STANDARDS & SAFE WORK

PRACTICES

COMPANY
Address 1
City, State, Zip
Phone Number
Fax Number
Point of Contact
 Table of Contents
I Safety and Health Policy Statement...............................................................1
II Management/Employee Leadership Responsibilities....................................2
a. Owner
b. Supervisor
c. Employees
d. Employee Acknowledgement
III Analysis & Review Component.....................................................................5
a. Activities & Documents to Reviews
b. Identified Hazards and Corrective Action
c. Accident Prevention Plan Review
IV Record Keeping.............................................................................................6
a. Injury Records & Logs
b. Inspection Records & Safety Work Order Log
c. Safety Meetings
d. Training
V Policies, Standard & Safe Work Practices.....................................................9
a. Required Documentation & Posters
b. Documentation
VI Disciplinary Program.....................................................................................10
a. Non-Serious Violations
b. Serious Violations
c. Safety Violation Notice
d. Records of Safety Violations
VII Employee Safety Rules & Responsibilities...................................................13
VIII Accident Reporting and Investigation...........................................................15
a. Reporting & Investigation Procedures
b. After An Injury is Reported
c. Investigation Procedures
IX A Return-to-Work Process Makes Sense.......................................................17
a. Put It in Writing
(1) Policy Statement
(2) Procedures for the Return-to-Work Process
(3) Statement of Responsibilities
(4) How to Communicate the Return-to-Work Process to Employees
b. Assess Job Using Job Safety Analysis (JSA)
(1) How to Use the Job Analysis (JSA) Inventory
(2) Job Inventory
(3) How to Use the Physical Demands JSA
(4) Physical Demands JSA Assessment
(5) Principles of Job Redesign
(6) Job Description Guide
c. Identify Modified Duty
(1) How to Identify Modified Duty Work
(2) Sample Modified Duty Work Agreement

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 d. Communicate with the Doctor and Employee
(1) Sample Letters for the Treating Doctor
(2) After-Injury Telephone Report Log
(3) Sample Medical Release of Information
e. Make a Bona Fide Offer of Employment
(1) TDI Rule 129.6 Bona Fide Offer of Employment
(2) Checklist for Making a Bona Fide Offer of Employment
(3) DWC Form 73
X Substance Abuse Policy.................................................................................52
a. Purpose and Scope
b. Disciplinary Action and Prohibited Conduct
c. Testing
d. Miscellaneous Provisions
XI Inspections & Audits......................................................................................55
a. Informal Inspections
b. Formal Inspections
c. Areas to Be Inspected
d. Job Site Hazard Assessments
XII Safety & Health Training...............................................................................57
a. New Employee Orientation
b. Training Topics
c. Safety Meeting
d. Safe Work Practices
e. Forms (Refer to Section XLI in manual)
(1) Safety Meeting
(2) Safety Inspection Checklist
(3) Employee Training Summary
(4) Job Safety Analysis Form (JSA)
XIII Abrasive Blasting...........................................................................................61
XIV Backhoe Operation.........................................................................................62
XV Blood-borne Pathogens Program...................................................................64
XVI Concrete & Masonry......................................................................................67
XVII Confined Space Program...............................................................................68
XVIII Cranes, Rigging & Hoists..............................................................................70
XIX Driving Safety................................................................................................72
XX Electrical Procedures.....................................................................................74
a. General
b. Temporary Wiring
c. Ground Fault Protection
XXI Electrical Hazard Energy Control Program (Lockout/Tagout)......................75
a. Policy
b. Lockout/Tagout Forms
XXII Excavation (Trenching & Shoring Program) ................................................81
a. Policy
b. Definitions
c. General Requirements

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 d. OSHA Soil Classifications
e. Daily Inspection Form
f. Safety Checklist
XXIII Fall Protection Program...............................................................................87
XXIV Fire Protection & Prevention.......................................................................90
XXV Forklifts……................................................................................................91
XXVI H2S……………………………………………………………………….. 92
XXVII Hazard Communication Program................................................................95
a. Policy
b. Responsibilities
c. Chemical Inventory Lists
d. Material Safety Data Sheets (MSDS)
e. Purchasing
f. Container Labeling
g. Employee Training
h. Personal Protective Equipment (PPE)
i. Hazards of Non-Routine Tasks
j. Emergency Response
k. Informing Other Employees
l. Posting
m. Sample of HAZCOM program
XXVIII Hearing Conservation Program.................................................................103
XXIX Housekeeping............................................................................................106
XXX Manual Lifting Procedures.......................................................................107
XXXI Mechanical Guarding................................................................................108
XXXII Office Safety.............................................................................................109
XXXIII Personal Protective Equipment/Hazard Assessment Program.................111
XXXIV Power & Hand Tool.................................................................................115
XXXV Respiratory Protection Program...............................................................117
XXXVI Scaffold ................................................................................................122
XXXVII Signs & Placards......................................................................................123
XXXVIII Stairways & Ladders...............................................................................124
XXXIX Warehouse Safety………………………………………………………125
XL Welding & Cutting..................................................................................131
XLI Forms
XLII Safety Meeting Records
XLIII Accident / Incident / Illness Records

Legend:

Highlighted Text denotes client company name needs to be inserted in place of

“company”

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 Safety and Health Policy Statement
The safety and health policy of COMPANY (herein after referred
to as COMPANY) is based on the firm conviction that accidents,
which cause personal injury or loss of assets, can and should be
prevented. No area of the company business is of greater
importance than the safety and health of the men and women
working at COMPANY.

COMPANY will strive to provide and maintain a safe and healthy

working environment and establish rules, procedures and training
pursuant to this goal.

The management encourages individual responsibility and supports

a climate of safety awareness and consistent enforcement of the
safety program. It is the responsibility of each employee to
comply with safety rules and to work in such a manner as to
prevent injuries to themselves and others.

The goal of this company is to perform the highest quality service

as efficiently as possible while maintaining the safety and health of
employees to the highest possible standard.

_______________________
Owner

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 Management / Employee Leadership
The success of COMPANY’s safety program is dependent on management and
employees accepting their assigned safety responsibilities. The acceptance of these
responsibilities will be the first step in the development of a proactive safety culture.
This company will hold personnel accountable to the following safety responsibilities.

I. Owner
The Owner’s Responsibilities:
A. Understand and support the elements of this Accident Prevention Plan.
B. Issue and support a Safety Policy Statement.
C. Periodically attend Supervisor / Employee safety meetings.
D. Periodically participate in a Supervisor / Employee job site inspection.
E. Monthly, checks the Supervisor’s Safety Work Order Logs (PBS form
110) and verifies that items have been corrected.
F. Each quarter, schedule and facilitate an Owner / Supervisor safety meeting
(PBS form 121).
G. Ensure safety standards, safe work practices, and operating procedures are
understood and implemented.
H. Set example.
I. Participate in Accident Investigations and follow up corrective action.

II. Supervisor
The Supervisor’s Responsibilities:
A. Assist in the development of policies and procedures.
B. Lead by example.
C. Solicit employee input on Accident Prevention Plan activities.
D. Consistently reinforce rules, procedures and safe work practices with
employees, visitors, vendors and contractors.
E. Weekly, schedule and facilitate a Supervisor / Employee safety meeting
(PBS form 120).
F. Monthly, schedule and participate in formal Supervisor / Employee job
site inspection. Record deficiencies on the Safety Work Order Log (PBS
form 110).
G. Verify employees’ job / task knowledge and provide appropriate training
where necessary.
H. Participate in the development of the assigned safe work practice / do’s &
don’ts list.
I. Coordinate work activities to comply with Safe Work Practices.

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III. Employees
The Employees Responsibilities:
A. Know, understand and comply with the safety policy, rules, procedures
and safe work practices.
B. Assist in the development and review of rules and procedures.
C. Attend, participate, and periodically lead scheduled safety meetings.
D. Maintain good housekeeping
E. Participate in safety inspections and audits.
F. Continually inspect tools and equipment. Repair, tag, or report items in
need of repair.
G. Identify safety and / or operational problems and offer suggestions for
corrective action.
H. Know the chemicals used and comply with the requirements of the
Material Safety Data Sheets.
I. Report all accidents, incidents, and near-misses to the most immediately
available Supervisor.
J. Properly use and maintain required personal protective equipment.
K. Observe and correct unsafe acts of visitors, vendors, contractors and
fellow employees. Safety is your responsibility!

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 Employee Acknowledgement

Every employer is required by law to provide a safe healthful workplace. This company
is committed to fulfilling this requirement. A safe and healthful workplace is one of our
highest priorities.

While we cannot anticipate every workplace hazard, the following general principals
should guide your conduct. In addition you will be given a copy of the Safety Rules.
Our employees have the following obligation:

•Study the safety rules.

•Discuss workplace situations with your Supervisor.
•Attend all company sponsored training and safety meetings.
•Read all poster and warnings.
•Listen to instructions carefully.
•Participate in accident investigations as requested.
•Accept responsibility for the safety of others.
•Maintain all required documentation.
•Report any unsafe conditions immediately to a Supervisor.
•Report any and all injuries when they occur.

By signing this acknowledgment, each employee promises to learn and follow safety
policies and rules established by the company. If you don’t understand any policy, please
ask your Supervisor for explanation. Failure to follow safety policies and rules is
punishable under the company’s Discipline Policy, up to and including termination.

______________________________
Employee’s Signature

______________________________
Supervisor’s Signature

______________________________
Date

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 Analysis & Review Component
I. Activities & Documents to Review
The Owner and Supervisor will review, analyze, and develop an action plan using
information generated from the following:
A. Accident / Incident Reports (Owner: as they occur) Inspection Reports
(Supervisor: as they occur / Owner: review weekly).
B. Safety Meeting information (Supervisor: as they occur / Owner: review
monthly)
C. Safe Work Practices (Supervisor: ongoing / Owner: review monthly).
D. Employee orientation, retention, and turnover (Supervisor: regularly /
Owner: review quarterly).
E. OSHA 300 log (Owner and Supervisor - annually)
F. Inspection Reports (Owner - monthly)
G. Insurance loss runs (Owner: review annually).

II. Identified Hazards and Corrective Action

The Owner will recommend corrective action and distribute needed changes to
the Supervisors for review and training.

Any new hazards identified during the review, audits, inspections, safety
meetings, or incident investigations will be communicated to all affected
employees and included in the Accident Prevention Plan.

Any new exposures or identified problems should be written on “Work Site

Hazard Assessment” (PBS form 105) kept on file by the Office Manager for a
period of one year.

III. Accident Prevention Plan Review

The Accident Prevention Plan shall be reviewed annually or more often if needed.
In addition to information generated in the Analysis Component the review should
include:
A. Completion of outlined responsibilities and activities.
B. Effectiveness of safety meetings, inspections, safe work practices, incident
reporting and investigations.
C. Identify new exposures, equipment, tasks etc.
D. Training requirements and timelines for identified areas.
E. Changes due to accident and injury trends.

Annually the Owner, with input from Supervisor, will review the elements of the
Accident Prevention Plan. The review should analyze the effectiveness of the
plan. The plan should be updated to reflect any needed changes identified during
this review.

The Owner is responsible for distribution and the follow up.

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 Record Keeping
I. Injury Records & Logs
A. Supervisor’s First Report of Injury and Investigation (PBS form 109)
The Supervisor of the injured employee will be responsible to complete
this report and send it to the PBS Worker’s Compensation Administrator
and COMPANY Office Manager as soon as possible; but no later than 24
hrs after the occurrence.

The Office Manager will be responsible to distribute the Supervisor’s First

Report of Injury to COMPANY’s Owner. A copy of the report should be
filed and kept for a period of 5 years.

B. Employee Incident Report (PBS form 103)

The injured individual(s) is responsible to complete this report and send it
to the PBS Worker’s Compensation Administrator and COMPANY’s
Owner as soon as possible; but no later than 24 hrs after the incident. A
copy of the report should be filed and kept for a period of 5 years.

C. Witness Statement(s) (PBS form 104)

Any person who witnesses the incident is responsible to complete this
report and send it to the PBS Worker’s Compensation Administrator and
COMPANY’s Owner as soon as possible; but no later than 24 hrs after the
incident. A copy of the report should be filed and kept for a period of 5
years.

D. OSHA Log (OSHA form 300A)

The Office Manager will be responsible to contact the PBS Worker’s
Compensation Administrator to update the OSHA log for all recordable
and/or lost time injuries.

The law requires a completed copy of the OSHA log be posted between
February 1st and April 30Th of each year in a place where employee
notices are normally kept. A copy of the report should be filed and kept
for a period of 5 years.

II. Inspection Records & Safety Work Order Log

A. Documentation
All inspection reports (job site, equipment, office or shop) should contain
the following information:
1. Date of Inspection
2. Name of Inspector(s)
3. Discrepancies identified
4. Person(s) responsible for corrective action
5. Estimated date corrective action will be completed

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 B. Safety Inspections Checklist (PBS form 111)
The Supervisor will be the one primarily responsible for completion of
this form and gather the appropriate documentation. This is a
comprehensive inspection that covers the work site, power and hand tools,
personal protective equipment, etc. The Supervisor should forward all
inspection documentation to the Office Manager.
The Office Manager will file the checklist in the Supervisor’s safety folder
and distribute copies to the Owner.

Documentation should be kept for a minimum of 12 months or as required

by law and/or directives.

C. Job Safety Analysis Form (JSA) (PBS form 107)

PBS Risk Management can facilitate training using the JSA form to gather
information about possible hazards and the recommended procedures to
minimize the possibility of accidents or injuries. The completed JSA form
can be used as a training tool for newly arrived personnel.

Documentation should be kept for a minimum of 12 months or as required

by law and/or directives.

D. Safety Work Order Log (PBS form 110)

Use this document to keep track of the corrective actions taken or needed
for every hazard recorded on the Work Site Hazard Assessment or Safety
Inspection Checklist.

E. Work Site Hazard Assessments (PBS form 105)

The Supervisor will be responsible to send copies of the completed
document to the Office Manager and the Company Owner. The Office
Manager will be responsible to maintain these reports for a period of 5
years.

III. Safety Meetings

A. Documentation:
All safety meeting documentation should include the following:
1. Date of Meeting
2. Name of Presenter
3. Outline of covered subject(s)
4. Names and signatures of attendees

A safety meeting form should be completed by the Supervisor or presenter and

signed by all in attendance. Safety meetings can be formal (classroom setting) or
informal (tailgate meeting) and a written record MUST be kept in file for 5 years.

The meeting form should be filed in the Supervisor’s manual and a copy sent to
the Office Manager for filing and distribution.

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IV. Training
A. Documentation
Documentation for training will include:
1. Date of training
2. Name of Trainer
3. Outline of subject(s)
4. Signed attendance roster

B. Responsibilities
The Supervisor will be responsible to complete training documentation per
the guidelines of this manual, any appropriate law, or company policy.
The Supervisor should distribute training documentation to the Office
Manager.

The Office Manager should file and distribute documentation to the

Owner and Superintendent for review.

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 Policies, Standards & Safe Work Practices
I. Required Documentation & Posters
II. Posters
• OSHA
• Texas Employment Commission
• Emergency phone numbers
• Texas Workers’ Compensation Commission notice
• Texas Equal Employment Opportunity Commission
_________________________________________________________________
_
_________________________________________________________________
_
_________________________________________________________________
_
_________________________________________________________________
_
_________________________________________________________________
_

III. Documentation
• Safety & Health training
• Hazard Communication Training & MSDS
• Equipment & Job site Inspection Reports
• Maintenance Records
• OSHA 300 log (Posted February 1 to April 30)
• Special Programs
Respiratory Protection
Trenching & Shoring
Fall Protection
Hazard Assessment Program
Lockout / Tagout
Forklift Training
Confined Spaces Training
H2S (and related safety equipment) Training
Personal Protective Equipment (use & maintenance)
Hand / Power Tool Maintenance
Vehicle Maintenance
Any other programs required by law.
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________

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10
 Disciplinary Program
I. Scope
Employment with PBS is voluntarily entered into, and the employee is free to resign at
will at anytime, with or without cause. Similarly PBS may terminate the employment
relationship at will at any time, with or without notice or cause, so long as there is no
violation of applicable federal or state law. The Disciplinary Program set forth here is not
intended to create a contract, nor is it to be constructed to constitute obligations of any
kind or a contract of employment between PBS and any of its employees.

The following disciplinary program has been implemented to protect the lives and safety
of PBS and COMPANY’s employees, clients, subcontractors and general public. The
purpose is not to punish but to develop better work habits by implementing a formal
corrective action program.

The Owner is responsible for the enforcement of this program. Any verbal or written
warning given an employee should be forwarded to the owner for review and follow-up.

The following constitutes a safety violation. This list is only an example of possible
safety violations. No list could cover every possibility.
1. Not wearing proper PPE
2. Did not follow safety procedures / work practices
3. Horseplay
4. Improper use of equipment / tools
5. Altering safety devices
6. Operating at unsafe speed
7. Other

Types of violations:

1. Serious
2. Non-serious

II. Non-Serious Violations

1st. Violation: Verbal Warning
2nd. Violation: Verbal and Written Warning
3rd. Violation: Verbal and Written Warning (3 day suspension if 3 warnings occur within
6 month period)

III. Serious Violations:

1st violations: Verbal and Written Warning (possible suspension or discharge depending
on seriousness of the violation)

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The Supervisor and Owner will discuss all violations with the employee. A 30-day
follow-up review will be conducted for serious violations.

Nothing in this policy prohibits the immediate discharge or removal of any employee on
any job site whose conduct constitutes a serious violation of the safety requirements that
could cause serious danger.

IV. Records of Safety Violations:

The employees Supervisor will write up all Safety Violations that require further action.
This will be done on “Safety Violation Notice” (PBS form 108). A copy of the
completed form will be placed in the employee’s file maintained by the company and the
original send to PBS.

