Injury Illness Prevention Plan

“Safety involves Teamwork”

Updated: 12/30/20

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TABLE OF CONTENTS

COMPANY SAFETY POLICY 3

SECTION 1.0 INJURY ILLNESS PREVENTION PLAN 4

SECTION 1.1 SAFETY RESPONSIBILITIES 4

SECTION 1.2 COMMUNICATION SYSTEM 5

SECTION 1.3 EMPLOYEE SAFETY TRAINING 6

SECTION 1.4 DISCIPLINARY PROCEDURES 8

SECTION 1.5 WORKPLACE HAZARD IDENT. & ABATEMENT PROCEDURES 8

SECTION 1.6 INCIDENT REPORTING & INVESTIGATION PROCEDURES 9

SECTION 1.7 MEDICAL TREATMENT & FIRST AID 11

SECTION 1.8 RECORDKEEPING 11

APPENDICES

APPENDIX A - GENERAL CODE OF SAFE PRACTICES 12

APPENDIX 1 - EMPLOYEE SAFETY SUGGESTION FORM 13

APPENDIX 2 - NEW EMPLOYEE SAFETY ORIENTATION CHECKLIST 14

APPENDIX 3 - SAFETY MEETING SIGN-IN SHEET 15

APPENDIX 4 - INSPECTION FORM 16

APPENDIX 5 - ACCIDENT INVESTIGATION REPORT (AIR) 21

APPENDIX 6 - SUPERVISOR'S REPORT OF WORKPLACE VIOLENCE 28

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Company Safety Policy

It is our policy that every employee is provided with a safe and healthful working

environment. To this end, every reasonable effort is made by Able Services to ensure

the safety and health of all employees.

Overall responsibility for safety lies with Senior Management, while specific

responsibility for taking corrective action at client sites rests with Managers and

Supervisors.

The success of our program depends on the commitment and cooperation of everyone.

Therefore, it is the responsibility of all our employees to follow safe work practices at

all times, and to report any unsafe conditions or work practices promptly to their

immediate supervisor.

Able Services National Safety Director is responsible for coordinating our corporate

safety efforts and has the authority for implementing and overseeing the Company's

Injury & Illness Prevention Program (IIPP). As needed, others may assist as designated

by Senior Management or the National Safety Director. A copy of the IIPP is available

for employee review from your manager or immediate supervisor.

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Section 1.0 Injury and Illness Prevention Plan The key elements of Able Service’s Injury and Illness Prevention Plan (IIPP) are as follows: Section 1.1 Safety Responsibilities

Senior Management National Safety Director Managers/Supervisors Employees

Section 1.2 Safety Communication Section 1.3 Employee Safety Training Section 1.4 Employee IIPP Compliance Section 1.5 Workplace Hazard Identification & Abatement Procedures Section 1.6 Incident Reporting & Investigation Procedures Section 1.7 Medical & First Aid Section 1.8 Recordkeeping Section 1.1 Safety Responsibilities Senior Management Senior Management, has the primary responsibility for establishing corporate policy, assigning responsibility, motivating employees, and interfacing with the Safety Director on a regular basis. National Safety Director The National Safety Director has the primary responsibility of administering and maintaining the Injury and Illness Prevention Plan. The National Safety Director’s responsibilities include:

1. Developing, implementing, and monitoring the IIPP. 2. Collecting and evaluating information about accidents, hazards, and safety

practices. 3. Advise senior management as to safety and health of the program. 4. Develop, implement, and monitor employee safety training. 5. Coordinating loss prevention and claims services with insurance carriers.

Managers/Supervisors Managers and Supervisors are the key to preventing workplace accidents. Their safety responsibilities include:

1. Acting as a leader and setting a good example by following all safety rules and by working safely.

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2. Investigating and immediately reporting all accidents and near miss accidents to your immediate supervisor and your regional safety manager. Implement appropriate corrective action to prevent recurrence of accidents.

3. Periodic inspections of work areas, including implementing corrective measures to address unsafe conditions and/or unsafe work practices.

4. Provision of safety training for all employees, new and existing. 5. Provision and enforcement of Personal Protective Equipment (PPE) as needed

(i.e. eye protection, hearing protection, appropriate clothing, gloves, foot-protection, etc).

