Be sure to transfer these totals to the Summary page (Form 300A) before you post it.

Days away

from workRemained at work

Identify the person Describe the case

Date of

injury or

onset of

illness

Inju

ry

Death

Case

No.

Form approved OMB no. 1218-0176

Establishment name

CHECK ONLY ONE box for each case based on

the most serious outcome for that case:

Enter the number of

days the injured or ill

worker was:

Other record-

able cases

Hearing L

oss

All

oth

er

illnesses

Away

From

Work

(days)

All

oth

er

illnesses

Skin

Dis

ord

er


Year

Street

City Zip

0 0 0 0

(G) (H) (I) (J) OR

0 0(K) (L)

Total number of… Knowingly falsifying this document may result in a fine.

(M)

(1) Injury 0 (4) Poisoning 0(2) Skin Disorder 0 (5) Hearing Loss 0

(3) Respiratory

Condition 0 (6) All Other Illnesses 0

Employment information

Your establishment name

Sign here

State

Company executive

I certify that I have examined this document and that to the best of my knowledge the entries are true, accurate, and

complete.

Phone

Total hours worked by all employees last

year

Standard Industrial Classification (SIC), if known (e.g., SIC 3715)

Annual average number of employees

North American Industrial Classification (NAICS), if known (e.g., 336212)

Total number of

other recordable

cases

Number of Days

Establishment information

Total number of

deaths

Number of Cases


Title

Date

U.S. Department of Labor

OSHA's Form 300A (Rev. 01/2004)

Summary of Work-Related Injuries and Illnesses Occupational Safety and Health Administration

Total number of

days away from

work

Total number of days of

job transfer or restriction

Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instruction, search and

gather the data needed, and complete and review the collection of information. Persons are no

Injury and Illness Types

Industry description (e.g., Manufacture of motor truck trailers)

Post this Summary page from February 1 to April 30 of the year following the year covered by the form

All establishments covered by Part 1904 must complete this Summary page, even if no injuries or

illnesses occurred during the year. Remember to review the Log to verify that the entries are complete

Using the Log, count the individual entries you made for each category. Then write the totals below,

making sure you've added the entries from every page of the log. If you had no cases write "0."

Employees former employees, and their representatives have the right to review the OSHA Form 300 in

its entirety. They also have limited access to the OSHA Form 301 or its equivalent. See 29 CFR 1904.35,

in OSHA's Recordkeeping rule, for further details

Total number of

cases with days

away from work

Total number of cases

with job transfer or

restriction


1) 10)

2) 11)

State Zip 12) AM/PM

3) 13) AM/PM

4) 14)

5)

15)

6)

7)

16)

State Zip

8)

Yes 17)

No

9)

Date Yes

No 18) If the employee died, when did death occur? Date of death

OSHA's Form 301

What was the injury or illness? Tell us the part of the body that was affected and how it was

affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn,

hand"; "carpal tunnel syndrome."

Completed by

Phone

What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor,

worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during replacement";

"Worker developed soreness in wrist over time."

Date hired

Date of injury or illness

What was the employee doing just before the incident occurred? Describe the activity, as well

as the tools, equipment or material the employee was using. Be specific. Examples: "climbing a

ladder while carrying roofing materials"; "spraying chlorine f

Time of event Check if time cannot be determined

Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing

What object or substance directly harmed the employee? Examples: "concrete floor"; "chlorine";

"radial arm saw." If this question does not apply to the incident, leave it blank.

Title

If treatment was given away from the worksite, where was it given?

Facility

Street

Male

Name of physician or other health care professional

Female

Information about the physician or other health care

professional

This Injury and Illness Incident Repor t is one of the

first forms you must fill out when a recordable work-

related injury or illness has occurred. Together with

the Log of Work-Related injuries and Illnesses and

the accompanying Summary , these forms help

Attention: This form contains information relating to

employee health and must be used in a manner that

protects the confidentiality of employees to the extent

possible while the information is being used for

occupational safety and health purposes.Injuries and Illnesses Incident Report

According to Public Law 91-596 and 29 CFR

1904, OSHA's recordkeeping rule, you must keep

this form on file for 5 years following the year to

which it pertains

Time employee began work

If you need additional copies of this form, you

may photocopy and use as many as you need.