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 Safety Violation Notice
Company: _______________________________________________________

Name __________________________________ Date _______________

Job Site/Client Location ___________________________________________

Not wearing proper PPE

Did not follow safety procedures/work practices
Horseplay
Improper use of equipment/tools
Altering safety devices
Operating at unsafe speed
Other
Serious
Non-serious

Explanation
____________________________________________________________

_______________________________________________________________________
_

_______________________________________________________________________
_

_______________________________________________________________________
_

_______________________________________________________________________
_

Issued by: ____________________________________ Date: ______________

Title: ________________________ Signature: _________________________

Recommendation by Supervisor: ______________________________________

Note: The portion below is to be completed by the Owner of the company or his / her
representative only.

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Action Taken: ____ Warning 1st 2nd. 3rd.
____ Suspension ____ Days
____ Discharge

Owner: _______________________________ Date: ____________

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 Employee Safety Rules & Responsibilities

Each employee is responsible to follow the listed policies, rules & procedures. If for any
reason an employee does not understand or has questions about a particular rule or
situation, THE EMPLOYEE SHOULD STOP and ASK! No employee will be expected
or required to perform a job / task in an unsafe manner or a job / task of which they have
little or no understanding of. If an employee is not comfortable or confident he or she
can perform a specific task safely, they should IMMEDIATELY STOP and contact their
Supervisor. The Supervisor will schedule all required training at the earliest available
opportunity.

The following pages contain rules, procedures and work practices on various topics.
These by no means are all-inclusive and complete but are the minimum requirements.
The employees, supervisors, and Owner must assess each situation and or piece of
equipment to decide the appropriate safe methods and procedures.

Basic Rules
• Employees are required to report any vehicle, tool, piece of equipment and/or
situation that appears to be unsafe.
• Report all injuries; minor as well as major. Report near-miss accidents and/or
equipment damage.
• Personal Protective Equipment appropriate for the job will be required. Additional
protection will be required if recommended on a MSDS, customer policy or company
policy.
• Clothing must be appropriate and not create a potential safety hazard. Loose
clothing, jewelry and bracelets are prohibited for certain jobs.
• All signs and tag warnings or instructions must be adhered too.
• All machine guards must be kept in place.
• Do not leave an electrical tool running and unattended.
• Do not operate any piece of equipment that has a faulty or broken switch, frayed or
taped wires or cord. This includes any equipment that in your opinion is not in a safe
working condition.
• Do not use electrical cords with bare wiring or a plug that is missing a ground plug.
• Return tools and cords to their proper places. Clean up your work area as you go, at
the end of the day, or when work is complete.
• Employees shall obey all company rules, governmental regulations, warning signs
and instructions. Be familiar with those that apply to you. If you do not understand
or know; ask you Supervisor.
• All employees will participate in safety meetings conducted or contracted by the
company and their Supervisor.
• Horseplay, scuffling and other acts which tend to have adverse influence on safety or
well being of other employees are prohibited.

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• No one shall be permitted to work while the employee’s ability or alertness is or
appears to be so impaired by fatigue, illness or other causes that might expose the
employee or others to injury.

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 Accident Reporting and Investigation

It is the policy of PBS and COMPANY that all injuries / incidents be promptly reported
and investigated. The severity or potential severity and probability of reoccurrence
should determine the depth of the review or investigation. Accident investigations can
and should provide an opportunity to evaluate and correct deficiencies found within the
Accident Prevention Plan.

I. Reporting & Investigation Procedures

All injuries, no matter how minor, should be reported immediately to the
Supervisor, Office Manager, and Owner. Equipment damage and near miss
incidents should be reported as soon as possible. All employees will receive a
pocket card with detailed instructions on how to report accidents.

Investigations are required on all injury, non-injury, equipment damage, and

near miss incidents.

All Accidents are to be investigated by the Supervisor of the injured employee,

the area supervisor where mishap occurred, or a person appointed by the company
owner. The Owner should participate in the investigation. Investigations should
be conducted as soon as possible but no later than 24 hours after occurrence.
Depending of the severity or type of incident, outside officials may conduct an
official investigation. The company owner may appoint a responsible person to
aid with the investigation if required.

The “Supervisor’s First Report of Injury and the Investigation” report (PBS form
109) is to be forwarded to the Owner for review.

Supporting Documents:
1. Inspection Reports 4. Hazard Assessment
2. Safe Work Practice’s 5. Training
3. Previous Incident Reports

II. Report an Injury

A. Call for help
B. Safe the area (ensure rescuers and bystanders do not become additional
victims).
C. Provide appropriate medical assistance. Do not move the injured employee if
unsure as to the extent and nature of injuries.
D. Secure the area, save material and evidence that might be important to the
investigation.

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III. Investigation Procedures
A. Take pictures and get witness to complete “Witness Statement” (PBS
form 104) and if possible get the injured employee to complete “Employee
Incident Report” (PBS form 103).
B. Gather facts
Who Where
What Why
When How

C. Analyze facts
D. Determine contributing causes
E. Identify which area of the Accident Prevention Plan need revision
(inspections, safe work practices, management commitment and
involvement, etc.).
F. Develop corrective action plan
G. Assign completion dates and responsibilities for implementation of
corrective action plan.
H. Follow up
I. Distribute information to other crews for review and to raise safety
awareness throughout the company.

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 A Return-to-Work Process
Makes Sense
Primary Business Systems, Inc. (PBS) and Texas Mutual Insurance Co. (formerly The
Texas Workers’ Compensation Insurance Fund), work hard to help our clients maintain a
safe work place, but we know that no business is immune to on-the-job injuries. When
an employee is injured on the job, your first responsibility is to get him or her prompt
medical care. But don’t stop there.

We know that by helping the injured employee get back on the job, they can actually help
speed his or her recovery. The longer an injured employee stays off work, the less likely
he or she will ever return to productive employment. That’s why we are developing this
return-to-work process. Our insurance carrier rehabilitation specialists are passionate
about the importance of their work, and they can help get our injured employees back on
the job as soon as medically reasonable.

Sections I through III take us through our return-to-work process. We learn how to assess
existing job tasks and identify alternative productive work before it’s actually needed. In
Sections IV and V, we learn how to use the information on Form DWC-73, and how to
communicate with the treating doctor to return the injured employee to work. We provide
a sample of a bona fide offer of employment letter once the treating doctor has cleared
the injured employee to return.

If you suspect fraud, let us know your concerns when reporting the claim or tell the
workers' compensation specialist assigned to the claim about your concerns.

What’s Inside?

Section I Put It in Writing........................................................................................18

Section II Assess Job Using Job Safety Analysis (JSA)..........................................25
Section III Identify Modified Duty..........................................................................35
Section IV Communicate with the Doctor and Employee.......................................40
Section V Make a Bona Fide Offer of Employment/Form DWC-73......................47

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 Section I

Put It in Writing
The goal of the return-to-work process is to provide prompt medical care to injured
employees and return them to work as soon as medically reasonable. Employees who
return to work quickly feel more productive, and they often recover faster. We benefit by
minimizing the cost of lost time.

What can we do to get these results? We can begin by providing a written return-to-work
process and communicating it to employees.

1. The policy statement signed by the PBS President:

• confirms our commitment to the return-to-work process,
• explains our company’s return-to-work philosophy, and
• stresses the importance of safe operations, immediate medical care, and returning
injured employees to work.

2. The procedures explain the steps that our employees, Supervisor and return-to-work
coordinator will take from the time an employee is injured until after the employee
returns to work.

3. Included, there is a statement that explains the responsibilities of the injured employee,
the company, the health care provider, our return-to-work coordinator, and your insurance
company. Everyone must know what is expected of him or her.

4. We will involve the employees in the development of the return-to-work process by

training them and seeking their support in making it work.

More info

We have included on the following pages.

Page
Policy Statement (English and Spanish)..............................................................19
Procedures for the Return-to-Work Process.........................................................20
Statement of Responsibilities (English)...............................................................21
Statement of Responsibilities (Spanish)..............................................................22
How to Communicate the Return-to-Work Process to Employees......................23
Attendance Roster................................................................................................24

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 Policy Statement for the
Return-to-Work Process
PBS and Our Client Companies are committed to providing a safe and healthy workplace
for our employees. Preventing injuries and illnesses is our primary objective.

If an employee is injured, we will use our return-to-work process to provide assistance.

We will get immediate, appropriate medical attention for employees who are injured on
the job, and we will attempt to create opportunities for them to return to safe, productive
work as soon as medically reasonable.

Our ultimate goal is to return injured employees to their original jobs. If an injured
employee is unable to perform all the tasks of the original job, we will make every effort
to provide alternative productive work that meets the injured employee’s capabilities.

The support and participation of management and all employees are essential for the
success of our return-to-work process.

Rick Matthews
President PBS

Declaración Política del

Proceso de Regreso al Trabajo
PBS y nuestros clientes se comprometen a proveer un lugar de trabajo seguro y saludable
para nuestros empleados. Nuestro objetivo principal es prevenir heridas y enfermedades.

Si un empleado se lastima, usaremos nuestro proceso de regreso al trabajo para

proporcionar ayuda. Proporcionaremos atención médica apropiada inmediatamente para
los empleados que se lastimen en el trabajo y crearemos oportunidades para que regresen
a un trabajo seguro y productivo lo más pronto posible.

Nuestra meta principal es regresar a los empleados lastimados a sus trabajos originales.
Si un empleado es incapaz de realizar todas las tareas de su trabajo original, haremos todo
lo posible por proporcionar un trabajo alternativo que vaya de acuerdo con las
capacidades del empleado lastimado.

El apoyo y participación de la gerencia y de todos los empleados es esencial para el éxito

de nuestro proceso de regreso al trabajo.

Rick Matthews
Presidente PBS

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 Procedures for the
Return-to-Work Process
Follow these procedures when an employee is injured on the job.

1. Get prompt medical attention for the injured employee if necessary.

2. An employee who is injured must immediately report the injury or incident to a

Supervisor or an appropriate person in management.

3. The onsite client contact is responsible for:

• following our requirements for reporting injuries and illnesses;
• completing an incident investigation record for every report of injury, whether or not
medical attention is needed; and
• making a report to OSHA (when required for serious incidents).

4. If the injured employee needs medical attention, the client contact or Supervisor should
go with the employee to the doctor or other medical provider. Whenever possible, the
employee or client should provide the doctor with the injured employee’s job description,
essential job elements, and an introductory letter explaining your return-to-work process.
The client can also ask to speak to the doctor after the visit.

5. If the doctor restricts the employee from work, the return-to-work coordinator should
communicate regularly with the employee and treating doctor. The client’s contact
person should talk with the employee on the day of the injury and once a week until the
employee returns to work. The return-to-work coordinator should check with the treating
doctor whenever the employee has a follow-up visit.

6. When the treating doctor releases the employee to modified duty (light duty), the
client, with the assistance of the return to work coordinator, should attempt to develop an
alternative assignment. Every assignment must meet the doctor’s restrictions as specified
on Form DWC-73. (see attached copy.) THE CLIENT SHOULD MAKE EVERY
EFFORT TO DEVELOP ALTERNATIVE PRODUCTIVE WORK.

7. PBS must keep a copy of the DWC-73 each time the doctor completes one, should the
client receive the DWC-73 it should be forwarded to PBS. TDI-DWC requires the doctor
to complete a DWC-73 when the injured workers’ work status changes, or when the
employer’s or carrier’s request, but not more than once every two weeks. The client, with
the assistance of PBS, must give the doctor a copy of the employee’s job description
when requesting a DWC-73.
8. The client contact must follow up with the employee on a regular basis after the
employee returns to work.

22
 Statement of Responsibilities

Employee responsibilities:
• Make sure you understand your company’s procedure for reporting injuries.
• If you are injured, tell your doctor that alternative work is available to you. Your
Supervisor will ask you to take a letter from work to your doctor. The letter will explain
your company’s return-to-work process.
• If a doctor restricts you from working, call your employer once a week to let them
know how you are doing.
• If a doctor releases you to work, return to work on the next scheduled shift.
• If a doctor gives you medical restrictions for modified duty assignment, follow the
doctor’s orders.

Client’s responsibilities:
• Train employees on proper reporting of incidents and injuries and return-to-work
procedures.
• Go with the injured employee to the doctor. Tell the doctor about your company’s
return-to work process and provide the doctor with an explanatory letter.
• Contact the injured employee once a week and make sure all necessary forms are
completed and returned.
• Express concern for the employee’s health and recovery.
• Provide information to PBS’s return-to-work coordinator.
• Help create modified duty assignments that are meaningful.
• Make sure the injured employee is following the doctor’s restrictions as specified in
Form DWC-73.
• Check the employee’s condition regularly to help get the employee back to his or
her original job.

Health care provider responsibilities:

• Provide immediate and appropriate medical care to the injured employee.
• Assess the injured employee’s abilities.
• Provide information regarding the injured employee’s physical restrictions and work
capabilities on Form DWC-73.
• Become familiar with operations at the employee’s workplace.

PBS return-to-work coordinator responsibilities:

• Act as the employer’s representative.
• Maintain contact with the health care provider, Texas Mutual Insurance Co., the
injured employee, and the client company.
• Develop and maintain recordkeeping and reporting systems for incidents and
injuries.
Insurance Company responsibilities:
• Assign a workers' compensation specialist to make a “four point” contact with the
injured employee, doctor, client, and PBS.
• Provide workers’ compensation benefits to the injured employee.
• Provide information about the return-to-work process.

23
 Declaración de Responsabilidades

Responsabilidades del empleado:

• Asegúrese de entender cómo reportar un accidente que pase en su compañía.
• Si sufre una herida, informe a su doctor que un trabajo alternativo está disponible
para usted. Su Supervisor puede pedirle a usted que proporcione una carta del trabajo a
su doctor. La carta explicará el proceso de regreso al trabajo de su compañía.
• Si el doctor le prohibe trabajar, informe al trabajo cada semana sobre su condición.
• Si su doctor le permite regresar al trabajo, hágalo el siguiente turno programado.
• Si el doctor le da restricciones medicas para modificación de tareas, sígalas.

Responsabilidades del cliente:

• Capacite a los empleados en reportar los incidentes y en el regreso al trabajo.
• Acuda con el empleado al doctor. Informe al doctor sobre el proceso de regreso al
trabajo de su compañía y proporcione al doctor una carta con una explicación.
• Comuníquese con el empleado cada semana y asegúrese de que todos los
formularios necesarios sean llenados y entregados.
• Demuestre su interés por la salud y recuperación del empleado.
• Proporcione información a su coordinador de regreso al trabajo.
• Ayude a crear tareas para el trabajo alternativo que sean productivas.
• Asegúrese de que el empleado lastimado cumpla con las restricciones del doctor.
• Revise la condición del empleado regularmente para que regrese a su trabajo
original.

Responsabilidades del proveedor de cuidados de salud:

• Proporcione cuidados médicos inmediatos y apropiados al empleado lastimado.
• Evalúe las habilidades del empleado herido.
• Proporcione informacion sobre la capacidad física del empleado y habilidad para
trabajar en Form DWC-73.
• Conozca las operaciones en el lugar de trabajo del empleado.

Responsabilidades del coordinador del regreso al trabajo de PBS:

• Actúe como el cliente representante de la compañía.
• Mantenga contacto con el doctor, Texas Mutual Insurance Co., el empleado, el
cliente.
• Desarrolle y mantenga los expedientes y sistemas de reportes de accidentes y
heridas.

Responsabilidades de Texas Mutual Insurance Co.:

• Designar un especialista de beneficios para mantener un contacto “de cuarto puntos”
con el empleado, el doctor, el cliente, y PBS.
• Proporcione beneficios de compensación al trabajador al empleado herido.
• Proporcione información acerca del proceso de regreso al trabajo.

24
 How to Communicate the
Return-to-Work Process to Employees
For your return-to-work process to be effective, workers must understand your
procedures and be willing to follow them. Here are ideas for successfully communicating
the process to employees.

1. Put up posters showing your return-to-work policy statement. Make sure employees
have access to return-to-work procedures and the statement of responsibilities.

2. Introduce a new or revised return-to-work process at safety meetings. Here is a sample

agenda.
a. Show a video on the return-to-work process (available from our video library).
b. Invite a member of management to read your return-to-work policy statement.
c. Review and discuss your return-to-work procedures.
d. Review and discuss the employee and Supervisor responsibilities shown on your
statement of responsibilities.
e. Explain why Supervisor is creating task assessments and identifying modified duty
work.
f. Wrap up with a question and answer session.

3. Educate employees about your return-to-work process at new employee orientations

and safety training sessions. Explain the purpose of modified duty assignments and their
benefits.

4. Remind employees about the return-to-work process by offering information in

company newsletters, payroll envelopes, and your company’s information center.

25
 Introduction to
The Return-to-Work Process

DATE: ___________________________ TRAINER: ______________________

RETURN-TO-WORK PROCESS REVIEWED

 Policy statement and benefits to the employees
 Procedures to follow after an injury
 Alternative productive work and bona fide offer of employment letter

EMPLOYEES IN ATTENDANCE:
NAME SIGNATURE
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

EMPLOYEES NOT IN ATTENDANCE

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

26
 Section II

Job Safety Analysis

Job safety analysis describes the jobs at your company. For each position at your
company, write down the separate activities or jobs. List the physical demands and
environmental conditions of each job.

You’ll need these analyses to modify duty assignments (described in the next section) for
injured employees who are returning to work. When possible, use JSA and create
modified duty assignments before they are needed.

The reason for taking this proactive approach is simple: You can prevent workplace
injuries by identifying unsafe aspects of a job and modifying them before an employee
gets hurt.

More info
On the following pages, we’ve provided forms that you can use to inventory jobs and
assess physical demands, along with explanations of how to use the forms. We’ve also
provided information on redesigning jobs and writing JSA.