6. Conducting regularly scheduled safety meetings with employees. 7. Enforcing all safety rules fairly and consistently.

Managers and supervisory personnel are responsible for managing safety in their respective work areas, and for addressing employee questions and comments concerning our IIPP. Employees You the employee, are the key to an effective injury and illness prevention plan. Without your willingness to “work safely”, an injury prevention plan cannot succeed. Therefore, all employees are expected to comply with all safety rules and regulations at all times. Employees are encouraged to provide safety suggestions to management concerning issues in the workplace. The following are safety responsibilities of each employee:

1. Complying with all company safety rules and regulations (see Appendix A for "General Code of Safe Practices").

2. Wearing appropriate personal protective equipment (PPE) as required. 3. Maintaining equipment in good condition, with all safety devices in place. 4. Knowing, understanding and following safety policies, procedures and protocols. 5. Prompt reporting of all work-related injuries, no matter how minor, to your

immediate supervisor. 6. Encouraging coworkers to work safely by setting an example, safety is

everyone's responsibility. 7. Reporting unsafe acts and conditions immediately to your supervisor/manager, or

the safety department. 8. Inspect equipment daily prior to use, and report defective equipment to your

supervisor. 9. Do not remove, tamper with or bypass any equipment safety device.

Section 1.2 Communication System Able Services has an internal communication system for the purpose of communicating safety & health information to their employees. All management and supervisory personnel are responsible for communicating to their employees’ information pertaining to safety & health. Employees are encouraged to inform their supervisors of all

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workplace hazards. The “Employee Safety Suggestion Form” should be used to report unsafe conditions and/or unsafe acts by employees (See Appendix 1). Our communication system includes a combination of the following:

1. New employee safety orientation. 2. Periodic employee safety meetings. 3. Distributing and posting of safety literature. 4. Employee safety training as new processes/tasks are introduced. 5. Management meetings. 6. Employee safety suggestions, some client sites have a suggestion box, if not

mail to the safety department attention: National Safety Director 868 Folsom Street San Francisco, CA 94107 or fax to 415-546-6535

7. Able Services 24-Safety Hotline 415-981-8070.

Section 1.3 Employee Safety Training

Note: OSHA requires that all training be documented to show:

Date of training Brief description of the content of the training Name & title of the trainer Employees attending the training-signature &

printed name

Training is an integral part of Able Services ongoing commitment to safety and is the cornerstone of our IIPP. Employees shall receive the appropriate training to perform their respective jobs in a safe manner.

New Employee Safety Orientation All new employees are provided with training as to general safety and client site-specific conditions when hired. Training includes the following:

1. Reviewing safety procedures as defined within the Able Services IIPP. 2. Safe work methods, proper use of equipment, and any conditions unique to the

client site. 3. Overview of Hazard Communication Program. 4. Reviewing specific rules and regulations as set forth by the client’s operations. 5. Review of Worker’s Compensation reporting procedures and forms.

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The “New Employee Safety Orientation Checklist” form shall be used to document training (See Appendix 2). New hire safety orientation to be completed at the client site, with a copy of the signed form kept at the client site and a copy forwarded to employees personnel file. Safety Training In addition to new hire, periodic safety meetings, and training appropriate for new processes/tasks introduced, additional "safety awareness" training may be provided as required by our clients. The National Safety Director, Managers/Supervisors are responsible to ensure employees receive appropriate training. The “Safety Meeting Sign-in Sheet” shall be used to document ongoing training (See Appendix 3). On-The-Job Training On-the-job site-specific training will be conducted by the Manager/Supervisor as needed. This can include:

Job task-specific safety, and if needed a JHA (Job Hazard Analysis). Location and content of SDS (Safety Data Sheets). HAZCOM as to use of chemicals. Equipment safety. Emergency procedures.

New Process or Procedure Training Whenever a new process, new job task, or new equipment is introduced or whenever employees change job assignments their Supervisor/Manager will provide employees with training commensurate with the new process/job task. Retraining Infractions of safety rules may require Supervisors/Managers to review correct procedures with the employee, provide instructions necessary to ensure that the employee understands proper protocol, and take disciplinary action, if appropriate. Safety Training - Annual Review Annual refresher training for employees on our IIPP is provided as subject matter for a toolbox safety meeting. Additionally, through supervisor and manager meetings, discussions made of safety lessons learned, safety violations, and safety records. Documentation All training shall be documented using the Safety Training Signature Sheet (Appendix 3), with documentation kept at the client site. During job site visits by the safety department, records will be reviewed for accuracy.