(Transfer the case number from the Log after you record the case.)Full Name

Street

City

Date of birth

Within 7 calendar days after you receive

information that a recordable work-related injury or

illness has occurred, you must fill out this form or

an equivalent. Some state workers' compensation,

insurance, or other reports may be acceptable

subst

Was employee hospitalized overnight as an in-patient?

Was employee treated in an emergency room?

City

U.S. Department of Labor

Occupational Safety and Health Administration


Information about the employee Information about the case

Case number from the Log


SUPERVISOR’S REPORT OF INJURY –INCIDENT REPORT

This report needs to be completed following any incident whether or no it resulted in an injury or

not. Near-misses are very important in determining causal factors that may be mitigated to ensure

the possibility of re-occurrence is reduced or eliminated. Any employee may fill this form out,

however there must be a supervisor follow-up to ensure that the incident is effectively dealt with.

INCIDENT REPORT (CONFIDENTIAL) RECEIVED DATE: ____________________

YOUR NAME: TITLE:

DEPARTMENT: SUPERVISOR:

(If additional space is needed please attach information on a separate page)

WHO WAS RESPONSIBLE FOR INCIDENT?

DESCRIBE INCIDENT (WHAT HAPPENED):

DATE, TIME, AND PLACE:

IS IT STILL OCCURRING?

HOW OFTEN HAS IT OCCURRED?

WHAT WAS YOUR RESPONSE?

HOW WERE YOU AFFECTED?

HAS YOUR JOB BEEN AFFECTED?

WITNESSES W/CONTACT INFO:

HOW DO YOU SEE THIS RESOLVED?

ANY OTHER RELEVANT INFORMATION

SUPERVISOR FOLLOW-UP DATE REPORTED: DATE RESPONDED:

WHAT WAS DONE TO REMEDIATE THIS INCIDENT?

I UNDERSTAND THAT THESE INCIDENTS WILL BE INVESTIGATED AND THIS FORM WILL BE KEPT CONFIDENTIAL TO THE GREATEST EXTENT POSSIBLE.

SIGNATURE:__________________________________________ DATE:__________________

SUBMIT A COPY OF THIS REPORT TO THE HOOPA TRIBAL OFFICE SAFETY WITHIN 10 DAYS


EMPLOYEE SAFETY INFORMATION FORM

The Hoopa Valley Tribe thanks you for helping us improve safety and prevent workplace injuries

and illnesses. Please complete this form to suggest ideas or report an unsafe workplace condition

or practice.

Please describe what the ____________________________ Department can do to improve safety:

Please describe any unsafe workplace condition or practice:

What do you think are the causes or other contributing factors to this unsafe condition or practice?

Has this matter been reported to the area supervisor? YES NO

Employee Name and Title (optional)


HAZARD REMOVAL FORM

As a result of your inspection, you may identify hazardous conditions. The next step is to work

with your employees and the Safety Officer to eliminate these hazards. Use this form to record

actions taken to correct hazards.

Please complete the following: Date: _________________________

An inspection of (work area) ________________________________________________ exposed

the following hazard:

To remove this hazard, the following action steps will be taken:

The deadline for removing this hazard is (date).

The hazard has been successfully removed as of (date).

Supervisor's Signature: __________________________________Date: ____________________


After employees have read the Hoopa Valley Tribal Safety Manual and any Departmental-

Specific Safety Rules and you've discussed the rules with them, they must sign this form for their

personnel file. Also forward a copy to the Hoopa Tribal Safety Office for compliance evaluation.

EMPLOYEE TRAINING LOG

I have read the complete list of safety rules, and I fully understand all of them. I agree to abide by

them while working for the Hoopa Valley Tribe. By initialing on the lines below, I acknowledge

that I have read the rules within the Hoopa Valley Tribal Safety Manual and I promise to follow

all of them:

______________ Emergency Action Plan (EAP)

______________ Fire Prevention Plan (FPP)

______________ Motor Vehicle Operator’s Policy (MVOP)

______________ Injury Illness Prevention Plan (IIPP)

List any additional trainings that you have completed pertaining to your specific job duties, which

may include outside consultant trainings, or trainings provided by the Tribal Safety Office

Training Name Trainers Name Date of Completion

Employee's Signature: ___________________________________ Date: ___________________

Employer's Signature: ___________________________________ Date: ___________________

Documents

HVT Injury Illness Prevention Plan 04.09hoopainsurance.com/documents/TSODraftIIPP0409.pdf · · 2009-04-20A periodic inspection system to identify workplace hazards. 3. Procedures