Page
How to Use the Job Safety Analysis (JSA) Inventory .............................................. 26
Job Inventory (blank form to photocopy) .............................................…... See Forms
How to Use the Physical Demands JSA ................................................................... 27
Physical Demands Job Assessment (blank form to photocopy) ................................30
Principles of Job Redesign......................................................................................... 32
Job Description Guide................................................................................................ 34

27
 How to Use the Job Safety Analysis (JSA)
The objective of a JSA is to list the steps or activities necessary to perform a job. Most
jobs have multiple steps. This analysis asks you to list each step separately and show the
specific actions or steps required to complete the job
.
Follow these steps for completing the JSA.

1. Use these definitions to fill out the top of the form.

Job title: Title of the job being observed.

Analyst: Name of the person completing the JSA.

Re: Purpose of the JSA. The purpose may be to identify alternative productive
work or to identify areas where safety may be improved.

Date: Date the form is completed.

2. Observe the job and break it down into specific steps. List each step separately, and
then write down the following information about each step.

Percent of time: Determine the percent of time spent on each task during the
entire workday. List the percent of time each step takes. Percentages for the steps listed
must add up to 100 percent.

Job description and steps: Write a short summary (one to two sentences) for each
job. Then observe the job and write down the specific steps (actions or activities) as they
occur from start to finish for each job.

EXAMPLE
You are analyzing the job of a cashier at a fast food restaurant. This job breaks down into
two jobs for the entire shift. The first job description is “takes customer orders for food
and drink.” The second job description is “fixes drinks for customers.” The cashier
spends 55 percent of the time taking orders and 45 percent of the time fixing drinks
(almost every order has a drink).

Each job breaks down into steps. For instance, the steps for the first job (taking orders)
are “greets the customer, answers questions, listens to the order, enters the cost for each
item into the cash register, takes money, gives back change and a receipt, and gives the
order to the cook.” The steps for fixing drinks are “takes a cup out of the cup holder, fills
the cup with ice and a drink, puts a lid on the cup, and hands the drink to the customer.”

Please photocopy the attached blank form.

28
 How to Use the
Physical Demands JSA Assessment
There are many types of assessment and analysis tools. This assessment asks you to
describe a job in terms of its physical demands and environmental conditions. Follow
these steps for completing the assessment.

Use these definitions to fill out the top of the form.

Company: name of client company
Description of Job or Task title: Name of the task being assessed.
Date: Date the form is completed.
Personal Protective Equipment: What PPE is needed for the job?
Tools Needed For This Job: List the tools needed or used.
Sequence of Basic Job Steps: List the steps to do the job.
Potential Hazard: Define the hazard with each step.
Recommended Procedures: List the recommended method for each step.

Section 1: Postures
Observe the employee’s postures (standing, sitting, walking, or driving) during the job.
First, circle the number of hours the employee stays in a posture without changing.
Second, circle the total (or cumulative) number of hours that the employee is in a posture
while doing this job throughout the day.

Section 2: Lifting and carrying

Observe any manual lifting and carrying during the task. For each category of weight,
mark how frequently the employee must lift or carry the weight. If the employee never
lifts this amount of weight, mark “0 percent.” If the employee lifts this weight less than
one third of the day, mark “occasionally,” between one third and two thirds of the day,
mark “frequently,” and more than two thirds, mark “constantly.” For each weight, say
how high the employee must lift the load (example: from the floor to waist height, about
three feet) and how far he or she carries the weight (example: from the dock to the
processing table, about 20 feet).

Section 3: Actions and motions

Observe the different actions and motions during the task. Write a description that
explains why the employee must take the action or motion (example: pushes mail cart
across room). Show the total amount of time during the day the employee does each
action or motion using these definitions.
Pushing Moving an object away from you, including kicking, slapping, pressing
and striking an object.
Example: Pushing a dolly.

Pulling Moving an object toward you, including jerking or sliding an object.

Example: Dragging a box across the floor toward you.

29
Climbing Using your legs, arms, hands or feet to move up or down a structure such
as stairs, ladders, scaffolds and ramps.
Example: Climbing a telephone pole to repair wires.

Balancing Moving in a manner that requires you to keep from falling because of
unstable, slippery or moving surfaces, or narrow spaces.
Example: Replacing shingles on a steep roof.

Bending Using your back and legs to bend forward and downward.
Example: Leaning over a car engine to do repairs.

Twisting Rotating your upper body in a different direction than your lower body.
Example: Reaching behind you to pick up parts while you remain seated at a
machine.

Squatting Lowering your body by bending at the knees.

Example: Checking the air pressure in a car’s tires.

Crawling Moving forward while on your hands and knees.

Example: Entering a crawl space to get to plumbing.

Kneeling Lowering your body onto one knee or both knees.

Example: Kneeling on one knee to remove a flat tire from a car.

Reaching Moving your hands and arms toward an object at arm’s length in any
direction from your body.
Example: Reaching upward to change an overhead light bulb.

Handling Using your hands to hold, grasp, grip or turn an object.

Example: Holding a drill while drilling holes.

Fingering Using your fingers to pinch, pick or manipulate objects, especially small
ones.
Example: Picking up nuts and placing them on bolts.

Feeling Using your hands and fingers to perceive the shape, size, temperature or
other characteristic of an object.
Example: Laying your hand on the hood of a car to check for heat.

Repetitive Using your feet or hands continuously in the same motion or motions.
Example: Typing at a computer or using a foot pedal on a sewing machine.

30
Section 4: Equipment
Observe any equipment, tools or machinery the employee uses during the JOB. Describe
the name or type of each tool, piece of equipment or machine. Mark how often it is used:
never, occasionally, frequently or constantly. Note any other information about the
physical demands of operating the equipment

Section 5: Environmental conditions

Observe the environmental conditions the employee is exposed to during the task, such as
vibration, noise, heat or cold. Describe the specific type of environmental condition, then
list the frequency of exposure: never, occasionally, frequently or constantly. Note any
other information about the physical demands of working in this environmental
condition.

Comments
Write any other information that you observe about the physical demands of the job.

31
 Physical Demands Job Assessment
Job title: ______________________ Date: ______________
Analyst:___________________
Job duration (hours/day): ______ With breaks: Yes / No Overtime (avg. hours/week):
_____
Description: of Job
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______

1. Postures:
Stand: Hours at one time: 0 1/2 1 2 3 4
______
Total hours per day: 0 1/2 1 2 3 4
______

Sit: Hours at one time: 0 1/2 1 2 3 4

______
Total hours per day: 0 1/2 1 2 3 4
______

Walk: Hours at one time: 0 1/2 1 2 3 4

______
Total hours per day: 0 1/2 1 2 3 4
______

Drive: Hours at one time: 0 1/2 1 2 3 4

______
Total hours per day: 0 1/2 1 2 3 4
______

2. Lifting/carrying
Not present Occasionally Frequently Constantly Height of Distance of
0% 0-33% 34-66% 67-100% Lift Carry
_______________________________________________________________________
1-10 lbs ________ ________
11-20 lbs ________ ________
21-50 lbs ________ ________
51-100 lbs ________ ________

32
> 100 lbs ________ ________

33
3. Actions and motions:
Not present Occasionally Frequently Constantly
0% 0-33% 34-66% 67-100% Description
_______________________________________________________________________
_
Pushing
__________________
Pulling
__________________
Climbing
__________________
Balancing
__________________
Bending
__________________
Twisting
__________________
Squatting
__________________
Crawling
__________________
Kneeling
__________________
Reaching
__________________
Handling
__________________
Fingering
__________________
Feeling
__________________
Repetitive:
hand motion
__________________
foot motion
__________________

4. Equipment:
Not present Occasionally Frequently Constantly
0% 0-33% 34-66% 67-100% Description
_______________________________________________________________________
_
Tools
__________________
Machinery
__________________

34
Equipment
__________________

5. Environmental conditions:
Not present Occasionally Frequently Constantly
0% 0-33% 34-66% 67-100% Description
_______________________________________________________________________
_
Vibration
__________________
Noise
__________________
Extreme heat
__________________
Extreme cold
__________________
Wet/humid
__________________
Moving parts
__________________
Chemicals
__________________
Electricity
__________________
Radiation
__________________
Other
__________________

Comments: ______________________________________________________________

35
 Principles of Job Redesign
When you identify unsafe aspects of a job, it’s time to redesign the job so you can prevent
injuries or re-injuries. Solutions are often simple and cheap. Here is a list of key
principles to follow when redesigning a job.

Minimize significant body motions

1. Minimize bending motions.
• Use lift tables, work dispensers, and similar mechanical aids.
• Raise the work level to an appropriate height.
• Lower the worker.
• Provide all materials at work level.
• Keep materials at work level. (For example, don’t lower anything to the floor
that must be lifted later.)
2. Reduce twisting motions.
• Provide all materials and tools in front of the worker.
• Use conveyors, chutes, slides or turntables to change the direction of material
flow.
• Provide adjustable swivel chairs for seated workers.
• Provide sufficient work space for the whole body to turn.
• Improve the layout of the work area.
3. Reduce reaching-out motions.
• Provide tools and machine controls close to the worker to get rid of horizontal
reaches over 16 inches.
• Place materials, work pieces, and other heavy objects as near to the worker as
possible.
• Reduce the size of cartons or pallets the worker loads, or allow the worker to
walk around them or rotate them.
• Reduce the size of the object the worker handles.
• Allow the worker to keep the object close to his or her body.

Reduce lifting and lowering

1. Reduce the need to lift or lower.
• Use lift tables, lift trucks, cranes, hoists, balancers, drum and barrel dumpers,
work dispensers, elevating conveyors, and similar mechanical aids.
• Raise the work level.
• Lower the worker.
• Use gravity dumps and chutes.
2. Reduce the weight of the object.
• Reduce the size of the object (specify size to suppliers).
• Reduce the capacity of the containers.
• Reduce the weight of the container itself.
• Reduce the load in the container.
• Reduce the number of objects lifted or lowered at one time.

36
3. Reduce the hand distance.
• Change the shape of the object.
• Provide grips or handles.
• Provide better access to object.
• Improve layout of the work area.

Reduce pushing and pulling

1. Eliminate the need to push or pull.
• Use powered conveyors.
• Use powered trucks.
• Use slides and chutes.
2. Reduce the required force.
• Reduce the weight of the load.
• Use non-powered conveyors, air bearings, ball caster tables, monorails, and
similar aids.
• Use four-wheel hand trucks and dollies with large diameter casters and good
bearings.
• Provide good maintenance of hand trucks, floor surfaces, and other work
surfaces.
• Treat surfaces to reduce friction.
• Use air cylinder pushers or pullers.
3. Reduce the distance of the push or pull.
• Improve the layout of the work area.
• Relocate production or storage area.

Reduce carrying
1. Eliminate the need to carry by converting to pushing or pulling.
• Use conveyors, air bearings, ball caster tables, slides, chutes, and similar aids.
• Use lift trucks, two-wheel or four-wheel hand trucks, dollies, and similar aids.
2. Reduce the weight of the object.
• Reduce the size of the object (specify size to suppliers).
• Reduce the capacity of containers.
• Reduce the weight of the container itself.
• Reduce the load in the container.
• Reduce the number of objects lifted or lowered at one time.
3. Reduce the carrying distance.
• Improve the layout of the work area
• Relocate production or storage areas.

37
 Job Description Guide
To write a job description, list the information requested for each section using the
guidelines provided.
SECTION GUIDELINES

Job title • Provide the title and the location of the job, if appropriate.

Purpose of job • Focus on outcomes of the job rather than processes.

• List required expectations and special requirements.
• List shift or hours worked, full or part time.

Education & • Describe required or desired licenses, certifications,

work experience number of years’ experience, training, and other
qualifications.

Skill requirements • Relate all pertinent skill requirements to job functions

when possible.

Job functions • Answer these questions when describing essential and

marginal job functions:
Does the job exist to perform this function?
Would removing this task fundamentally change
the job?

Job duties • Be as specific as possible.

• State how frequently a task is performed and what
equipment, tools and materials are used.

Physical demands • Be very specific. Use measurements, frequency and

duration.
• Describe body position, required exertion, and parts of the
body used.
• Give hours per day spent performing each function.

Environmental conditions • Describe temperature, hazards and other conditions.

38
 Section III

Identify Modified Duty

Modified duty, sometimes called light duty, lets you match job tasks to the capabilities of
injured workers. But how do you find these assignments? Ask the client and employees.
These are the people who know their jobs the best, and they can be an excellent resource.

Keep the employee’s doctor informed as you create a modified duty assignment to make
sure it meets with the doctor’s medical restrictions. Fill out a modified duty agreement
form to ensure the injured employee and the client understands the employee’s
capabilities and any medical restrictions.

Texas law now requires PBS and our clients to report whether they offer modified duty
opportunities for injured employees. Upon request, an employer must share this
information with the injured worker, the treating doctor, and the workers’ compensation
insurance carrier.

On the following pages, we’ve provided samples that you can use to identify and assign
modified duty work.

Page
How to Identify Modified Duty Work ..........................................................................36
Sample Modified Duty Work Agreement (English).…………….................................38
Sample Modified Duty Work Agreement (Spanish)…………………………………..39

39
 How to Identify
Modified Duty Work
Employers use modified assignments to bring injured employees back to the workplace
as soon as medically reasonable. In most cases, workers won’t be able to return to their
original jobs while recovering from an injury. Bring them back to work by modifying
their duties or developing an entirely new assignment. Here are some helpful tips.

Before an injury occurs

1. Identify possible jobs for modified duty work assignments. Ask employees and
Supervisor to help you brainstorm about everyday jobs as well as new jobs that could be
done by an injured employee. Suitable jobs usually are not physically demanding, and
they also should be safe, meaningful and productive. To get started, ask:
• What jobs are not being performed now?
• What jobs are performed occasionally?
• What jobs could an injured employee do that would free other employees to perform
their jobs more efficiently?

2. Organize information about these jobs. Do a job safety analysis to identify physical
demands and other conditions (helpful information is provided in this kit). If possible,
make a short videotape of the jobs. Keep the job safety analyses and videotapes in an
accessible area.

3. Keep job safety analysis’s up to date and accurate. Write a job safety analysis for
every job at your company. If an employee is injured, you’ll already have the
information you need about the employee’s original job assignment.

After an injury occurs

1. Tell the doctor that your company has a return-to-work process. Give the doctor a job
safety analysis, a job analysis of the employee’s original job, and information about
possible modified duty work. Ask the doctor the following questions:
• Can the injured employee return to the original jobs with no changes?
• Can the injured employee return to the original jobs under special conditions, such as
working for reduced hours or using modified equipment?
• Can the injured employee do alternative productive work?

2. The doctor must complete Form DWC-73, which lists the employee’s medical
restrictions and current capabilities. The doctor must approve all modified duty
assignments and any changes to the job duties.

3. Have the return-to-work coordinator, the employee, and the client sign a modified duty
work agreement. This agreement describes the new work duties, start and end dates for
the duties, and medical restrictions. The agreement states that the injured employee will
not work or be asked to work outside of medical restrictions.

40
4. Continually monitor the employee’s progress. Talk with the employee regularly and
discuss any concerns. Make sure the doctor agrees to any changes in the modified duty.

5. When the employee reaches the end date for the agreement, discuss the employee’s
medical status and the success of the assignment. If the doctor gives the employee a full
release to work, the employee can go back to the original job. If the doctor continues the
employee’s medical restrictions, evaluate continuing alternative productive work.

Troubleshooting
What if I bring an injured employee back to modified duty and the employee is re-injured
on the job?
There is no guarantee that an employee will not be re-injured. In some circumstances, a
re-injury may be considered a new claim. The treating doctor should always approve
modified duty, which will reduce the risk of re-injury.

What if an injured employee on modified duty is constantly late to work, does not carry
out assigned tasks, and often has unexcused absences?
If you have company rules for all employees, the same rules apply to injured employees.
Follow your existing disciplinary process. However, if the employee has not reached
maximum medical improvement, and you send the employee home without pay, Texas
Mutual Insurance Co. will pay temporary income benefits.

41
 Modified Duty Work Agreement
Employee’s name: ______________________ Department: _______________________

Employee’s title: _______________________ Date: _____________________________

My work duties are changed from _______________ (date) until _____________ (date).
I am assigned to modified work duties or limited duties. My new work duties are listed
below.
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_

The duties above have been described to my doctor. My doctor has signed Form DWC-
73 stating that I may do these activities under the following medical restrictions.
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_

I agree to do the above work duties and follow my doctor’s medical restrictions. If I
ignore my medical restrictions, I understand that my employer may take disciplinary
action.

If a anyone else asks me to do work assignments or activities that don’t follow my

medical restrictions, I must immediately report the situation to _____________________
(name of return-to-work coordinator), who will take action to correct the situation. If I
think my new work duties are causing discomfort or making my medical condition worse,
I will report this immediately to ____________________________ (name of return-to-
work coordinator).

Employee signature: _____________________________ Date: __________________

Supervisor signature: ____________________________ Date: ___________________
Return-to-work coordinator signature: _______________ Date:___________________

42
 Un Acuerdo
De Trabajo Alternativo
Nombre del empleado: ______________________ Departamento:__________________
Puesto del empleado: ________________________ Fecha: ________________________
Mis deberes de trabajo han cambiado de _________ (fecha) al _______________ (fecha).
Estoy asignado a los deberes de trabajo alternativo o limitado. Mis deberes de trabajo
nuevos están listados en la parte inferior.
_______________________________________________________________________
_
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___

Los deberes descritos en la parte superior han sido explicados a mi doctor. Mi doctor ha
firmado una Form DWC-73 estableciendo que yo puedo realizar estas actividades bajo
las siguientes restricciones médicas.
_______________________________________________________________________
_
_______________________________________________________________________
_
_______________________________________________________________________
_

Acepto los deberes de trabajo listados en la parte superior y seguir las restricciones del
doctor. Si ignoro mis restricciones médicas, entiendo que la compañía para la que trabajo
puede tomar acciones disciplinarias.