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Section 1.4 Disciplinary Procedures

Disciplinary Process

Disciplinary procedures, when necessary, will entail the following:

1. Verbal Warning – supervisor will issue a verbal warning to any employee who violates safety rules or rules of conduct. Such verbal warnings will become part of the employee’s personnel file.

2. Written Warning – continued violation of the aforementioned rules will result in a

written warning which will also become part of the employee’s personnel file.

3. Suspension - this warning is considered serious and may result in temporary suspension of an employee. After review of the infraction, the employee may be placed on probation for a determined length of time during which further rules infractions may result in termination of employment.

4. Termination – employee may be terminated if performance does not improve

during probation. Employee may also be terminated if the employee violates another safety rule within 12 months of the first violation.

Note: Certain rules infractions may result in immediate termination of employment. They include:

Use of drugs or alcohol on the job. Coming to work impaired from the use of drugs or alcohol. Willful disregard for safety or failure to follow safety instructions. Physical violence. Intentional damage to equipment or client property.

Section 1.5 Workplace Hazard Identification & Abatement Procedures Inspections Inspections will be made to identify hazards in the workplace so that the necessary action can be taken to control or eliminate noted deficiencies. At new client sites, inspections will be conducted initially by Supervisors/Managers. Once the initial inspection has been completed, inspections will be conducted periodically thereafter by Supervisors/Managers using the ”Safety Inspection Form” (See Appendix 4). Note: Separate inspection reports exist for each entity of Able Services. Appendix 4 of your IIPP will contain the safety inspection report appropriate for your operation. Inspections will also be conducted whenever new substances, processes, procedures, equipment, or job tasks are introduced into the workplace that may present new safety/health hazards, and whenever new or previously unrecognized

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hazards are brought to the attention of management. This includes conditions on the part of Able Services as well as client responsible conditions. Regarding client responsible safety conditions, it is the responsibility of the Able Services Account Manager to tactfully address these conditions with the client for correction. Supervisors should NOT give a copy of completed inspection reports to clients. Employees are always encouraged to take an active role in the inspection process. Employees should advise their supervisors of any hazards they notice in the workplace; anything they believe to be hazardous to their own safety and that of co-workers. Hazard Abatement Supervisors/Managers are responsible for ensuring that the appropriate action is taken to correct identified hazards. Whenever possible, immediate corrective action to eliminate the unsafe act or condition should be taken. Once corrective action has been taken, Supervisors/Managers shall review the situation regularly to assure hazards are properly abated.

Documentation Inspection document Appendix 4 to be kept at the client site. During job site visits by the safety department, records must be reviewed for accuracy.

Note: If there are hazards that have been identified as being life threatening in nature, employees shall be removed from the affected area(s) immediately. Employees shall not be allowed to re-enter the area(s) until the hazards have been abated.

Section 1.6 Incident Reporting & Investigation Procedures

Employee Reporting Employees must report every on-the-job injury or illness, no matter how slight, to their immediate supervisor. Employees are to follow the following procedures whenever a job-related incident occurs: 1. Seek the necessary assistance, report the incident no matter how slight. 2. Inform your immediate supervisor as to what has occurred. 3. Assist in the filling-out of the necessary forms, if possible. 4. Keep your supervisor apprised of your status if the injury results in time away from

work. 5. Obtain a Doctor's return-to-work statement prior to returning to work. Provide your supervisor or the Able Services Safety Department with a copy of the doctor's return-to-work statement.

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Supervisor Reporting If on the job injury sustained, the following procedures should be followed:

1. Completion of the "Accident Investigation Report" as to "root cause" loss investigation.

2. Supervisors must provide and assist injured employees in completing the State Required Workers’ Compensation claim forms, Medical Records Release forms, within 24 hours. Note, if employees do not sign their medical release this will hinder payment to employee.

3. Supervisors must immediately contact the Able Services Safety Department as notice or knowledge of the illness or injury is known.

4. Collectively, these documents are named within Appendix 5 (Accident Investigation Report).

Note: All completed accident reports must be sent to the Able Services safety department. Forms can be either faxed to 415-723-7840, or mailed to Attn: Workers Compensation, 868 Folsom Street, San Francisco, CA 94107 or emailed to safety@ableserve.com. Copies of these forms must ALSO be kept confidentially at the client site.

