Small Employer Certificate of Recognition

(SECOR) with NSC Safety and

Maintenance

Report

Prepared for:      

Prepared by:      

Assessment Date(s):      

Revised 20130103 AFPA SECOR/NSC Assessment

 Table of Contents
SECOR Assessment Summary Sheet.......................................................................................................   

Description of Activities..............................................................................................................................   

SECOR Summary Score Sheet.................................................................................................................   

SECOR Reconciliation Score Sheet...........................................................................................................   

Comments Regarding the Contractor Questionnaire..................................................................................  

Worksite Observations...............................................................................................................................   

Documentation Review Checklist...............................................................................................................   

Action Plan.................................................................................................................................................   

Owner/Employer Sign-Off..........................................................................................................................   

Appendices (A- G) with Documentation Review Checklists.......................................................................  

Revised 20130103 AFPA SECOR/NSC Assessment

 SECOR with NSC Safety and Maintenance
Assessment Summary Sheet

SECOR Assessor Information

SECOR Assessor(s):      
Company:      
Address:      
City:       Province:       P/C:      
Phone:       Fax:       E-mail:      
Company Information
Legal Name:      
Address:      
City:       Province:       P/C:      
Key Contact:       Telephone:      
E-mail:       Total # of workers:      

SECOR Assessment Information

WCB Account(s) #:      WCB Industry Code(s) included in Scope:
     
Audit Date(s):       Operating Site(s) Included in Scope
(List site(s) and location(s)) Yes No
Total # of operating sites:            
     
     
SECOR Assessment Details
Date Yes No
Pre-Assessment Letter      
Pre-Assessment Meeting      
Familiarization Tour      
Documentation Review      
*Interviews Total # # Intrvw’d n/a
Senior Manager(s)        
Manager(s)        
Supervisor(s)        
Workers        
Total Staff Interviews        
Contractors (sub)        
Visitors        
Site Observations      
Post Assessment Meeting      
Draft Assessment Report and Protocol forwarded to AFPA      

*Interview sampling for SECOR Assessments should include everyone on the payroll for the specific
WCB Account and industry codes covered in the scope of the assessment.

Revised 20130103 E-1 AFPA SECOR/NSC Assessment

 Description of Activities
Checklist:
(Include all of the following in your Description of Activities below.)
Brief description of assessment process
Overview of type of operation being assessed
Breakdown of sampling details, including worksites covered
Rationale for anything missed in the scope of the SECOR assessment

     

Revised 20130103 E-2 AFPA SECOR/NSC Assessment

 SECOR Summary Score Sheet
Evaluation of: (Organization Name):      

Date of SECOR Assessment:      

Assessed by: (Print and Sign):      

Total Possible Score

Element Possible – N/A Awarded
Percentage

1. Owner Commitment and Program 7            %

Administration
2. Hazard Identification, Assessment and Control 4            %

3. Inspections 3            %

4. Training, Emergency Response and 7            %

Accident/Incident Investigation

5. Contracting Services 3            %

6. Action Plan 4            %

7. NSC Safety and Maintenance 17            %

Totals 45            %

Yes No
Contractor Questionnaire Completed?

If NO, please provide details:

     
     
     

Revised 20130103 E-3 AFPA SECOR/NSC Assessment

 SECOR Reconciliation Score Sheet
Evaluation of: (Organization Name):      

Date of SECOR Assessment:      

Assessed by: (Print and Sign):      

Total Possible Score

Element Possible – N/A Awarded
Percentage

1. Owner Commitment and Program 7            %

Administration
2. Hazard Identification, Assessment and Control 4            %

3. Inspections 3            %

4. Training, Emergency Response and 7            %

Accident/Incident Investigation

5. Contracting Services 3            %

6. Action Plan 4            %

7. NSC Safety and Maintenance n/s

Totals 28            %

NOTE: Item 7 which is scored in SECOR with NSC Safety and Maintenance is not mandated under
present PIR regulations.