Si un Supervisor o cualquier otra persona me piden que haga tareas o actividades que no
cumplan con mis restricciones médicas, debo reportar la situación inmediatamente a
_______________________________________________ (nombre del coordinador del
regreso al trabajo), quien corregirá la situación.

Si pienso que mis nuevos deberes de trabajo están causando incomodidad o están
empeorando mi condición médica, lo reportaré inmediatamente a
____________________________ (nombre del coordinador del regreso al trabajo).

Firma del empleado: _____________________________________ Fecha: ___________

Firma del Supervisor: ____________________________________ Fecha: ___________
Firma del coordinador del regreso al trabajo:__________________ Fecha: ___________

43
 Section IV

Communicate with
the Doctor and Employee
Texas law now requires employers to report whether they offer modified duty
opportunities for injured employees. Upon request, an employer must share this
information with the injured worker, the treating doctor, and the workers’ compensation
insurance carrier.

Communication is vital to the return-to-work process. Maintain regular contact with the
treating doctor and the injured employee. Have the employee’s Supervisor send a letter
to the doctor explaining your company’s return-to-work process. Have the employee sign
a release so the doctor can discuss work-related medical information with your company.

The Supervisor should accompany the injured employee on his or her first visit to the
doctor. If this is not possible, we suggest that you ask the injured employee to take along
a return-to-work folder, and the Supervisor can follow up with a phone call later. A
typical return-to-work folder may contain:
• a letter telling the treating doctor you want to return the employee to work as
soon as medically reasonable,
• a medical release signed by the employee that allows the doctor to provide you
with medical information about how the injury affects the employee’s ability to
work, and
• a copy of Form DWC-73, Work Status Report, so the doctor can make return-to-
work recommendations.

The information in Form DWC-73 will be crucial for assigning modified duty. Always be
sure the doctor agrees with any return-to-work assignments. Keep track of what benefits
the injured employee receives and how long Texas Mutual Insurance Co. pays benefits.

More information
On the following pages, we’ve provided samples for communicating with the doctor,
keeping track of communications with the employee, and understanding benefit
payments.
Page
Troubleshooting………………………………………………………………….41
Sample Letters for the Treating Doctor.................................................................42
After-Injury Telephone Report Log (blank form to photocopy)......………….....44
Sample Medical Release of Information...............................................................46

44
Troubleshooting

If my employee is injured on the job, can I choose the doctor I want the employee to
visit?

You may ask the injured employee to see your company doctor; however, injured
employees have the right to choose their treating doctors in accordance with the Texas
Labor Code and Texas Department of Insurance’s Division of Workers’ Compensation
rules.

45
 Sample Letters for the Treating Doctor
Use this letter when asking for the doctor’s recommendations for returning the
employee to regular duties.

Dear Doctor:

Ref: Employee’s Name

SS Number.***-***-(0000)

This letter provides important information about employees who work for PBS and our
client companies. You may verify insurance coverage by calling Texas Mutual Insurance
Co. at (800) 859-5995. Our policy number is 0001101931.

We have a return-to-work process designed to return employees to work as soon as

medically reasonable. We would like to work with you on these items:

• Your Recommendations
Please assist us by providing your recommendations for returning this employee to work.
We have attached a job safety analysis and physical demand of the job for this
employee’s regular duties, a medical release form, and a form for your recommendations.
We would appreciate an update after each appointment.

• Modified duties, if required

If the employee is unable to return to regular duties, we can arrange for alternative
productive work.

• Scheduling appointments
We can arrange work schedules around diagnostic or treatment appointments.

Please call me at the number below if you have any questions. Thank you in advance for
your assistance.

Sincerely,

Return to Work Coordinator

PBS
1/888/658-4675

46
Use this letter when asking for the doctor’s recommendations for returning the
employee to alternative productive work.

Dear Doctor:

Ref: Employee’s Name

SS Number: ***-**-(0000)

This letter provides important information about employees who work for PBS and our
client companies. We have a return-to-work process designed to return employees to
work as soon as medically reasonable.

Since this employee is unable to return to regular duties, we would like to request your
recommendations on returning the employee to modified duty. We have attached a job
description and job safety analysis for alternative productive work, based on our
knowledge of the employee’s injury.

We have attached a form for your recommendations. We will ensure that this position
meets ALL medical restrictions you prescribe.

Please call me at the number below if you have any questions. Thank you in advance for
your assistance.

Sincerely,
Return to Work Coordinator
PBS
1/888/658-4675

47
 After-Injury Telephone Report
Employee’s name: __________________________ Home phone: __________________

Employee’s Supervisor: _______________________ Date of injury: ________________

Treating medical facility: __________________________________________________

Treating doctor: _____________________________ Doctor’s phone: _______________

Has the employer discussed workers’ compensation benefits with the employee?
Yes _____ No ______

Has the employer discussed the return-to-work process with the employee?
Yes _____ No ______

_______________________________________________________________________
Log of Doctor’s Appointments
Date: ____________________________________ Time: _________________________

Comments:
_______________________________________________________________________
_

_______________________________________________________________________
_

Contacted by: _________________________________________

Date: ________________________________________ Time: _____________________

Comments:
_______________________________________________________________________
_

_______________________________________________________________________
_

Contacted by: _________________________________________

(Please photocopy this blank form.)

48
49
 After-Injury Telephone Report, cont.
Coordinator’s Telephone Log
Date: ___________________________________ Time: __________________________

Comments:
_______________________________________________________________________
_

_______________________________________________________________________
_

Contacted by: _________________________________________

Date: ___________________________________ Time: __________________________

Comments:
_______________________________________________________________________
_

_______________________________________________________________________
_

Contacted by: ____________________________________________

Date: __________________________________ Time: ___________________________

Comments:
_______________________________________________________________________
_

_______________________________________________________________________
_

Contacted by: _________________________________________

(Please photocopy this blank form)

50
 Sample Medical Release of Information
I, ____________________, hereby release my treating doctor, ___________________ ,
to give my employer, PBS, pertinent information about my current work-related injury
and how that injury may affect my ability to complete the essential functions of my job.
No other confidential information may be released without my written consent. This
release will be valid no longer than 60 days, at which time it will be re-evaluated.

Employee’s Signature ______________________________, Date ________________

Employer’s Signature ______________________________, Date_________________

51
 Section V

Make a Bona Fide Offer of Employment

PBS will make a written bona fide (valid) offer of employment if we have a job the
injured employee can perform, and the doctor has released the employee for the job. To
be bona fide, the offer must meet the requirements of DWC Rule 129.6.

More info
On the following pages, we’ve provided a copy of DWC Rule 129.6 and a checklist for
making an offer of employment. We’ve also provided a sample letter making a bona fide
offer of employment.
Page
Troubleshooting………………………………………………………………………48
DWC Rule 129.6 “Bona Fide Offers of Employment”................................................49
Checklist for Making a Bona Fide Offer of Employment............................................51
DWC Form-73..............................................................................……….......See Forms

52
Troubleshooting
If I offer my injured employee a job, can the employee refuse it?
Injured employees may refuse an offer for alternative productive work, but if the offer of
employment was bona fide (according to DWC Rule 129.6), the insurance company may
discontinue the injured employee’s temporary income benefits. This does not mean the
injured employee is terminated from employment
.
If an injured employee returns to work at a lower pay rate, does the employee receive
workers’ compensation benefits?
Yes. If the injured employee has not reached maximum medical improvement and is not
receiving the average weekly wage that he or she earned before the accident, the
employee will receive income benefits.

53
 DWC Rule 129.6
Bona Fide Offers of Employment
(a) An employer or insurance carrier may request the treating doctor provide a Work
Status Report by providing the treating doctor a set of functional job descriptions which
list modified duty positions which the employer has available for the injured employee to
work. The functional job descriptions must include descriptions of the physical and time
requirements of the positions.

(b) An employer may offer an employee a modified duty position which has restricted
duties which are within the employee's work abilities as determined by the employee's
treating doctor. In the absence of a Work Status Report by the treating doctor an offer of
employment may be made based on another doctor's assessment of the employee's work
status provided that the doctor made the assessment based on an actual physical
examination of the employee performed by that doctor and provided that the treating
doctor has not indicated disagreement with the restrictions identified by the other doctor.

(c) An employer's offer of modified duty shall be made to the employee in writing and in
the form and manner prescribed by the Division. A copy of the Work Status Report on
which the offer is being based shall be included with the offer as well as the following
information:
(1) the location at which the employee will be working;
(2) the schedule the employee will be working;
(3) the wages that the employee will be paid;
(4) a description of the physical and time requirements that the position will
entail; and
(5) a statement that the employer will only assign jobs consistent with the
employee's physical abilities, knowledge, and skills and will provide training if
necessary.

(d) A carrier may deem an offer of modified duty to be a bona fide offer of employment
if:
(1) it has written copies of the Work Status Report and the offer; and
(2) the offer:
(A) is for a job at a location which is geographically accessible as
provided in subsection (e) of this section;
(B) is consistent with the doctor's certification of the employee's work
abilities, as provided in subsection (f) of this section; and
(C) Was communicated to the employee in writing, in the form and
manner prescribed by the Division and included all the information
required by subsection (c) of this section.

(e) In evaluating whether a work location is geographically accessible the carrier shall at
minimum consider:

54
 (1) The effect that the employee's physical limitations have on the employee's
ability to travel;
(2) The distance that the employee will have to travel;
(3) The availability of transportation; and
(4) Whether the offered work schedule is similar to the employee's work schedule
prior to the injury.
(f) The following is the order of preference that shall be used by carriers evaluating an
offer of employment:
(1) The opinion of a doctor selected by the Division to evaluate the employee's
work status;
(2) The opinion of the treating doctor;
(3) Opinion of a doctor who is providing regular treatment as a referral doctor
based on the treating doctor's referral;
(4) Opinion of a doctor who evaluated the employee as a consulting doctor based
on the treating doctor's request; and
(5) The opinion of any other doctor based on an actual physical examination of
the employee performed by that doctor.
(g) A carrier may deem the wages offered by an employer through a bona fide offer of
employment to be Post-Injury Earnings (PIE), as outlined in §129.2 of this title (relating
to Entitlement to Temporary Income Benefits), on the earlier of the date the employee
rejects the offer or the seventh day after the employee receives the offer of modified duty
unless the employee's treating doctor notifies the carrier that the offer made by the
employer is not consistent with the employee's work restrictions. For the purposes of this
section, if the offer of modified duty was made by mail, an employee is deemed to have
received the offer from the employer five days after it was mailed. The wages the carrier
may deem to be PIE are those that would have been paid on or after the date the carrier is
permitted to deem the offered wages as PIE.
(h) Nothing in this section should be interpreted as limiting the right of an employee or a
carrier to request a benefit review conference relating to an offer of employment. The
Division will find an offer to be bona fide if it is reasonable, geographically accessible,
and meets the requirements of subsections (b) and (c) of this section.

55
 Checklist for Making a
Bona Fide Offer of Employment
When the treating doctor releases an injured employee to return to work in any capacity,
you should make a bona fide offer of employment to the employee. To be bona fide
(valid), the offer must meet the requirements of DWC Rule 129.6.

The Texas Department of Insurance established the requirements because a bona fide
offer of employment can affect a worker’s income benefits. When deciding whether an
offer is bona fide, the Division considers the following:
• how long the job is expected to last
• how long the offer was kept open
• the way you made the offer to the employee
• the job’s physical requirements and accommodations compared to the
employee’s physical capabilities
• the distance the employee has to travel to get to work (A job is accessible if it is
within a reasonable distance of where the employee lives, unless the employee
shows through medical evidence that a medical condition won’t allow the
employee to travel that distance.)

To help you make a bona fide offer, we have provided a sample letter on the next page.
Be sure to attach a copy of Form DWC-73 to the letter. Follow this checklist when you
write an offer:
__ State the job title, what the hourly or weekly wage will be, the hours of work, where
the employee will work, and how far the job is from where the employee lives.
__ State how long you will keep the job offer open.
__ Describe the job duties.
__ Describe the maximum physical requirements of the job.
__ Indicate that you understand the employee’s physical limitations and will abide by the
work restrictions sanctioned by the employee’s doctor.
__ If the employee is more fluent in a language other than English, translate the letter into
the appropriate language. We can help you with the translation.
__ Deliver the offer during the time the employee is eligible for workers’ compensation
income benefits.
__ Send the offer by certified mail, return receipt requested, and by regular mail.
__ Send a copy of the letter and mail receipt to your carrier.

If you don’t make an offer in writing, it is difficult to show the Division that you made an
offer.

56
 SUBSTANCE ABUSE POLICY
The welfare and success of PBS and COMPANY, depends on the physical and
psychological health of all its employees. While they are committed to maintaining a safe
workplace, it is the responsibility of PBS, COMPANY, and their employees to create and
maintain a safe, healthful and efficient working environment. Therefore, for the
protection of its employees, property, and the general public; PBS and COMPANY have
adopted this Substance Abuse Policy.

1. PURPOSE AND SCOPE

1.01 PURPOSE: The purpose of this Policy is to maintain a safe, healthful, and
efficient working environment by eliminating any abuse of legal or illegal drugs, alcohol,
and inhalants at any time while on Company Business or on the Company premises. We
require all employees of the Company to be free from the effects of legal or illegal drugs,
alcohol, inhalants, and any other drug that may impair the employee’s ability to perform
his/her job in a safely manner.
1.02 SCOPE: This Policy applies to all employees of this Company: (a) at all times
while on the Company’s premises, (b) during the course and scope of their employment
regardless of location and (c) during any Company-sponsored activities.

2. DISCPLINARY ACTIONS AND PROHIBITED CONDUCT

2.01 DISCIPLINARY ACTION: Any employee’s failure to comply with any part of
this policy will result in disciplinary action up to and including termination of
employment.
2.02 PROHIBITED CONDUCT: Any employee will subject to the above measures of
paragraph 2.01 for any of the following:
a.) The manufacture, distribution, possession, use or sale of alcohol, inhalants,
unauthorized or illegal drugs or the misuse of any legal or prescription drugs on
Company’s premises, while on Company business, or during any Company-sponsored
activities.
b.) Being under the influence of any substance described (a) above which impairs
judgment, performance, or behavior while on Company’s premises, while on Company
business, or during any Company-sponsored activities.
c.) Conviction under any criminal statute for the possession, use or sale of drugs or
alcohol or any related activity.
d.) Refusing to submit to a medical evaluation, including drug and alcohol testing
as provided for in section 3 of this policy.
e.) Generating test results, which indicate any drug, alcohol or other substance
abuse.

57
3. TESTING

3.01 DEFINITION: For the purpose of this Policy, “drug” is defined as any alcoholic
beverage, illegal inhalant, illegal drug or other substance, the use, possession,
manufacture, distribution or dispensation of which is prohibited by any state or federal
law or regulation and any drug substance obtained by prescription, over-the-counter or
otherwise.
3.02 APPLICATION OF DRUG TESTING:
a) All persons applying for a position with COMPANY may be required to submit
to a drug test as a condition of employment.
b) All current and future employees must submit to a drug test upon the request of
PBS or COMPANY under the following:
1.) When special safety considerations attendant to certain jobs indicated that
such testing presents a reasonable means to assure a safe working environment.
2.) When employee either sustains an injury in the course and scope of
employment or contributes to or causes another employee to sustain an injury in the
course and scope of employment.
3.) When the employee causes, indirectly or directly, damage to the Company’s
property or to the property of another.
4.) When the employee contributes or causes injury to any third party while the
employee is in the course and scope of employment.
5.) When the employee is convicted under any criminal drug statue for a
violation occurring during the course and scope of employment. If such a conviction
occurs, it is the employee’s responsibility to notify the Company within five (5) days of
the conviction. This requirement includes any finding of guilt, guilty plea, plea of no
contest or imposition of sentence or any other penalty whatsoever by any court of
competent jurisdiction or otherwise in connection with any state or federal criminal
statute involving the manufacture, distribution, dispensation, use or possession of any
controlled substance or drug, including alcohol.
6.) When PBS or the Company, in its sole discretion, determines that it is in
PBS or the Company’s best interest to conduct such a drug test.

4. MISCELLANEOUS PROVISIONS

4.01 COOPERATION WITH LAW ENFORCEMENT: In addition, any illegal drug or

other substance obtained by the Company from any employee may be turned over to law
enforcement agency and may result in criminal prosecution.
4.02 REPORTING: Each employee is responsible for promptly reporting to the
appropriate Company officers any use of prescribed medication which may affect the
employee’s judgment, performance, or behavior.
4.03 OTHER PROCEDURES: The Company will establish such other procedures as
it-finds necessary to effectively enforce this Policy. This may include a requirement that
employees cooperate in personal or facility searches when there is a reason to believe
drugs or alcohol are present when their performance is impaired or whenever their
behavior is erratic. Refusing to cooperate with these procedures may be cause for
disciplinary action as provided in Section 2.

58
 4.04 MEDICAL FACILITY: The Company shall not be responsible for, and makes no
representations or warranties on behalf of the, laboratory or medical facility conducting
the drug test.

59
 Inspections and Audits
I. Inspections
It is the intent and policy of COMPANY to provide a workplace free from
recognizable hazards. To accomplish this objective the company has developed a
planned structured process for the maintenance of safe work conditions.

The success of this program is dependent on the participation and hazard

awareness of each and every supervisor and employee.

If an unsafe condition is identified - repair, tag and/or take equipment out of

service. The condition should be reported to the job site supervisor as soon as
possible.

A. Informal Inspections
At the start of each job a visual inspection of tools, equipment, vehicles
and the general work area should be performed.

Informal inspections are a regular part of every employee’s job and

individual responsibility.