Investigation Procedures Whenever an accident occurs it is important that the injured employee receive immediate medical attention and care. Accident investigations are to be completed by Supervisors/Managers. The investigation process is not intended to find fault, but rather to determine root cause factors that contributed to the accident so that the proper measures can be taken to prevent recurrence of similar incidents. Able Services has established an accident investigation process for this purpose. The individual responsible for initiating investigations shall be the immediate supervisor. The “Accident Investigation Report” shall be used whenever conducting investigations (Refer to Appendix 5). If the incident involves workplace violence, the “Supervisor’s Report of Workplace Violence” (Appendix 6) form shall be used to report the incident. Accidents shall be investigated as soon as possible. The investigation for the root cause(s) of accidents must be done to determine the true cause(s) of the accident. The implementation of specific recommendations/suggestions resulting from accident investigations is the direct responsibility of the immediate Supervisor/Manager. Investigations should provide the following information at the very least:

• Who was injured and the nature of the injuries • What the employee was doing at the time of the accident • Include specific root cause(s) of accident

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• Names of other individuals involved/witnessed in the incident • Physical and behavioral factors that contributed to the accident • Information as to job training injured employee received • A description of any job procedures violated • Control measures implemented as a result of the accident

Note: Accidents that involve serious injuries (e.g., loss of limb, disfigurement, fatalities, etc.), acute or chronic occupational injuries, or major damage to equipment or property shall include investigation by the safety department. Since all serious accidents must be reported to OSHA within 8 hours, it is imperative for Supervisors/Managers to immediately contact their regional safety manager in the event of any serious injury. Section 1.7 Medical Treatment & First Aid Medical Treatment If an employee sustains an on-the-job injury, they are to notify their supervisor immediately. The supervisor will direct the injured employee to the appropriate medical facility. If not already posted at your client site, contact the Able Services safety department for your nearest Employer Preferred Provider health care facility. In an emergency, the injured worker should go to the nearest hospital emergency room or call the local 911 emergency number for assistance. The injured employee must notify the treating facility that the injury/illness is work related.

First-Aid Program First aid kits are provided and to be kept within secured areas with access to kits limited to supervisory and trained first responders. Supervisors/Managers are responsible to inventory kits as to contents. Under no circumstances should first aid kits contain ingestible items (i.e. aspirin, Tylenol, etc.). Regardless of how minor an accident/injury, remember to complete the "Accident Investigation Report" (found within Appendix 5) to document any accidents.

Section 1.8 Recordkeeping Able Services will maintain appropriate records keeping as to our IIPP. This includes records of employee training, accident investigation, recordable injuries/illnesses, safety inspections, etc. These records will be maintained on file in the corporate office in accordance to applicable federal and state regulations.

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Appendix A

GENERAL CODE OF SAFE PRACTICES

• Report all unsafe conditions immediately to your supervisor

• Report all injuries to your supervisor as soon as possible, and seek medical attention

• The use of illegal drugs or alcohol on the premises is prohibited

• Working while impaired by drugs or alcohol is prohibited, and may be grounds for immediate termination

• Practical jokes and/or horseplay are not permitted

• Smoking is prohibited within all buildings, smoke only within designated areas

• Access to fire extinguishers and fire alarm stations must be kept clear at all times

• Employees must be familiar with a primary and secondary evacuation route from the buildings they work in

• Evacuation exit routes must be kept clear of obstructions at all times

• Personal protective equipment (PPE) use is required whenever appropriate

• Properly maintain PPE. Report any defective PPE to supervisor. Replace PPE as necessary

• Regardless of content/quantity, all chemical containers must be properly labeled

• Supervisors should review SDS’s with their employees

• Review SDS whenever employees have questions regarding chemicals in use

• Where diamond-shaped NFPA labels are posted, supervisors should instruct employees as to the meaning of such labels

• Always use proper lifting techniques when handling objects-regardless of object size

• Always seek assistance when lifting heavy/awkward objects

• Use proper care when handling chemicals

• Do not clean up chemical spills unless you have been properly trained, contact supervisor if you are unsure about the spilled liquid

• Do not handle clean up of bodily fluid spills unless properly trained

• Store heavy items on lower shelves whenever possible

• Do not use equipment unless you have been properly trained. Check with your supervisor if you have a question about safe equipment use