Revised 20130103 E-4 AFPA SECOR/NSC Assessment

 Comments Regarding the
Contractor Questionnaire

     

Revised 20130103 E-5 AFPA SECOR/NSC Assessment

 Worksite Observations

Strengths:
     

Suggestions for Improvement

     

Revised 20130103 E-6 AFPA SECOR/NSC Assessment

 SECOR Action Plan
Company Name:
SECOR Assessor Name:
Assessment Date(s):

Suggestion for Improvement Person Target Actual

Start
Accountable for Action Taken Completion Completion
(Include Action items for all Date
Action Date Date
questions marked below standard)
                                   

                                   

                                   

                                   

                                   

                                   

Sr. Manager Signature: Date:

Revised 20130103 E-7 AFPA SECOR/NSC Assessment

 Owner/Employer Sign-Off

*Note: For Certification/Recertification purposes, this form must be signed by the Owner/Employer indicating their approval of the
submission.

Company Name:

SECOR Assessor Name:

Assessment Date(s):

Owner/Employer Name:

Phone Number: Email:

Owner/Employer Signature:

Revised 20130103 E-8 AFPA SECOR/NSC Assessment

 APPENDIX A

Owner Commitment and Program

Administration

Checklist:
(Did you attach all of the following in Appendix A?)
Health and safety policy.
List of company employees.
Info on how owner encourages discussion and resolution of H&S issues with employees.
Records of all incidents, investigations and follow-up steps.

Revised 20130103 E-9 AFPA SECOR/NSC Assessment

 APPENDIX B

Hazard Identification, Assessment and

Control
Checklist:
(Did you attach all of the following in Appendix B?)
A copy of your formal hazard identification and assessment.
Copy of maintenance records for past 12 months.
List of available PPE.
PPE training records.
PPE codes of practice.

Revised 20130103 E-10 AFPA SECOR/NSC Assessment

 APPENDIX C

Inspections

Checklist:
(Did you attach all of the following in Appendix C?)
Three most recent inspection reports.
Examples of how employees report hazards.

Revised 20130103 E-11 AFPA SECOR/NSC Assessment

 APPENDIX D

Training, Emergency Response and

Accident/Incident Investigation

Checklist:
(Did you attach all of the following in Appendix D?)
List of orientation topics.
Last three orientations with sign-off.
Copy of job health and safety training records.
Copy of emergency response plan.
Record of first aid training.
Recent incident report, and indication of corrective action taken.

Revised 20130103 E-12 AFPA SECOR/NSC Assessment

 APPENDIX E

Contracting Services

Checklist:
(Did you attach all of the following in Appendix E?)
Description of a meeting with contracting organization.
Contracting organization H&S questionnaire.

Revised 20130103 E-13 AFPA SECOR/NSC Assessment

 APPENDIX F

Action Plan

Checklist:
(Did you attach all of the following in Appendix F?)
Action plan for next year.
Schedule for action plan completion.
Last year’s action plan with description of changes that have taken place.
Any additional action items identified by the quality assurance review from last year’s audit
must be included.

Revised 20130103 E-14 AFPA SECOR/NSC Assessment

 APPENDIX G

NSC Safety and Maintenance

Checklist:
(Did you attach all of the following in Appendix G?)
List of transportation regulations.
Info on how owner ensures knowledge of legislation.
List of record keeping requirements.
Authorized use of equipment policy.
List of safe use and operation of commercial vehicles policies.
Safety equipment use instructions.
List of available driver training.
Driver conduct and discipline policy.
List of driver file requirements.
Info on process for monitoring and verification of hours of service documents.
List of maintenance requirements.
Copy of maintenance inspection forms.
List of equipment file requirements.
Three most recent CVIP and trip inspection reports.
Info on how compliance to weights & dimensions regulations is ensured.
List of safety equipment carried.

Revised 20130103 E-15 AFPA SECOR/NSC Assessment