B. Formal Inspections
Monthly, or as required by law the Supervisor and crew will be
responsible to perform a formal job site and equipment inspection. The
“Inspection Checklist” (PBS form 111) should be completed and
deficiencies noted on the “Safety Work Order Log” (PBS form 110).

Noted deficiencies should be tracked on the safety work order log until
items are corrected.

The Owner should periodically attend and participate in a Supervisor /

Employee Inspection.

Inspection reports should be reviewed in the Supervisor / Employee and

the Owner / Supervisor safety meetings.

C. Areas To Be Inspected Frequency Responsibility

1. Office Monthly Spv. & Employees

2. Vehicles Daily Operators
3. Job Sites Weekly Spv. & Employees
4. Assigned Machinery Daily Operators
5. Power Tools Daily Spv. & Operators
6. ______________ ___________ _______________
7. ______________ ___________ _______________

60
D. Job Site Hazard Assessments
The Supervisor should conduct a hazard assessment for each new job site.
If new equipment or change in activity is introduced additional assessment
or training should be completed.

The Supervisor, along with his/her employees should review the job site
and tasks to be performed. This review should identify areas of potential
exposure or injury to employees. The proper methods and/or Personal
Protective Equipment needed should be reviewed and implemented.

The Hazard Assessment should be completed on “Work Site Hazard

Assessment” (PBS form 105).

61
 Safety & Health Training
It is the policy of COMPANY that employees receive training in the various OSHA
standards, regulations, hazards and safe work practices associated with their assigned
tasks. Completion of training will depend on the complexity of the task and the level of
competency required to perform the task safely and productively.

Training will be completed while on the job and regularly scheduled safety meetings.
The main focus of the training program will consist of the safe work practices related to
the employees’ jobs and tasks. The outline of topics for New and existing employees is
outline below.

I. New Employee Orientation

A A. Training will Include:
1. Basic rules and procedures
2. Required Personal Protective Equipment and proper use and care
3. Accident Reporting Procedures
4. Hazard Communication
5. Emergency Response
6. Safety Signs and Tags
7. Specialized Work (confined space, hot work etc.)

B. Documentation:
1. Subject(s) covered
2. Presenter
3. Name & Signature(s) of trainee(s)
4. Date

C. Responsibilities
The Supervisor is primarily responsible for the new employee training
and orientation. The employee is responsible to communicate their level
of knowledge and expertise.

The Owner should periodically audit and review the content and
effectiveness of training.

This training should be completed before the employee begins their

assigned duties.

II. Training Topics

The following is a list of standards, regulations and safe work practices that may
require formal training. Employee position, experience level and exposure will
determine timelines and depth of training.

62
 Training should be documented on either the “Supervisor Safety Meeting” (PBS
form 120) or “Safe Work Practice Development” (PBS form 101) and “Job
Safety Analysis Form” (form 107).
A. Documentation should include:
1. Date
2. Presenter
3. Person(s) trained
4. Outline of training topic

B. Training Topics
1. Fire Extinguishers
2. First Aid
3. Back Injury Prevention
4. Electrical (LOTO)
5. Machine Guards
6. Hand & Power Tools
7. Ladders & Scaffolds
8. Housekeeping
9. Heavy Equipment
10. Motor Vehicles
11. Cutting & Welding
12. Safe Work Practices related to tasks (see tasks list)
13. Preventive Maintenance
14. ___________________________
15. ___________________________
16. ___________________________
17. ___________________________
18. ___________________________

III. Safety Meetings

It is the policy of COMPANY that all employees attend their crew’s scheduled
safety meetings. The safety meeting format, documentation, frequency etc. is
outlined below.

These meetings are most effective when they are planned and scheduled in
advance, employees participate (lead part of meeting), and the information is crew
specific, relevant and timely.

A. Documentation
1. Name of Presenter(s)
2. Date
3. Subjects Covered
4. Name and Signatures of attendees

B. Supervisor / Employee Meeting

63
 Weekly, the Supervisor should schedule and facilitate a “Supervisor
Safety Meeting” (PBS form 120) with his/her crew. The primary focus of
the meeting should be on the safe work practices of the jobs and tasks
performed.
In addition to the development of safe work practices, relevant standards,
recent injuries and/or new MSDS should be discussed.

One meeting per month should be used to develop the assigned safe
work practice. Another meeting should be used to review the previous
month’s master safe work practice.

Several days before the scheduled meeting, the Supervisor should assign
one or more employees various parts of the meeting (MSDS, incident
review and/or assigned work practice).

C. Owner / Supervisor
Quarterly, the Owner is responsible to schedule and facilitate a meeting
(form ASI-121) with the Supervisor. The purpose and content of the
meeting should be as follows:
1. Outline of Meeting
a.) Review injury / incident reports and trends
b.) Review inspections and deficiencies
c.) Review Safe Work Practices and assign new topics
d.) Identify new equipment and/or tasks
e.) Review completion of Accident Prevention Plan activities.
f.) Develop an action plan to address any deficiencies of (a-e
above).
g.) Assign responsibilities and timelines for completion of
action plan.

IV. Safe Work Practices

The primary focus of this safety program is the development of and training in the
jobs and tasks performed by the employees of COMPANY.

The purpose of the safe work practice program is to solicit the knowledge and
experience of employees to develop a practical common sense approach to work
place safety. Nobody knows the ins and outs of the jobs and tasks better than the
people who perform them do.
There are four steps to the Safe Work Practice Program
• “Tasks Inventory List” (PBS form 102)
• “Safe Work Practice Development” (PBS form 101)
• “Job Safety Analysis” (PBS form 107)
• Follow Up

A. “Tasks Inventory List” (PBS form 102)

The first step in the Safe Work Practice Program is the development of a

64
 Tasks Inventory List. This list will be comprised of the various jobs and
tasks performed. This list should be continually revised and updated.

B. Safe Work Practice Development

Monthly, the Owner will assign each Supervisor and crew one task from
the tasks inventory list. Crews that perform similar work will be assigned
the same task.

Each month, one of the weekly safety meetings will be used to develop
the crew’s assigned work practice. Two or more employees should be
assigned the job of writing down the dos and don’ts of the task using the
forms “Safe Work Practice Development” (PBS form 101) as a cover
sheet for “Job Safety Analysis Form” (PBS form 107) before this
scheduled meeting. They should lead the discussion and solicit additional
input from other crewmembers in order to complete the JSA.

The Supervisor should bring the crew’s copy of the completed work
practice to the Owner / Supervisor safety meeting.

C. Master Safe Work Practice Development

As part of the Owner / Supervisor safety meeting the “Safe Work
Practices Development” sheet will be reviewed and combined into the
“Job Safety Analysis Form (PBS form 107) for each task. It is not
uncommon to see crews have a sometimes dramatically different view of
the hazards and how the job should be performed.

The Safe Work Practice Program allows an opportunity to evaluate not

only each employee’s view but also the view of other crews performing
similar work.

The JSA should be discussed and reviewed at the next scheduled

Supervisor safety meeting.

D. Follow Up
The Supervisor will be responsible to follow up by observation and
review the guidelines developed in the masterwork practice.

The JSA can and should be used for 5-minute tailgate meetings or before
performing a particularly hazardous task.

Observation or accident trends may indicate a need to revisit previously

developed JSA. Sometimes it is necessary to revise the JSA.

65
 Abrasive Blasting
These requirements only apply to the remote sand blasting operations that are common to
most construction or fabrication sites.
1. A supplied air hood shall be worn when sand blasting is done. This applies to the
person doing the actual blasting and the person attending the pot.
2. Protective clothing shall be worn which protects the arms, legs, hands and feet.
3. Persons working in close proximity of the blaster shall wear eye protection with side
shields and a dust mask to protect against flying dust particles.
4. The compressor and pot shall be grounded with an approved ground and the blast
nozzle bonded to the object being blasted. This will prevent buildup of static
electricity.
5. The air used in the supplied air hood can come from the air blast compressor if proper
filters are used to extract the oil, water and odor.
6. The blast nozzle shall be equipped with a dead man trigger. This allows the nozzle to
shut off if dropped or if the operator falls. A positive switch can be used if it can be
shut off with the movement of one finger.
7. All hoses and connections shall be inspected before each use to prevent rupture
during operation.
8. The supplied air hood shall be cleaned and sanitized after each use to insure the
sanitation of the user.
9. This equipment should be stored in a dry and safe place.
10. The air supply to the hood should be regulated to be compatible with the hood
requirements.
11. All work should be completed down wind from other employee activity.

66
 Backhoe Operations

1. All operators shall be fully qualified and become thoroughly familiar with the
backhoe before they will be allowed to operate any piece of equipment. Each
operator must thoroughly read and understand the operator’s manual.
2. Each unit shall be equipped with a seat belt and roll bar.
3. The operator should use step plates and handholds when entering the machine. Never
enter from rear.
4. Do not start engine unless seated in the operator’s seat.
5. Controls shall be operated only when the operator is seated.
6. All operators shall wear a seat belt when backhoe is equipped with a rollover bar.
Seat belts should not be worn if the rollover bar has been removed.
7. No riders permitted at any time.
8. Keep bystanders away from backhoe operations. No one is allowed in the excavation
while backhoe is digging or back filling.
9. Locate utility lines and overhead power lines before starting to dig. Do not operate
backhoe within 15’ of overhead power lines.
10. Never attempt to lift loads in excess of backhoe capacity.
11. Never allow anyone to be under bucked when lifted.
12. Never allow anyone to reach through lift arms when bucket is raised.
13. Maintain stability at all times. Operate at slow speeds on rough ground, when
crossing ditches and turning around.
14. To prevent upsets when operating on a slope, avoid using the full reach and swinging
a loaded bucket to the downhill side.
15. Always center and raise the boom before engaging or disengaging the transport.
16. Do not get off the tractor while it is in motion.
17. Do not lubricate or make mechanical adjustments to the unit while it is in motion or
when the engine is running.
18. Never repair or tighten hydraulic hoses for fittings when the system is under pressure,
when the engine is running or when the backhoe cylinders are under a load.
19. Park the unit on level ground when possible. When parking it on an incline, lower the
bucket so that the cutting lip contacts the ground. Apply the parking brake and
securely block the wheels.
20. Use car in attaching towing lines to the backhoe. Pulling from the tractor rear axle or
any point above the axle may cause an accident.
21. Observe good maintenance and repair of all pivot pins, hydraulic cylinders, hoses,
snap rings and main attaching bolts daily.
22. Maintain the brakes in good working order.
23. When loading on haul trailer always use low range and low gear. Keep buckets as
low as possible to maintain low center of gravity on unit.
24. Always set parking brakes on haul truck and chock wheels to keep trailer stable and
in place when loading or unloading.
25. Never load or unload backhoe on haul trucks with buckets loaded with any type of
load.

67
26. Double cross chain and boom both front and rear of backhoe on haul trailer with
chains rated for the maximum load (grade 7).
27. If there are no lock pins on rear boom of backhoe then the boom may need to be
chained to trailer to prevent swinging in case of accident.
28. Know how tall the load is when hauling the backhoe down the road.
29. ____________________________________________________________________
_
30. ____________________________________________________________________
_

68
 Blood-borne Pathogens Program
I. Policy
COMPANY’s policy is to train employees in the basic understanding and awareness of
the potential exposures to deadly diseases that can be contracted through bodily fluids
and tissues. By following the guidelines outlined in this program the chances of
contracting one of these diseases will be greatly reduced.

Since there is no way to recognize an infected individual, the company policy is that all
body fluids could be considered contaminated and handled accordingly.

II. General
Accidental exposures can happen on and off the work site. The company believes that
each employee must have a basic understanding and awareness of the dangers of
contracting a potentially deadly disease. Communicating basic information about these
hazards and methods to minimize the risks is part of the company’s safety and health
program. Therefore, each employee shall be trained in Blood-borne Pathogen
Precautions at the time an employee is assigned to an area where occupational exposure
may take place and at least annually thereafter. Otherwise, employees will be trained
within a reasonable period of time as part of the company’s ongoing training program
concerning affected standards.

Two well-known and deadly diseases can be contracted through infected bodily fluids,
blood and tissue, they are:
• The Hepatitis B Virus (HBV)- this virus is known for causing severe liver disease that
frequently results in death and
• The Human Immunodeficiency Virus (HIV)- this virus causes Acquired Immune
Deficiency Syndrome (AIDS).

III. Potential Methods of Exposure

1. Administering First Aid/CPR-If an employee is injured and bleeding from a cut or
laceration, and a fellow worker comes to the rescue, the rescuer has no way of
knowing if the victim’s blood is potentially carrying the HIV or HBV virus. This
means unless the rescuer takes certain precautions a fatal disease could infect him or
her.

2. Blood-borne Pathogens can also be present in feces, urine, vomit and other bodily
excretions. This means someone could be exposed while performing routine cleaning
or housekeeping jobs such as:
• Cleaning toilets or sinks
• Wiping or mopping accidents involving blood, vomit, feces or urine
• Handling laundry that may be soiled with blood, semen or other bodily excretions
• Picking up trash bags that may contain discarded needles, syringes, blades, broken

69
 glass or other sharps that have been contaminated with blood.

IV. Preventing Exposures

The obvious answer is to keep the HIV, HBV or other blood-bone pathogens from getting
into your body. These virus can enter through small wounds or breaks in the skin
(dermatitis, skin rashes, acne, chapping or a torn fingernail).

Sexual contact, sharing needles, eyes or nose, cuts and puncture wounds by an object that
is contaminated with infected blood are the most common ways people get contract
blood-borne pathogens.

Therefore, no employee is required to render first aid or CPR. If an employee decides to

render first aid the following precautions should be taken:
• Wear protective medical gloves
• Safety glasses or face shield
• If blood gets on your skin, wash it off immediately using water and a non-abrasive
soap.
• If you should get blood in your eyes, lips, mouth or nose, flush with water as quickly
as you can.
• After you have washed or flushed the area, report the incident to the Owner.

After handling potentially contaminated laundry or being exposed to bodily fluids, be

sure to wash your hands and remove protective clothing before:
• Eating
• Drinking
• Smoking
• Handling contact lenses

V. Cleaning Up Blood/Body Fluid After An Injury

After an injury there may be blood and blood stained equipment, material or garments at
the scene. The following is the company policy for cleaning up an accident scene.

1. Wear two pairs of protective gloves when doing the clean up (one pair over the
other).
2. Wear a leak proof apron or over-garment to keep contamination form getting on
your regular clothes.
3. Restrict access to the area by keeping other persons out of the area until the clean
up is accomplished.
4. Soak up most of the blood and contamination by using disposable towels.
5. Place all contaminated trash, bandages, towels and other waste in a color-coded or
labeled leak-proof bag. Ensure the bag is labeled reading Regulated Waste.
6. Thoroughly clean the area with a disinfecting solution. Regular chlorine bleach
mixed ¼ cup with a gallon of water.
7. Make sure all mops; buckets and other equipment used in the clean up are
themselves disinfected.

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8. Employees should wash their hands, face or any other potentially contaminated
body part by using an antiseptic hand cleanser.

VI. First Aid Stations

First aid stations will include the following supplies:
• Latex gloves
• One-way valve CPR mask
• Biohazard bags
• Leak-proof containers
• Plastics baggies for placing severed body parts
• Tongs

71
 Concrete & Masonry
General
1. Re-enforced steel will be covered if it poses a threat to employees.
2. No employees will be allowed to ride concrete buckets.
3. Employees are not to work under overhead concrete buckets.
4. Head and face protection should be used when operating concrete pumping devices.
5. Employees tying re-steel 6 ft. above any surface will be required to wear a lifeline
and safety harness.
6. Concrete trucks must chock wheels when pouring from a sloped surface.
7. Employees should protect themselves from Portland burns. A washing facility will be
provided in close proximity of the job site.
8. Power trowels must be equipped with an automatic shut off switch.
9. Verify proper guarding is on all masonry and concrete saws. Never operate without
guards in place.
10. Face shield and safety glasses are required when working with saws or right angle
grinders.
11. __________________________________________________________________
12. __________________________________________________________________

72
 Confined Space Program
I. Policy
It is the policy of COMPANY that before any employee is allowed to enter a confined
space that certain precautions and procedures as outlined below be followed and
implemented. No employee will be permitted to enter a confined space without prior
training and approval from a person deemed competent in confined space entry.

Every confined space is unique, therefore, each confined space must be carefully
evaluated and hazards must be eliminated or controlled before entry is permitted.

II. Definition of a Confined Space

• Limited or restricted means of entry and exit,
• Large enough for a person to enter, and
• Not designed for continuous employee occupancy.

III. Definition of a Permit Required Confined Space

• A known potential to contain a hazardous atmosphere,
• Potential for engulfment or entrapment,
• An internal configuration that could trap or asphyxiate the entrant, or
• Contains any other recognized serious safety and health hazards.

IV. Confined spaces may include but are not limited to:
•Manholes
•Sewers
•Pipelines
•Culverts
•Underground utility vaults
•Storage tanks
•Tunnels
•Septic Tanks
•Trenches or excavations greater than 4ft.

V. Requirements for Enter of a Confined Space

•Employees required to enter a confined space or enclosed spaces shall be instructed as
to the nature of the hazards involved, the necessary precautions to be taken and in the use
of protective and emergency equipment required
•Prior to entry the following shall occur:
•1. Test and evaluate the space for potential hazardous atmosphere
•2. Review the step-by-step procedures for entry and exit in the confined space (this 3
includes employees as well as Supervision).
•3. Stipulate acceptable entry conditions
•4. Post confined space-warning signs at the entrance to the confined space

73
 1. If the inspection indicates the confined space falls under the guidelines of a permit
required confined space, then a permit shall be followed and filled out according
to the outlined guidelines.
2. Each confined space area will have a competent person qualified in recognition of
a confined space and sufficient knowledge in proper entry and emergency exit.