• Always inspect equipment prior to use

• Remove all defective equipment from service immediately and properly tag “Out of Service.” Do not use equipment until it has been repaired and approved by your supervisor for use

• Watch out for slip, trip and fall hazards

• Properly cordon off work areas using signs and/or barricades

• Report any suspicious activity immediately to your supervisor

• When driving always wear a seat belt

• Never use a handheld cell phone while driving

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APPENDIX 1

EMPLOYEE SAFETY SUGGESTION FORM

Employee Name: Date:

Location:

Contact Phone Number:

Employee Suggestion for Improving Safety

Please describe unsafe condition:

Please list your suggestions to address problem:

Able Services encourages employees to communicate health and safety suggestions, comments and complaints, and to report unsafe work practices and unsafe conditions to management. Employees have the option of remaining anonymous or signingthe report. Employee safety suggestions should be forwarded to supervisor or the Safety Department - FAX: 415-723-7840 or E-mail: safety@ableserve.com

Follow Up

Management Action:

Manager Name: Date:

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Appendix 2

New Employee Safety Orientation Checklist

Safety Topics presented during General New Employee Orientation

1. Company Safety Policy

2. Injury & Illness Prevention Plan

• Safety Responsibilities

• Safety Communication

• Employee IIPP Compliance

• Workplace Hazard Identification & Hazard Abatement

• Incident Reporting

• Medical Treatment & First Aid

3. General Code of Safe Practices

4. Proper Lifting Techniques

5. Equipment Use

6. Chemical Safety

INJURY & ILLNESS PREVENTION PLAN TRAINING STATEMENT

Injury & Illness Prevention Plan (IIPP). More,ServicesAbleintrainingI have receivedspecifically:

• I am aware of the Company’s IIPP and its” location and I know that I may see the written plan by asking my supervisor.

• I am aware that the National Safety Director is responsible for the overall conduct of the IIPP.

• I am aware of the list of chemicals used in my workplace and that I may see the list and any Safety Data Sheet (SDS) by asking my supervisor.

• I am aware that I have the right to have any SDS shown and explained to me for all chemicals that I work with.

• I understand the labeling system used to identify chemicals.

• I am aware of how to use the equipment safely to perform my job.

I understand that I am to take all proper precautions, including proper use of Personal Protective Equipment (PPE); reporting unsafe conditions/acts; safe operation of equipment; and reporting work related accidents immediately to my supervisor.

Trainer: ____________________________ Employee Signature: ___________________________

Date: ______________________________ Employee Name: ______________________________

Client Site: ______________________________________________________________________

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APPENDIX 3

SAFETY MEETING SIGN-IN SHEET

Location: Date:

Trainer:

Subject:

EMPLOYEE NAME (print clearly) SIGNATURE

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Use the back if more room is needed.

Please list any comments or questions during the meeting.

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APPENDIX 4

SAFETY INSPECTION FORM – Janitorial

Page 1 of 5

Client: _________________________ Facility Address: ________________________________________

Operations Manager: _______________________ Supervisor: __________________________________

Inspection Date: ___________________________

Introduction: Use this format to conduct, and document safety inspections of the Janitorial work area. Use the

"Comments" section to record action steps needed for any item checked "NOT OK". Administra tive Conditions

Item OK Not OK

N/A Comments

IIPP Binder • Available to all employees?

• Employees trained on IIPP, and know its

location

Safety Posters and Placards

• Labor Law poster

• Workers Compensation Insurance

Information Poster

• Nearest MPN clinic poster

• PC 365 Hotline flyer

• Anti-Harassment Hotline Poster

• Monthly Newsletter flyer

• Adequacy by subject matter

Records Keeping

• Safety training meetings, safety

orientation)

• Monthly safety training

• Safety inspections

• Work task specific Job Hazard Analysis

Accident Prevention • Accident investigations (supervisor

investigation report) • Accident Review with employees

Emergency Preparedness

• Adequately stocked first aid kits

• Trained "first-aiders" on shift

• AED(s) available and if so, location of

it/them

• Written procedures (i.e. event of

earthquake, evacuation, etc.) • Drill documentation

• Emergency procedures training

• Emergency numbers posted

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APPENDIX 4

SAFETY INSPECTION FORM – Janitorial

Page 2 of 5

Item OK Not OK

N/A Comments

Hazard Communication/Health

• Written Program available

• All chemical containers labeled as to

contents

• Storage of flammables and corrosives

(i.e. use of UL listed cabinets and chemical

compatibility)

• Chemicals placed back in storage after

employee use

• Respiratory protection (if required by

chemical use), include; respirator type,

employee training as to use- storage-

maintenance, base line medical testing,

and records keeping

• Personal hygiene (no food/drink in work area, employees wash hands before eating)

• Chemical spill clean up procedures in place and signs/barricades available

SDS • Ensure contents kept current • Regular review (at least annual, and as

substances obtained/removed)

• Chemical inventory list available?