VI. Permit Required Confined Space

1. All entry to a permit space is restricted to those with permits
2. Permits shall be available to all employees requiring entry to a confined space that
requires a permit.
3. The permit shall only be extend for the duration of the task but not longer than the
original crew’s shift.
4. The company will retain all permits for a period of one year. The permit program
will be reviewed annually.

VII. Permits will include the following:

•Identification and location of the space
•Purpose of entry
•Date and duration of permit
•List of authorized entrants
•List of authorized attendants
•List of hazards specific to the confined space
•List of measures to isolate, eliminate or control the hazards.
•Acceptable entry conditions
•Results of the test initialed by the person(s) performing the tests
•Rescue and emergency procedures and services and method of communication in case of
an emergency
•Communication procedures for attendants and entrants
•Type of personal protective equipment required to enter the space
•Rescue equipment required
•Additional permits if required (hot work etc)
•Provisions for canceling the permit if conditions are discovered

74
 Cranes, Rigging & Hoists
I. Cranes
1. Rated load capacities, operating speeds, instructions and special hazard warnings
will be posted on all equipment.
2. The boom angle indicator shall be in good working order.
3. An illustration of hand signals for crane and derrick operators will be posted on
the outside of the crane.
4. A competent person will inspect all machinery and equipment prior to and during
use.
5. A thorough annual inspection will be performed by a competent person or agency
recognized by the U.S. Department of Labor.
6. The Supervisor will keep inspection records.
7. Wire ropes will be taken out of service when any of the following occur:
a. Six randomly distributed broken wires in one lay or three broken in one
lay.
b. Wear of 1/3 the original diameter of outside individual wires.
c. Kinking, bird caging or any other damage resulting in distortion of the
rope structures.
d. Evidence of heat damage.
8. Belts, gears, shafts or other moving parts or equipment will be guarded if such
parts are exposed to employees.
1. Accessible areas, that expose employees to injury, will be barricaded in such a
manner as to prevent an employee form being injured.
2. Windows in cabs will be made of safety glass or equivalent and is free of visible
distortion.
3. Ladder and steps leading to cab roof shall be kept in good working order.
4. Platforms or walkways should have anti-skid surfaces.
5. An accessible, approved fire extinguisher will be provided.
6. A person will be assigned to observe the clearance of equipment when operating
under power lines or other overhead structures.
7. A minimum clearance of 10 ft. will be maintained for all power lines. For lines
over 50 kilovolts or higher the clearance will be 10 ft. plus 5 in. for every kilovolt
over 50.
8. No modifications will be allowed without written approval of the manufacturer.
9. No one is allowed to ride the material being hosted.

75
II. Rigging
1. Know the safe working loads of the rigging equipment.
2. Inspect for defects before use.
3. All hooks require safety latches or need to be moused.
4. Only put one eye on a hook.
5. Use shackles if two or more eyes or to be on one hook.
6. Keep hands and fingers from under loads, chokers and slings.
7. Never walk or work under suspended load.

76
 Driving Safety
I. Speed Limits
All traffic laws are strictly enforced and must be observed by our employees on company
business.

II. Vehicle Use

Employee driving on company business must have a valid driver’s license for the class of
vehicle he/she is authorized to operate. If the employee is using their personnel vehicle
for business they must have proof of adequate liability insurance.

III. Responsibility
Each client company has the responsibility to verify that leased employee’s have valid
driver’s license and adequate liability insurance before driving on company business.
The client company also has the responsible for limiting use of vehicles to properly
authorized personnel. Employees who misuse company vehicles are subject to
disciplinary and financial responsibility for any accident.

All employees driving on company business are responsible for reporting any incident or
accident to their Supervisor by the end of that day’s work or as soon as possible. Failing
to follow the reporting guideline could subject the employee to disciplinary action. If the
employee driving is unable to make a report, another employee who knows the details of
the accident must make the report.

IV. General
1. Wear seat belts
2. Obey speed limit
3. Obey traffic signs and signals
4. Do not tailgate.
5. Stay at least two seconds behind the vehicle in front.
6. Pass on left only.
7. Signal before passing.
8. Yield right of way
9. Do not overload vehicle
10. Do not drink and drive
• slows reactions
• blurs vision
• reduces ability to judge distance
• impairs judgment
11. Be cautious at night
• check headlights
• allow more distance
• stop when tired-take break

77
 • try not to stop on side of the road
12. Slow down on wet roads
13. Be careful of large puddles
14. Do not brake suddenly
15. Perform an informal vehicle check before operating.
• lights and signals
• tire wear and inflation
• fluid levels
• secure load
16. _________________________________________________________________
_
17. _________________________________________________________________
_
18. _________________________________________________________________
_
19. _________________________________________________________________
_
20. _________________________________________________________________
_
21. _________________________________________________________________
_
22. _________________________________________________________________
_

78
 Electrical Procedures
I. General
1. Only trained employees will perform electrical work
2. Electric power is to be disconnected before work begins.
3. Connection and junction boxes are to have the proper covers.
4. Label all circuits on panel
5. Light fixtures below 7 ft. must have adequate guarding.
6. All wires should be treated as live wires
7. Turn off power if equipment smokes or sparks
8. _________________________________________________________________
_
9. _________________________________________________________________
_
10. _________________________________________________________________
_

II. Temporary Wiring

1. Extension cords will be the 3 prong type
2. Examine cords before use for cuts frays or bad connectors.
3. Do not drag cords over sharp edges or leave them exposed to traffic areas.
4. Repairs made to cords should be soldered and insulated so the cord retains its
original properties.
5. _________________________________________________________________
_
6. _________________________________________________________________
_

III. Ground Fault Protection

10. Job sites should use ground fault circuit interrupters.
11. GFCI’s are required to be used on all 120 volt, single phase, 15 & 20 amp
receptacles that is not part of the permanent wiring of building.
12. GFCI’s shall be installed when using extension cords.
13. _________________________________________________________________
_
14. _________________________________________________________________
_

79
 Electrical Hazardous Energy Control Program
(Lockout / Tag out)

I. Policy
It is the policy of COMPANY to comply and implement the OSHA regulations
regarding the control of hazardous energy and the proper use of lockout / tag out
procedures. This program is designed to establish the requirements for the control
of any source of hazardous energy, electrical, mechanical, hydraulic, chemical
steam, etc.

The intent of the energy control program is to provide a formal procedure for
disabling machines or equipment in order to prevent injury to employees. This is
accomplished by following procedures for attaching lockout/tag out device(s) to
energy isolating devices, which will prevent the unexpected start-up or release of
stored energy.

II. Responsibility
The Owner or designee is responsible for the following:
A. Support and oversee the lockout / tag out program.
B. With Supervisor and employees identify the tasks and equipment that need
to be locked or tagged.
C. Periodically follow up and audit the lockout / tag out program.

The Supervisor or designated employees will be responsible for the following:

A. Identify and train employees authorized to lockout/tag out equipment or
machinery.
B. Instruct employees whose work operations are in the area or may be
affected by the lockout/tag out procedure.
C. Assist in the establishment of a Hazardous Energy Control Procedure on
each piece of equipment. Complete (PBS form -114).
D. Develop and up-date the Lockout/Tag out Inventory List (PBS form
-113).
E. Follow up and enforce the lockout / tag out procedures.

III. Lockout/Tag Out Procedure

A. Notify affected employees that a Lockout or Tag out is going to be
performed. The authorized person must obtain the proper Hazardous
Energy Control Procedure for the machine/equipment to be locked or
tagged out.
B. Shut down the machine or piece of equipment in accordance with the
listed procedures.
C. Lock or tag out all sources of energy associated with the equipment or
machine.
D. Place a lock or tag out device on each source of energy.

80
 E. Release, disconnect, restrain or otherwise neutralize all stored energy.
F. Verify the machine or piece of equipment is de-energized (operate normal
start-up controls or buttons). Make sure the equipment will not
operate!
G. Return operating controls to off position. The equipment is now ready to
be serviced.

IV. Removal Of Lockout/Tag Out Device

A. Inspect the work area to see non-essential items have been removed.
Replace all guards and insure components of the equipment or machine
are operationally in tact.
B. Insure that personnel are safely away from the machine or piece of
equipment.
C. The authorized employee who attached it can only remove each lock and
tag device.
D. Reconnect power.

V. Employee or Shift Change

A. New employees, or employees on the in-coming shift are to attach their
own locks or tags before operating or proceeding with work. The new
employee is responsible to go through the same procedure as identified in
section IV. Do not assume the equipment is de-energized!

VI. Training
A. The Supervisor or designee is responsible for the following:
B. To train authorized employees prior to their initial involvement in the
lockout/tag out procedures.
C. Train affected employees prior to work assignment.
D. Retrain employees whenever there is a change in job assignment,
equipment or process.
E. Complete all training documentation.

VII. Group Lockout/Tag Out Procedure

A. Conform to all procedures as listed above.
B. Designate one authorized person to coordinate the lockout/tag out
procedure for the group.
C. Each group member must attach his/her individual lock or tag.
D. No employee is allowed to remove another employee’s lock or tag without
proper authorization.
E. Employees will remove their own lock or tag when their part of the
operation is completed.

81
VIII. Definitions
A. Affected Employee-One whose job requires them to operate or use a
machine or piece of equipment on which service or maintenance is being
performed, or work is being done.
B. Authorized Employee-One who locks or tags out a system, machine or
piece of equipment or service, maintain or otherwise work on it.
C. Energy Isolation Device-A mechanical device that physically prevents
the transmission or release of energy, a disconnect switch, line valve,
blocking device etc. Not a push button or selector switch.
D. Lockout Device-A key or combination type positive locking device to
prevent energizing a machine or piece of equipment.
E. Tag-Out Device-A prominent warning device that is securely fastened to
an energy isolating device indication that the device is not to be operated
until the tag-out is removed.

IX. Energy Sources

A. Direct Electrical: Electricity from a direct source such as a
power box, switch or battery.
B. Indirect Electrical: Capacitors or other devices, which store an electrical
charge, will be discharged in a safe manner.
C. Mechanical: Springs or any similar mechanical arrangement where
energy is stored within the machine or piece of equipment.
D. Pneumatic: Pressurized air or gas lines, reservoirs, etc.
E. Hydraulic: Pressurized hydraulic fluids in lines, cylinders, reservoirs, etc.
F. Kinetic: Energy associated with motion produced by physical or chemical
force, pressure, weights or changes in velocity.
G. Thermal: Heat energy stored in a retaining medium, such as hot water in
a storage or holding reservoir.
H. Fluids & Gasses: Stored in such a way that weight and/ or pressure of the
fluid or gas can activate a machine or cause movement in the mechanism.
I. Gravity: Where weight or mechanism is in a raised position, with the
stored potential energy or gravity pulling down and causing activation of
the machine or movement in the mechanism.
J. Other Energy: Any other physical system, arrangement or condition that
has the capacity to store energy that might cause activation of the machine
or movement in the mechanism during repair or maintenance operations.

82
 Lockout / Tag Out

Inventory List

Listed below are the machines or equipment requiring the use of

Lockout / Tag out procedures.

1._________________________________________________

2. _________________________________________________

3. _________________________________________________

4. _________________________________________________

5. _________________________________________________

6. _________________________________________________

7. _________________________________________________

8. _________________________________________________

9. _________________________________________________

10. ________________________________________________

This form supplied by Primary Business Systems LLC PBS-113

83
 Hazardous Energy Control Procedure Form
The following is a step by step procedure for the Lockout / Tag out of
the listed piece of equipment or machinery:

_______________________________
Equipment

1.
____________________________________________________________

2,
____________________________________________________________

3.
____________________________________________________________

4.
____________________________________________________________

5.
____________________________________________________________

The following are the employees that are authorized to perform the
Lockout / Tag out procedure on this piece of equipment.

_____________________________ ______________________________

_____________________________ ______________________________

_____________________________ ______________________________

_____________________________ ______________________________

This form supplied by Primary Business Systems LLC PBS -114

84
 Lockout / Tag Out

Inventory List

Listed below are the machines or equipment requiring the use of

Lockout / Tag out procedures.

1._________________________________________________

2. _________________________________________________

3. _________________________________________________

4. _________________________________________________

5. _________________________________________________

6. _________________________________________________

7. _________________________________________________

8. _________________________________________________

9. _________________________________________________

10. ________________________________________________

This form supplied by Primary Business Systems LLC PBS form-TX RM 113

85
 Excavation (Trenching & Shoring Program)

I. Policy
It is the policy of this company that no employee will enter a trench or excavation until a
competent person determines that the trench is safe for entry. Any trench deeper than 5
ft. must be either sloped shored or the excavation is entirely in stable rock.

II. Definition
•Excavation-is any man-made cut, cavity, trench or depression in the earth’s surface,
formed by earth removal.
•Trench Excavation-is a narrow excavation made below the surface of the ground where
the depth is generally greater than the width. However, the width of a trench as measured
at the bottom is not greater than 15 feet.
•Note: Excavations greater than 20 feet must be designed by a registered professional
engineer and are not covered in this policy.
•Competent Person-is one through experience, testing and/or training is capable of
identifying existing and predictable hazards in the surrounding or working conditions
which could be potentially hazardous to employees. He has the authorization to inspect
and take prompt corrective measures if necessary.

III. General Requirements

1. The Supervisor in charge is responsible for implementation of the requirements
outlined in this program.
2. Prior to opening an excavation, utility companies will be notified so they can
identify the location of utility installations.
3. A stairway, ladder, ramp or other safe means of egress shall be located in trench
excavations that are 4 feet or more in depth. A safe means of egress must be
within 25 feet of each employee working in the excavation.
4. Ladders shall be secured in a manner to prevent movement while in use and shall
extend 3 feet over the trench top.
5. An earth ramp may be considered a safe means of egress only if employees are
able to walk the ramp in an upright manner when entering or exiting the trench.
6. Excavations greater than 4 feet in depth in which oxygen deficient or hazardous
atmospheres could reasonably be expected to exist shall be treated as a confined
space. Atmospheric testing and a confined space permit will be completed before
employees enter such excavations.
7. Excavated soil or equipment must be at least 2 feet or more away from the trench
edges.
8. When excavation operations approach the estimated location of underground
installations, the exact location of the installation shall be determined by safe and
acceptable means.
9. No employees shall be permitted underneath loads handled by lifting or digging
equipment.

86
10. Employees shall not work in excavations where water has accumulated unless
adequate protection has been provided against the hazards posed by the
accumulated water.
11. A competent person shall make daily inspections of the trench, adjacent areas and
protective systems. Inspections will be documented and filed.
• An inspection shall be conducted by the competent person prior to the
start of work and as needed throughout the day.
• After any occurrence that could create a hazard for exposed employees
such as after a rainstorm, the competent person will perform an
inspection.
• If any evidence is discovered that could possibly be a threat to employee’s
health and safety, exposed employees will be removed from the hazardous
area until the necessary precautions have been taken to ensure it is safe to
resume work.
12. Employees are not allowed to work outside the shored areas.
13. Where employees or equipment are required or permitted to cross over
excavations, walkways or bridges with standard guardrails shall be provided.
14. Adequate barrier protection or covers shall be provided after work has been
completed for the day. After completion of the project the trench or excavation
shall be back-filled.
15. The sloping, shield protection and soil classifications will be per the OSHA
standard (CFR 1926.652)
16. The excavation will be cut to a slope of 1 ½ horizontal to 1 vertical or 34 degrees.
A slope of this gradation is considered safe for any type of soil. If the sloping
requirements cannot be met then protection by shoring or trench boxes will be
utilized.

IV. OSHA Soil Classifications

1. Type A-means cohesive soils with an unconfined compressive strength of 1.5 tons per
square foot (tsf) [144 kPa] or greater. Examples of cohesive soils are clay, silty clay,
sandy clay, clay loam and in some cases, silty clay loam and candy clay loam. Cemented
soils such as caliche and hardpan are also considered type A. However, no soil is type A
if:
• The soil fissured or
• The soil is subject to vibration from heavy traffic, pile driving or similar effects or
• The soil has previously been disturbed or
• The soil is part of a sloped, layered system where the layers dip into the excavation
on a slope of four horizontal to one vertical [4H:1V] or greater or
2. Type B
• Cohesive soil with an unconfined compressive strength greater than 0.5 tsf [48 kPa]
but less than 1.5 [1” kPa] or
• Granular cohesion-less soils including; angular gravel (similar to crushed rock), silt,
silt loam, sandy loan and in some cases silty clay loam and sandy clay loam.
• Previously disturbed soils except those which would otherwise be classed as Type C
soil or

87
• Soil that meet s the unconfined compressive strength or cementation requirements for
Type A, but is fissured or subjected to vibration or
• Dry rock that is not stable or
• Material that is part of a sloped, layered system where the layers dip into the
excavation on a slope less steep than four horizontal to one vertical [4H:1V], but only
if the material would otherwise be classified as type B.
3. Type C
• Cohesive soil with an unconfined compressive strength of 0.5 tsf [48kPa] or less or
• Granular soils including gravel, sand and loamy sand or
• Submerged soil or soil from which water is freely seeping or
• Submerged rock that is not stable or material in a sloped, layered system where the
layers dip into the excavation or a slope of four horizontal to one vertical [4H:1V] or
steeper.