• Employee training (how to read SDS) • Historical binder onsite

Fire Safety

• Closed container storage of soiled rags • Clearance to sprinkler heads (at least 18-

inches) • Fire extinguishers (adequate number,

properly mounted, inspected monthly- check tags)

• All exits must be kept clear, marked and doors swing outward

Personal Protective Equipment (PPE)

• Annual Hazard assessments

• PPE usage enforced • Eye protection

• Hand protection

• Footwear

• Face

• Eyewash stations & inspection records

• Surplus of most used PPE available or

attainable

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APPENDIX 4

SAFETY INSPECTION FORM – Janitorial

Page 3 of 5

Item OK Not OK

N/A Comments

Fall Prevention • Written Program • High-reach work equipment adequate to

minimize falls • Elevated surfaces (ramps) provided with

guardrails

Ladder Safety • Ladder program if applicable

• Ladder inspections records • Work from heights (i.e. "A" frame ladders-

adequate height, and proper set up;)

Equipment • Grounding plugs on all equipment • Power cords free of splices or tape (tape

often covers damages)

• Proper use/storage of cords and hoses

• All equipment (power and non-power) maintained and in good condition

• Damaged items removed or tagged "out

of service"

Compactor • Written program • Training • List of employees trained in use • Verify room warning and operational

signage

Housekeeping

• Adequate lighting

• Floor surfaces (clean and dry)

• Rack storage (bolting-laterally or to wall,

stable placement within)

• Protruding stock from racks

• Isles and exits kept clear

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APPENDIX 4

SAFETY INSPECTION FORM – Janitorial

Page 4 of 5

Item OK Not OK

N/A Comments

Bloodborne Pathogen • List of first responders trained in BBP • BBP request for Hep B vaccine • BBP Declination forms • Hazard waste removal agreement • Hazardous waste labeled and dated

• Body fluid clean up kits available and

employees trained on use

Waste Storage

• Waste fluorescent tubes disposal

location

• Unused chemicals removed from site

Other Items:

Areas of Physical Site Evaluation: MAIN CLOSET • IIPP available in predominant language • Postings conditions • Toolbox Training Records • SDS binder present and accurate

contents • Equipment Condition such as plugs and

bad cords • Accident Reports/Investigations forms

available • Other ___________________

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APPENDIX 4

SAFETY INSPECTION FORM – Janitorial

Page 5 of 5

ITEM OK Not OK

N/A Comments

Areas of Physical Site Evaluation cont. PPE • Glasses, gloves, mops available • Splash goggles/shield • Respirators • Plumbed Eyewash Station provided and

Inspected Monthly

JANITORS CLOSET(S) • Equipment Condition such as plugs and

bad cords • Blue – Green system in place • Chemical Spray bottles labeled • SDS binders available • Blending station condition – working,

Caps in place on concentrates • Clean in appearance and uncluttered • Other ___________________

FIRST RESPONDERS • Gloves • Mask • Biohazard bags • Sharps container • Other ___________________

Inspection Conducted By:

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APPENDIX 5

ACCIDENT INVESTIGATION REPORT (AIR)

Page 1 of 7 SAF 15.F-1.0

Instructions: Complete this form within 24 hours of an incident that results in injury or illness.

Fax forms to: 415-723-7840 or 415-546-6535 or E-mail to: workerscomp@ableserve.com.

Step 1: Injured Employee

Division: ☐ Building Maintenance ☐ Engineering

Employee Name: Sex: ☐ M ☐ F

Job Title: Employee #:

Union Represented? ☐ Yes ☐ No If Yes, Name: Local #:

Type of Event: ☐

Near Miss

☐ Basic First Aid

☐ Medical Treatment

☐ Lost Time Injury

☐ Hospitalization ☐ Fatality

Date of Incident:

Time (24hr): ☐ PST ☐ MST ☐ CST ☐ EST

Day of Week: ☐ Sun ☐ Mon ☐ Tue ☐ Wed ☐ Thu ☐ Fri ☐ Sat

Type of Facility: ☐ Commercial ☐ Medical/Research ☐ Residential ☐ Construction

Site Street Address:

City: State: Zip:

Site Contact: Phone #:

Where Did Incident Occur?

Project Management Company/Client Name:

Job/Project #:

What Part of the Employee’s Workday? ☐ Entering / Leaving Work ☐ During Normal Work Activities

☐ During Meal Period ☐ During Break ☐ While Working Overtime ☐ Other:

Identify Body Areas on Body Map: (select/shade all that may apply)

Nature of Injury: (check all that apply)

Employee Works:

☐ Abrasion / Burn ☐ Regular full time

☐ Blood or Body Fluid Exposure ☐ Regular part time

☐ Bruise / Contusion ☐ Seasonal

☐ Chemical Exposure / Splash ☐ Temporary

☐ Crushing Injury Reg. Scheduled Work Hours:

☐ Cut / Laceration / Puncture

☐ Dermatitis / Allergic Reaction

☐ Electric Shock Reg. Scheduled Work Days:

☐ Eye Irritation / Foreign Object ☐ Mon ☐ Sat

☐ Head Injury / Concussion ☐ Tue ☐ Sun

☐ Slip / Trip / Fall ☐ Wed

☐ Strain (lifting/pulling/pushing) ☐ Thu

☐ Struck by / Struck Against ☐ Fri

☐ If Other (specify):

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Page 2 of 7 SAF 15.F-1.0

Step 2: The Incident

List Names of Witnesses Below:

Name: Phone #:

Name: Phone #:

Name: Phone #:

Number of Attachments:

Incident Statements Photographs Maps and Drawings

What Personal Protective Equipment (PPE) was Being Used?

Identify Equipment or Machinery Involved in Incident (include mfg. name and

model # / serial #):

History of Previous Incidents (site / employee / equipment):

Describe the Events (step-by-step) of the Incident: (include FACTS only - names of any objects, tools, materials and other important details)

Description continued on attached sheets: ☐

Name of Medical Facility:

Ambulance Provider:

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Page 3 of 7 SAF 15.F-1.0

Step 3: Why Did the Incident Occur?

What CONDITION of Tools, Equipment, or Work Area Contributed to Incident? (check all that apply)

☐ Congested/Limited Clearance ☐ Floors/Work Surfaces ☐ Poor Housekeeping

☐ Hazardous Placement ☐ Inadequate Illumination ☐ Equipment Failure

☐ Excessive Noise ☐ Inadequate Guards/Barrier ☐ Hazardous Materials

☐ Improper Material Storage ☐ Defective Tools or Equipment ☐ Inadequate Ventilation

☐ Inadequate/Improper PPE ☐ Equipment/Workstation Design ☐ Other – Explain Below

Explain:

What ACTION or INACTION Contributed to Incident? (check all that apply)

☐ Failure to Secure ☐ Used Defective Equipment ☐ Failure to Use PPE

☐ Improper Lifting ☐ Safety Policy Violation ☐ Use of Improper PPE

☐ Use Equipment Improperly ☐ Unsafe Act of Another Staff ☐ Failure to Warn/Signal

☐ Rushing/Acting in Haste ☐ Improper Position/Placement ☐ Guards Not Used

☐ Servicing Equipment in Motion ☐ Used Wrong Tool/Equipment ☐ Horseplay/Teasing

☐ Operating at Improper Speed ☐ Not Following Instructions ☐ Improper Loading

☐ Lack of Situational Awareness ☐ Improper Technique ☐ Other – Explain Below

Explain:

What CAUSED or INFLUENCED the Contributing Conditions or Behaviors? (check all that apply)

☐ Lack of Proper Procedures ☐ Inadequate Job Instructions ☐ Inadequate Tools/PPE

☐ Unsafe Design/Construction ☐ Improper Layout or Design ☐ Improper Planning

☐ Insufficient Safety Training ☐ Inadequate Maintenance ☐ Lack of Skill

☐ Inadequate Enforcement of Safe Work Practices

☐ Inadequate Preventative Maintenance

☐ Inadequate Cleaning/Housekeeping

☐ Lack of Attention ☐ Lack of Communication Between Staff

☐ Other – Explain Below

Explain:

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Page 4 of 7 SAF 15.F-1.0

Step 4: Corrective Actions

What CORRECTIVE ACTIONS Have Been Taken (or Needed) to Prevent a Reoccurrence?