88
 Daily Inspection Form
Date/Time________________________ Location ___________________________

Depth___________________________ Supervisor__________________________

Soil Type Stable Rock A_______ B_______ C_______ Other _________________

Slope Ratio- (H: V) ½:1______ ¾:1______ 1:1_____ 11/2:1_____ Other _____________

Shoring OK- Timber___ Hydraulic___ Other___ From OSHA Charts___ Eng. Data_______

Shielding OK- Single____ Stacker____ Sloped to 18” below top if necessary _______________

Barricades and Traffic Control _______________________________________________________

Water Removal ____________________________________________________________________

Atmospheric check if over 4’ deep_____________ Oxygen %___________ LEL%__________

Spoil Pile- Minimum 2 ft. back_______________________ Other ________________________

Comments ________________________________________________________________________
__________________________________________________________________________________

Competent Person Signature_________________________________________________________

89
 Safety Checklist
Job site Yes No
Prior to starting the job, were utilities notified and
Underground services located? ____ ____

Are overhead transmission lines noted and are

precautions taken to avoid contact by cranes, etc? ____ ____

Housekeeping at job site satisfactory? ____ ____

Is material and equipment storage satisfactory? ____ ____

Excavation or Trench
If over 5 ft. deep, is it sloped to maximum allowable
slope, or shored, or is a trench box used? ____ ____

If less than 5 ft. deep, but soil is unstable, is it sloped,

shored or shielded? ____ ____

If shoring system inspected daily by a competent person? ____ ____

If necessary to use a pump, is it placed downwind from

the excavations? ____ ____

Exits
If trench is 4 ft. or more in depth, is a ladder, ramp or
steps provided? ____ ____

Are they located to require no more than 25 ft. of

lateral travel? ____ ____

Are secured at the top? ____ ____

Do they extend from the floor of the trench to 3 ft. above

the top of the excavation? ____ ____

Are ladders in good condition? ____ ____

Completion of Job
Is trench back filled as the shoring is dismantled? ____ ____

Is shoring removed from the bottom up and are jacks

and braces removed slowly? ____ ___

90
 Excavation
General
1. Contact local utility companies to locate lines prior to beginning excavation.
2. For trenches 4 ft. or greater a ladder or ramp will be provided and accessible
within a distance of no greater than 25 ft.
3. The atmosphere will be tested in trenches when the potential of a hazardous
atmosphere exists.
4. Barricades and warning devices will be installed to alert equipment operators,
pedestrians and/or other employees of the trench hazard.
5. A competent person will supervise each job site involving trenching.
6. Sloping and benching of trenches will follow the guidelines set forth in OSHA
1926 subpart P.
7. Spoils or loose material will be stacked a minimum of 2 ft. away from the edge of
trench.
8. _________________________________________________________________
_
9. _________________________________________________________________
_
10. _________________________________________________________________
_
11. _________________________________________________________________
_
12. _________________________________________________________________
_

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 Fall Protection Program
I. Policy
It is the policy of COMPANY to comply with the OSHA Fall Protection Standard
and to provide safe work practices to prevent falls in the work place. It is our
policy that employees on a walking or working surface with an unprotected side
or edge which is 6 feet or more above a lower elevation shall be protected from
falling by the use of guardrail systems, safety nets or personal fall arrest systems.

Due to the potential consequences of a fall, the company will strictly enforce the
following requirements. If an employee or Supervisor violates these requirements
they shall be subject to disciplinary action up to and including discharge.

II. Responsibilities
The Owner is responsible for ensuring that the fall protection program is
implemented according to these policies and procedures. The Owner with his
staff will be responsible to periodically evaluate and update the program.

Supervisor will be responsible for the following:

• Train employees in the fall protection requirements.
• Continually evaluate job site hazards and update policies and procedures.
• To provide the proper fall protection (guardrails, nets or personal fall arrest
system).
• To consistently reinforce and enforce the fall protection policies and
procedures

II. Fall Protection Systems Criteria & Practices

1. Guardrail Systems
Guardrails will be used on all walking or working surfaces above 6 ft. in
height. When guardrails cannot be used or are not present for a particular
work site other personal fall arrest systems will be required.

The following are the requirements when using guardrail systems:

1. The top rail should be no less than 42 inches in height above the
walking or working surface. A midrail shall be installed halfway
between the top rail and working surface (approx. 21 inches). A
toe board shall be installed at the base of the working surface.
2. Guardrail systems shall be capable of withstanding a force of no
less than 200 lbs. Applied within 2” of the top rail, in any outward
or downward direction.
3. Mid rails, screens and vertical members should be able to
withstand at least 150 lbs.
4. Guardrail material should be made of smooth material.
5. The ends of guardrails should not overhang the vertical posts.
6. Steel and/or plastic banding is not acceptable top rail material.

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7. If wire rope is used it shall be flagged at no more than 6ft intervals
with high visibility material.
8. All vertical posts should be no more than 8ft apart.
9. When guardrails are used around points of access, they shall have a
gate or be offset so that a person can walk directly into the hole.
10. When guardrails are used at floor openings they shall be guarded
on all four sides.
11. When guardrails are used at hoisting areas, a chain, gate or
removable guardrail section shall be placed across the access
opening between the guardrail sections when hoisting is not in
place.
12. Guardrails used on ramps and runways shall be erected along each
unprotected side or edge.

2. Safety Nets
Safety nets are another form of fall protection but rarely used in our
industry. If the situation would arise a competent person would be hired to
design and install the system.

3. Covers
Covers shall be designed to prevent workers from falling through a hole or
opening.
1. All holes are to be covered if any gap or void exists of 2 or more
inches on a floor, roof or any other working surface.
2. All covers shall be capable of supporting at least twice the weight
of employees, equipment, materials or vehicles to cross cover.
3. All covers shall be secured as to prevent accidental displacement
by wind, equipment or employees.
4. Each cover shall be marked with the Hole or Cover in large easy to
see letters or color-coded to provide warning of the hazard.

4. Personal Fall Arrest System

The fourth method of fall protection is the personal fall arrest system.
This system shall be used and specifically designed to protect workers in a
free fall situation. Anytime employees are exposed to falls above 6 ft.
without whole covers or guardrails the personal fall arrest system will be
used.

1. Full Body Harness

• A full body harness shall be used in all situations. A body belt
is not an acceptable alternative.

2. Lanyards
• They shall be connected to the anchor point and attached to the
full body harness between the employee’s shoulder blades.

93
 • The lanyard shall not be used for any purpose other than the
personal fall arrest system. Do not use it to hoist or tie
materials of any kind.
• The lanyard shall be inspected each time before use.
• If a lanyard is subjected to impact caused by a fall, it shall be
immediately removed from service.
• Two lanyards shall be in use at all times. Hook the second
lanyard before removing the first.
3. Snap hooks
• Snap hooks shall be double locking and made of smooth
corrosion resistant steel.
• All company employees shall prohibit non-locking snap hooks
for use.
• When using snap hooks, employees shall ensure to only attach
snap hooks to Dee-rings or the anchor point.
• The standard rule is one snap hook per Dee-ring and use
compatible hardware to prevent rollout.
• Snap hooks and Dee-rings are to be the same size and made by
the same manufacturer.
• Employees should always check the connection each time to
ensure everything is in good working order.
4. Anchorage point
• The anchorage point shall be a solid unmovable object that can
support up to 5,000 pounds per employee.
• Anchorage points that must support anything else, like a
platform, scaffold or platform shall never be used.
• Lanyards shall be anchored so that they employee can fall no
more than 6 ft.

94
 Fire Protection & Prevention
I. Fire Extinguishers
1. Class A Fire-Ordinary combustible fires caused by cloth, paper, trash, wood etc.
(recommended extinguisher-water, soda acid, carbon dioxide)
2. Class B Fire-Flammable liquids, oils, grease etc. (recommended extinguisher-
carbon dioxide, dry chemical and foam)
3. Class C Fire-Electrical type fire- (recommended extinguisher-non conducting
agent such as carbon dioxide and dry chemical)
• Signs need to be posted above fire extinguishers
• Extinguishers should be inspected at least monthly and serviced by a qualified
person annually and/or after use.
• There should be a minimum of a 2A-rated extinguisher for every 3000 square feet of
building space.
• Fire extinguishers should be located within 100 feet of workers
• A minimum of one 2A fire extinguisher at the top of each stairway
• A fire extinguisher not rated less than 10B should be provided within 50 feet
of 5 gallons or more flammable/combustible liquids.

Locations of Fire Extinguishers Type Required

1. ____________________________________________
_____________________

2. ____________________________________________
_____________________

II. Exits should be clearly marked, unobstructed and unlocked

III. Temporary Heaters

1. Need adequate ventilation
2. Solid fuel salamanders and barrel fires are prohibited in buildings.
3. Heaters are to be kept at least 10 feet away from combustible material.
4. Heaters should not be left unattended

IV. General
1. Familiarize employees with location of fire fighting equipment.
2. The use of open fires is prohibited unless specifically authorized.
3. Only approved solvents should be used for cleaning and degreasing.
4. All flammable liquids must be kept in approved containers.
5. Hot work near a pit, sewer, drain, manhole, trench or any area containing potential
combustibles requires a hot work permit.
6. Outdoors fuel storage area are to be properly graded, curbed or diked and
protected from possible danger of vehicle traffic.

95
7. A minimum of a 20B extinguisher is to be located within 75 feet of outside
storage facilities.
8. Emergency Phone numbers are posted in easily accessible areas.

96
 Forklifts
I. Personnel
1. Only qualified and licensed employees will be allowed to operate.
2. No riders will be allowed.
3. Forks are not to be used as an elevator or work platform.
4. No person shall be allowed to stand or pass under the elevated portion of the fork
truck.

II. Operation
1. Arms and legs must be kept inside while operating.
2. When fork truck is left unattended the forks must be fully lowered, power shut off
and brakes set.
3. A truck is considered unattended when it is out of the operator's view or when
farther than 25 feet away.
4. Trucks should not be used for opening freight doors.
5. A load backrest extension must be used when necessary to prevent the load from
falling rearward.
6. Back downgrades when carrying load.
7. Drivers must slow down and sound horn at intersections and pedestrian crossways
that have obstructed view.
8. Railroad tracks must be crossed diagonally.
9. Secure duckboards or bridge plates before driving over.
10. Verify load does not exceed rated capacity.
11. A safety inspection is to be performed each day or at the beginning of each shift.
12. _________________________________________________________________
_
13. _________________________________________________________________
_

97
 H2S (Hydrogen Sulfide)
Invisible…Explosive…Flammable…Deadly

Properties and Characteristics

H2S smells like rotten eggs at low concentrations, however, don’t trust your sense of
smell to warn you because:

• Other chemical odors can hide or mask the smell of H2S

• With continued exposure, your ability to smell will become paralyzed. Then, you
could make the mistake of thinking that no rotten-egg smell means no H2S, and
more critical symptoms could develop
• H2S is heavier than air, so it collects in low-lying areas

Effects of Exposure and Exposure Limits

Breathing H2S is the most dangerous route of exposure. But how you are affected
depends on the concentration you’re exposed to and the length of exposure. To help
avoid severe effects, OSHA has established exposure limits:

• Permissible Exposure Limit (PEL) – The PEL for hydrogen sulfide is 10ppm.
This is an amount you can safely breathe, based on an eight-hour day over a five-
day workweek.
• Short-Term Exposure Limit (STEL) – The STEL for hydrogen sulfide is 15ppm.
This is how much you can safely be exposed to averaged over a 15-minute period.
The STEL should be checked four times a day, when your risk is likely to be the
greatest.

Engineering Controls

Engineering controls are another measure OSHA requires your employer to take in
ensuring your safety. The most widely used engineering control is ventilation, either
natural or mechanical.

1. Natural Ventilation comes from normal airflow. If you are relying on natural
ventilation, remain alert for the safest way to escape by noting which way
windsocks, streamers, and flags are blowing. This is called being “wind
conscious”.
2. Mechanical Ventilation is common in confined spaces where only fans and
blowers can move air. But do not become too comfortable knowing fans and
blowers are ventilating your workspace. If you suspect H2S, evacuate the area
immediately.

98
Personal Protective Equipment (PPE)

Three types of personal protective equipment (PPE) are used by workers at risk of
exposure to hydrogen sulfide:

1. Escape Units: completely self-contained, equipped with an air cylinder rated for
(5) five minutes, used only to escape from (NOT ENTER) a hazardous area.
2. Air-Line Units: have an air-line or hose that supplies air during normal use,
equipped with a self-contained emergency-escape air cylinder in case the air-line
supply fails.
3. Self-Contained Breathing Apparatus (SCBA): have an air cylinder rated for (15)
fifteen or more minutes, the most flexible because they allow you to move from
area to area, even if you have to disconnect from the air-line supply, equipped
with devices that warn you when approximately (5) minutes of air remain.

Respiratory Program

This program will follow the respiratory standards set by OSHA and the American
National Standards Institute (ANSI). Each year, your employer should train you to use
respiratory protection. This training will include fit testing, proficiency drills,
maintenance programs, and medical surveillance.

• Fit Testing – ensures that your respiratory equipment is properly adjusted, if you
wear glasses, get fitted with a facepiece spectacle kit, which will allow room for
you to wear your glasses under the facepiece (DO NOT WEAR BEAR OR
SIDEBURNS).
• Proficiency Drills – will help you know how to wear and use respiratory
protection and air monitoring equipment properly.
• Maintenance Programs – will help ensure that you know how to take care of your
respiratory and air monitoring equipment.
• Medical Surveillance – will help make sure that you do not have a health
condition that would: be aggravated by exposure, prevent you from wearing your
PPE, or keep you from escaping in an emergency. It should help you recognize
any of the early symptoms caused by exposure on you or your co-workers.

Emergency Procedures

There are four steps to follow if you are in the immediate area of danger:

1. Hold your breath

2. Move upwind or crosswind and away from the gas
3. Put on appropriate PPE
4. Assist anyone in distress and move to a pre-determined safe assembly area

99
Always follow company policies and procedures for escape and rescue. Before
attempting to rescue anyone else: protect yourself first (don’t become another victim), put
on appropriate PPE before attempting rescue, and use the buddy system (don’t attempt to
rescue anyone alone, always proceed in pairs whenever possible). After taking these
precautions, lift or drag the person to an upwind area. Use caution if the victim has
fallen, as the victim may have suffered neck or spinal injuries. Use your portable H2S
monitor to ensure the area is clear before removing your mask. If you are not trained in
first aid, alert supervisory personnel and activate the Emergency Response System.

100
 Hazard Communication Program
I. Policy

It is the policy of this company to comply with the Hazards Communication

Regulation, thus ensuring that our employees and others are made aware of, and
properly trained in, the safe use of hazardous substances which they may come in
contact with prior to their starting to work with these chemicals. The specifics of
the program are outlined below.

This will be accomplished by compiling a hazardous substance list, by

maintaining and using Material Safety Data Sheets (MSDS), by ensuring that
containers are properly labeled, and by providing training to employees and others
involved with our organization.

II. Responsibilities

The Program Coordinator, the Owner, or designee, will be responsible for the
administration of the Hazardous Communication Program. He will be responsible
to develop, update and oversee the implementation of the guidelines outlined in
this program.

The Supervisor will be responsible for the identification of hazardous chemicals

brought onto the job site and verify the corresponding MSDS information is
communicated and understood by employees.

III. Chemical Inventory Lists

The first step in the program is to compile and list all hazardous or potentially
hazardous chemicals. This list will be used to gather the associated MSDS sheets.
The list is to be updated as new chemicals are purchased and introduced to the job
sites.

The Supervisor is responsible to include and update the inventory list for any
chemicals brought onto the job site. He should inform the program administrator
of any changes.

The employees are responsible to advise the Supervisor when a chemical is

introduced in which they are unfamiliar.

IV. Material Safety Data Sheets (MSDS)

The Supervisor is responsible to have the MSDS sheets associated with the
hazardous chemicals used or to be used on each job site. The Supervisor is also

101
 responsible to verify that each employee understand and comply with the
precautions as outlined on the MSDS.

The employee is responsible to understand and follow the handling and exposure
control guidelines as listed on the MSDS. No employee shall handle any
chemical in which they are unfamiliar!

The information contained in the MSDS is outlined in the employee training

section.

V. Purchasing

Hazardous chemicals, any chemical, brought onto the workplace need to be

accompanied by a MSDS if one is not already on file. It is the responsibility of
the person purchasing the material to see the proper MSDS is delivered with the
hazardous chemical.

It is the responsibility of each supplier to supply a MSDS with each shipment.

Remind the supplier to send the MSDS when purchasing chemicals.

VI. Container Labeling

All chemicals should be in their properly labeled containers. The only exception
would be small quantities for immediate use. After use, the product should be
returned to the original container or be properly disposed of. No chemicals will
be left unattended in unmarked containers!

VII. Employee Training

Employees exposed to hazardous chemicals will be trained and informed

whenever a new hazard is introduced or before an initial assignment. Employees
are to be trained in the following:

A. The location of the Hazard Communication Program, the chemical

inventories list and the corresponding MSDS.
B. The purpose of and how to read and understand the Material Safety Data
Sheets.
1. Manufactures name, address, an emergency telephone number
and the trade name of the product.

2. Hazardous Ingredients Identity Information-this section

describes the chemical composition of the product, common
names, PEL, TLV and usually the percentage of each component in
a mixture.

102
 3. Physical/Chemical Characteristics-This section describes the
physical characteristics of the substance, such as: boiling point,
solubility or ability to mix in water and/or its appearance and odor.
4. Fire and Explosion Hazard Data-This section describes the risk
of fire or explosion, equipment necessary to extinguish a fire, fire
fighting procedures and unusual hazards of the substance.
5. Reactivity Data-This section lists materials to keep away from the
substance and the potential result if the two come in contact with
each other.
6. Health Hazard Data-This section describes exposure limits when
using the product, how long you may work with the substance
without ill effects. It also describes the proper emergency and first
aid procedures if exposed.
7. Precautions for Safe Handling and Use -This section describes
special precautions and appropriate procedures in case of a spill. It
may also describe emergency first aid treatment for injuries caused
by the substance.
8. Control Measures-Proper procedures and equipment will be listed
for the safe handling and storage of the substance. Appropriate
safety equipment will also be recommended.
C. The safe work practices associated with the various substances used on the
job site or office location.

VIII. Personal Protective Equipment (PPE)

The MSDS information includes the types of personal protective equipment

required when working with or exposed to hazardous chemicals.