☐ Repair/Replace Equipment ☐ Improve Housekeeping ☐ Job Task Analysis

☐ Re-instruct Employees ☐ Improve Storage ☐ Rotation of Employee

☐ Eliminate Congestion ☐ Change Work Method ☐ Identify/Improve PPE

☐ Improve Design/Construction ☐ Install/Modify Guards/Devices ☐ Improve Enforcement

☐ Improve Illumination ☐ Improve Ventilation ☐ Improve Maintenance

☐ Improve Clean-Up Procedures ☐ Mandatory Pre-Job Instructions ☐ Other – Explain Below

Explain:

Detail Corrective Action Responsible

Person

Target Completion

Date

Action Item

Completed

☐ Yes

☐ IP

☐ Yes

☐ IP

☐ Yes

☐ IP

☐ Yes

☐ IP

☐ Yes

☐ IP

IP = In Process

Continue List of Corrective Actions on back.

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Page 5 of 7 SAF 15.F-1.0

Step 5: Investigator

Report is Submitted by: ☐ Supervisor ☐ Safety ☐ Other:

Total Pages of Report (includes all attachments):

Name: Title:

Email Address:

Phone #:

Date Manager Notified:

Time(24hr): ☐ PST ☐ MST ☐ CST ☐ EST

Date Report Completed:

Time(24hr): ☐ PST ☐ MST ☐ CST ☐ EST

Step 6: Review

Regional Manager:

Comments:

Signature: Approval Date:

Regional Safety Manager:

Comments:

Signature: Approval Date:

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Page 6 of 7 SAF 15.F-1.0

Instructions: Please complete this form as accurately as possible. Thank you for helping us assess this incident so we can prevent future incidents.

Step 7: ATTACHMENTS

Attach all Additional Documents: Photos, Drawings, Maps, Statements, RCA, etc. (List all attached documents)

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INCIDENT STATEMENT

Page 7 of 7 SAF 15.F-1.0

Role: ☐ Affected Employee

☐ Witness Type of

Incident: ☐ Injury ☐ Illness ☐

Near Miss

Date of Incident:

Time (24hr): ☐ PST ☐ MST ☐ CST ☐ EST

Witness Name: Phone #:

Affected Employee Name:

Job Title:

Able Supervisor: Phone #:

Site Street Address:

City: State: Zip:

Names of Employees Involved:

Where did Incident Occur?

What Were You Doing at the Time?

Describe (step-by-step) the Incident (include FACTS only - continue on the back or separate page if necessary):

Signature: Date:

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Appendix 6

SUPERVISOR’S REPORT OF WORKPLACE VIOLENCE

EMPLOYEE: INCIDENT DATE: POSITION: TIME OF INCIDENT: VICTIM’S NAME: JOB TITLE: WITNESS NAME & ADDRESS: ____________________________________ LOCATION WHERE INCIDENT OCCURRED: SUPERVISOR’S NAME: DATE SUPERVISOR BECAME AWARE OF THE INCIDENT:

TYPE OF INCIDENT (circle all that apply): Assault Robbery Verbal Threats Disorderly Conduct

Harassing or threatening phone calls, voicemails or e-mails Harassing surveillance or stalking Possession of Weapons

WAS THE VICTIM INJURED? (circle) Yes No If yes, please specify the injuries and location of any treatment given:

DID POLICE RESPOND TO THE INCIDENT? Yes No

POLICE REPORT FILED: Yes No

Report Number: WAS A RESTRAINING ORDER REQUESTED AGAINST THE ASSAILANT? Yes No

ASSAILANT/PERPETRATOR: (circle one) Co-Worker Supervisor Customer Former Employee

Client/Customer Family Friend Other (specify):

WITNESSES (name and contact number):

PLEASE BRIEFLY DESCRIBE THE INCIDENT (weapons involved, work days lost):

INCIDENT DISPOSITION: No action taken Verbal Warning Written Warning Action Plan

(circle all that apply) Suspension without Pay Arrest Other (specify):

_____________________ __________ _________________________ _______ MANAGER DATE SUPERVISOR’S SIGNATURE DATE

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