COMPANY will provide the required PPE as listed on the MSDS. It is company
policy that each employee or exposed person follow and adhere to the
requirements as listed.

The Supervisor is responsible to see the required PPE is made available and
properly used when the potential of a hazardous exposure exists.

IX. Hazards of Non-Routine Tasks

The Supervisor is responsible to inform employees of special or non- routine

tasks, which could involve possible exposure to hazardous chemicals. Review of
the safe work practice and the PPE required should be conducted prior to the start
of such tasks. Sometimes it may be necessary to post or mark off hazardous
areas.

103
X. Emergency Response

Any unintentional, unexpected, non-routine and/or uncontrolled event that involve

a hazardous substance may constitute an emergency situation.

It is the policy of COMPANY that the safety of employees not be jeopardized in

the protection of property or equipment.

A. Immediately notify the appropriate personnel in the event of a hazardous

chemical spill or overexposure. The information needed for an emergency
response can be found on the container label or MSDS.

B. Personnel should evacuate the area as soon as any danger to health and
safety becomes apparent.

C. Measures that can be taken to lessen the emergency, without endangering

personnel, should be implemented. This could include closing a valve, up
righting a container, and shutting doors, moving equipment and/or other
chemicals to a safe distance.

D. Formal shut down procedures for processes, equipment or operations

should begin if it can be accomplished without endangering personnel.

E. Personnel should not attempt to clean up or dispose of any hazardous

substance(s) that have been leaked or spilled. Contact the Program
Administrator for proper instructions.

XI. Informing Other Employees

The Supervisor is responsible to inform contractors, visitors and/or others of the

hazards to which they may be exposed while in the work area.

The Supervisor is responsible to provide employees with MSDS information on

hazardous chemicals used by outside contractors where the possibility of exposure
exists.

The employee is to notify the Supervisor if they suspect exposure of to a

hazardous chemical used by an outside contractor.

XII. Posting

The Supervisor is required to post information about the Hazard Communication

Program/Standard on the job site. A copy of the poster and contents are included
at the end of this section.

104
 COMPANY Has a Written Hazard
Communication Program
(In compliance with OSHA 1926.59 & 1910.1200)

In accordance with the standard the following

items are available upon request

1. Copy of the company Written Hazard Communication

Program.

2. Copy of the OSHA Hazard Communication Standard

3. Copy of the company’s List of Hazardous Chemicals

4. Copies of the Material Safety Data Sheets for chemicals

used to which employees may be exposed.

To obtain any or all of the above information contact

your supervisor

105
The Material Safety Data Sheet Collection for
hazardous chemicals at this job site is located at:

____________________________________

The Written Hazard Communication Program for

this job site is located at:

____________________________________

The Hazardous Chemical List for this job site is

located at:

____________________________________

Questions regarding chemicals, chemical handling or

health and safety should be directed to:

____________________________________

106
 Material Safety Data Sheets Chemical
Inventory List

The following is a list of hazardous chemicals used in this work place. The
corresponding MSDS can be found in the MSDS section of this manual.
Further information on these or other components of the program can be
obtained from the Supervisor and/or Program Administrator.

MSDS No. Chemical Name

1. _________________________________

2. _________________________________

3. _____________________________

4. _________________________________

5. _________________________________

6. _________________________________

7. _________________________________

8. _________________________________

9. _________________________________

10. _________________________________

107
 Employee Hazard Communication Training
Certification

I, _________________________________, have been provided the

following information:

• Names of hazardous chemicals to which I may be exposed while in

the work place

• Measures to lessen the possibility of exposure

• Location of MSDS for all hazardous chemicals

• Procedures to follow if I am exposed

• The safe work practices and required PPE for the specific chemicals
used

Signed: ________________________________ Date __________

Signature of employee

Presenter/Trainer ______________________ _______________________

Print signature

108
 Hearing Conservation Program

I. Policy
It is the policy of this company that all employees be protected from noise exposure
through the following hearing conservation program. Where feasible, administrative or
engineering controls will be used to reduce employees’ exposure to noise at or below an
eight-hour time weighted average of 85 decibels. When administrative and or
engineering controls are not feasible, hearing protection such as earplugs or muffs will be
required.

II. Employee Monitoring

Based on an industrial hygiene evaluation the following areas and job assignments will
require the listed hearing protection. Additional jobs and areas will be added whenever
exposures are expected to change. All sound levels between 80 and 130 decibels will be
included in the noise measurements.

Area Required Hearing Protection

• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Jobs/Tasks Required Hearing Protection

• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Employees in the above job positions or those who perform any of the above tasks will be
included in the Hearing Conservation Program.

Areas or equipment that usually require hearing protection:

• Grinders, power tools cutoff saws etc.
• Air compressors
• Jack hammers
• Compressor rooms or areas
• Diesel engines
• Heavy Equipment
• Sand blasting

109
 III. The objectives of this programs
1. To insure that employees will not be exposed to noise levels at or above 85db
without approved hearing protection.
2. To identify hazardous noise areas and sources through appropriate monitoring
surveys.
3. To educate and train employees in the hazards of noise exposure and how to
properly protect themselves against potential exposure.

IV. Responsibilities
The Owner and Supervisor are responsible to identify high noise exposure areas and
will hold management accountable for the implementation and compliance with
COMPANY hearing conservation program.

The Supervisor is also responsible to provide the proper hearing protection to each
employee under his supervision. Train employees in the proper use and care of the
provided hearing protection. Consistently enforce the requirements of this policy with
all employees.

The Employees are responsible for:

• Complying with the guidelines of the hearing conservation program.
• Use the provided hearing protection where required.
• Notify supervision when conditions or practices change and result in increased noise
levels.

IV. Audio-metric Testing

Annual audio-metric testing will be performed on affected employees by _____________
___________________________, who will review all audiograms and refer employees
with questionable audiograms to ________________________________.

New employees in the job positions listed above will be tested within the first 90 days of
employment. Exposure to noise will be minimized for 14 hours prior to testing.

If a standard threshold shift (an average shift in either ear of 10 dB or more at 2000,
3000, or 4000 Hz) is identified the following will occur:

• The employee will be notified of the threshold shift within 21 days of testing.
• The employee will be informed of the need for further evaluation if a medical
problem is suspected.
• The use of hearing protection will continue to be enforced.
• The employee will be refitted or retrained in the use of hearing protection.

V. Training
Employees will be trained on an annual basis in at least the following:
1. The importance of a hearing conservation program
2. The effects of noise on hearing

110
3. Selection, fitting, use and care of hearing protection equipment.
4. The various types of hearing protection.

VI. Care & Inspection

• Only the person to whom they were issued shall use insert type earplugs.
• Disposable type earplugs shall not be used for more than one week.
• All other insert type plugs will be cleaned at least weekly with a solution of mild
soap and warm water or follow specific manufacturer recommendations.

VII. Record keeping

1. Audiometric test records will be retained for the duration of the affected employees’
employment at COMPANY.
2. All records shall be provided to employees at their request

111
 Housekeeping

Housekeeping Requirements

Housekeeping is a priority at this facility. All employees have a duty to keep their
workstations clean and are expected to follow all housekeeping rules.

1. All employees will be reminded of the housekeeping requirements of this facility

through periodic safety meetings, memos, bulleting board, and any other means available.

2. Dispose of trash or scrap materials from job tasks and any other disposable
materials left over immediately upon finishing the task or shift. Leave your workplace
clean and orderly.

3. Immediately report any conditions which present a safety or health hazard,

especially those that are persistent or continuous.

4. Return tools and equipment to their storage place immediately after using them.
All tools and equipment will be cleaned and in good condition when stored. Any tools or
equipment in need of repair will be tagged and sent for repairs or replacement as needed.

5. Never use empty food containers for any other purpose. Chemicals should never
be put into food containers under any circumstances. Dispose of empty food containers.

6. All paths to doorways, the doorway itself, and paths leading away from doorways
must be kept free of obstructions. Do not stack equipment or supplies near doorways.

7. Floors must be kept clean and dry to the extent the nature of the work and
environment conditions allow. Where wet processes are used, drainage must be
maintained and false floors, platforms, mats, or other dry standing places should be
provided wherever practical. Mud scrapers and mats should be used to clean shoes from
mud and other debris before entering buildings or entering a place where such debris may
contribute to a slip/trip/fall accident. All spills should be promptly cleaned up and the
clean-up materials should be disposed off properly.

8. Covers used to guard holes and openings must be securely fastened and strong
enough to withstand any load placed upon them. They must be in place when the hole or
opening is not in use.

9. _________________________________________________________________
_

10. _________________________________________________________________
_

112
113
 Manual Lifting Procedures

The following are the rules and procedures for proper lifting at COMPANY.

Safe lifting is a critical part of your job and everyday personal activities. Practicing safe
lifting techniques when at work is a condition of employment.

Before you lift anything, think about the load you shall be lifting. Ask yourself; is it too
heavy? Can I lift it alone or do I need help?
• Size up the load-make sure load is stable and balanced.
• Plan the job-plan a route free of tripping and slipping hazards. Think through the lift
and face toward the direction that you plan to go. Use mechanical devices where
possible.
• The base support is Firm Footing with shoulders width feet apart, a staggered stance
and one foot slightly behind the other.
• Bend at the Knees not the waist. Bend down as far as possible using legs and back.
• Get a good grip-use whole hand not just the fingers.
• Keep the load close to your body. The closer it is to the spine the less force it puts on
the back. Ten pounds at arms length is like lifting 100 lbs.
• Lift with the legs not the back.
• Lift smoothly
• Pivot, don’t twist
• Carry the load using short steps with feet far enough apart to maintain good balance.
• Lower slowly by flexing the knees and hips. Do not bend at the waist after releasing
the load; straighten up using the legs.
• When possible push instead of pull. Lean into the object and let the body weight and
thigh muscles do the work.

_______________________________________________________________________
_

_______________________________________________________________________
_

_______________________________________________________________________
_

_______________________________________________________________________
_

114
 Mechanical Guarding
Purpose and Scope

Mechanical guarding must encompass both the power transmission parts of all
mechanical equipment and the points of operation on production machines.

Guards must be provided where rotational motion, nip points, cutting, shearing, punching
and forming mechanisms can cause injury to personnel or damage to tools and
equipment.

Mechanical guards must be designed or otherwise procured to meet the following

specification:
•The guard must provide positive protection equal to that specified in ANSI B15.1.
•The guard must be considered a permanent part of the machine or equipment, capable of
being easily or quickly removed or replaced.
•The guard must not interfere with efficient operation or maintenance of the machine or
give discomfort to the operator.
•The guard must not weaken the machine structure.
•The guard must be designed for a specific job and a specific machine.
•The guard must be durable, easily repaired, resistant to fire and corrosion.
•The guard must not present hazard in of itself, such as rough edges, splinters, pinch
points or sharp corners.

Methods of guarding that must be considered include the following:

1. Enclosing the point of operation.
2. The use of interlocking devices.
3. Installing and using moving barriers.
4. Devices that remove the hazard from the area of the point of operation.
5. Use of remote control operating devices.
6. Devices that require two-handed operation to operate the equipment.
7. The use of electronic safety devices.

Machine designed for fixed locations must be securely anchored to the floor or bench to
prevent walking or tipping. Employees may operate machinery only when properly
trained and authorized to do so. Proper clothing and personnel protective equipment
must be worn when specified by laws, work rules, Supervisor or shop foreman.

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 Office Safety
I. General Hazard
When we hear about “on-the-job” hazards, we usually picture a factory or construction
site. A surprising number of accidents occur every day in the office environment.

II. Goals
Goals of the COMPANY’s Office Safety Program:
•To create an understanding of some of the potential office hazards.
•To equip employees to readily identify and correct those hazards.
•To reduce accident in the office environment.

III. File Cabinets

• File cabinets should be arranged side by side and bolted together.
• Do not overload upper drawers.
• Close when not in use.
• Do not stack 2 drawer cabinets unless they designed to be stacked and fastened.
• Do not leave open drawers unattended

IV. Furniture
• Check for sharp burrs, splintered edges broken casters and seats.
• Do not use chairs or desks in place of ladders.

V. Printers & Copiers

• Avoid touching the heated parts.
• Be aware of the sharp edges inside the machine
• Close the cover when copying. Avoid looking directly into intense light.
• Never stick metal object into a machine

VI. Laptops and PCs

Over the years PCs have revolutionized the work world. Many task are easier. However
PCs require us to use concentration and precision. Work is visually “close-up”. Calling
for prolong use of hands, wrist and figures. By spending long hours in front of a PC can
cause physical problems, including eyestrain, stress in the back, neck and shoulder
muscles, plus strain on the lower arms and wrists. What can we do?
•We can learn to fine-tune our bodies.
•Adjustment to the workspace can be made easily to ease the stress on our muscles.
•Small changes can make big differences in comfort, productivity and job satisfaction

VII. General
1. Remove staples with puller.
2. Never overload paper cutters or shredders
3. Keep paper cutters in closed and latched position

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4. Pass scissors handle first
5. Keep razor knife or box cutters in the closed position.
6. Do not keep pointed objects in upright position
7. Never throw broken glass into waste basket
8. Follow label precautions when handling solvents and cleaners
9. Avoid storing heavy objects (paper, manuals etc) above eye level.
10. Do not attempt to make electrical repairs
11. Watch for extension, telephone, computer cords and other tripping hazards.
12. Do not stand or talk in front of closed doorways.
13. Do not attempt to fix, clean or adjust power driven office machines when in
motion.
14. Keep ties and loose clothing or jewelry out of shredders
15. Electric heaters should be turned off before leaving office.
16. Report slippery or wet floor surfaces.
17. Use dollies and similar equipment to move large or heavy items.

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 Personal Protective Equipment / Hazard Assessment
Program
I. Policy
It is the company’s goal to protect all employees from workplace injury and illness
through engineering controls and safe work practices. Sometimes, additional protection
may be required in the form of Personal Protective Equipment.

All employees shall follow the published guidelines concerning the requirements of this
program. Failure to use the required personal protective equipment shall result in
disciplinary action. Questions about safety protection should be brought to the Owner’s
attention and resolved before the job is started. If you have any question about the job at
hand STOP and ASK!

II. Hazard Assessment

A. Before personal protective equipment (PPE) is
selected a hazard assessment shall be performed on all
jobs and tasks that may require the use of various types
of PPE. If hazards or present of likely to be present,
COMPANY shall:
• Select the type of PPE that will properly protect the employee
• Require the employee to use the PPE
• Communicate selection decisions to each affected employee

B. COMPANY shall verify the hazard assessment has been performed through a written
certification. The certification shall:
• Identify the workplace where the assessment was performed
• Name of the person(s) that performed the assessment
• Date the assessment was performed
• Be written on a hazard assessment form (form ASI-)

C. The company will provide training to each employee who is required to use the
selected PPE. Each employee shall be trained in the following:
• When PPE is necessary
• What PPE is required
• How properly wear the PPE
• Limitations of PPE
• Proper care, maintenance, useful life and proper disposal of PPE
• Each employee shall demonstrate an understanding of the training provided
• Demonstrate the ability to properly use the PPE
• All training will be documented on a safety meeting form or similar type form. The
form should list the date, person trained, topic and trainer.

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D. Retraining will be required when the Owner or Supervisor has reason to believe the
employee does not possess the proper skills required to use the PPE. Retraining will also
be required when:
• There are changes in the workplace that render previous training obsolete
• Changes in PPE that render previous training obsolete

In addition to the written hazard assessments the following is a summary of what types of
PPE is required and when they are to be used.

II. Head Protection

Head protection shall be worn whenever the possibility exists for overhead hazards,
falling objects, electric shock or flying debris.

All head protection shall meet the ANSI specifications Z89-.1-1986 either class A, B, &
C.

Hard hats will be required and used in the following situations and/or locations.
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

III. Eye & Face Protection

Safety glasses are required on any job site where the potential exists of hazards to the
eyes and/or face. All safety glasses are to ANSI type Z87. Regular sunglasses do not
meet ANZI requirements. Eye protection for employees who wear corrective glasses
must be one of the following:
• Approved safety glasses which have prescription lenses
• Safety goggles worn over regular corrective glasses
• Safety goggles with corrective lenses behind the protective lenses

Contact lenses do not provide eye protection and their use without appropriate eye or face
protection will not be permitted in hazardous environments.

When working with chemicals employees are required to follow the PPE guidelines as
listed on the product’s Material Safety Data Sheet.

Below are some examples of when it will be necessary to wear additional protection.
Job/Task Type Required
• _________________________________
___________________________________

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• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

IV. Hearing Protection

Refer to the hearing conservation program for more detail. Hearing protection is to be
used in the following areas:
Job/Task Type Required
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

V. Hand & Trunk Protection

Gloves should be used in the following situations:

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 Job/Tasks Type Required
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

VI. Trunk Protection should be used when performing the following:

• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

VII. Foot & Leg Protection

• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

VIII. Fall Protection will be used when performing the following:

• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

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IX. Respiratory Protection
Job/Tasks Type Required
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

X. General PPE Requirements

• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________
• _________________________________
___________________________________

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 Power & Hand Tools
I. General
• Tools should be inspected before use
• Tools should be neatly stored when not in use
• Broken or defective tools should be properly tagged
• Use proper tool for job
• Power tools should be unplugged before servicing
• Guards are to remain in place
• No moving parts should be exposed (belts, shafts, gears, pulleys and sprockets)
• Proper PPE is required appropriate for the job
• Chisels and impact tools should be free of mushroomed heads
• Tools with wooden handles are to be kept tight in tool and free from splinters
• Do not carry sharp or pointed objects in pockets
• Never hold work in hand when using screwdriver
• Do not use screwdrivers for chisels or pry bars.
• When using wrenches always pull the wrench toward you.
• Stand to the side when using wrenches above your head.
• Power hand tools are not be hoisted from the cord.
• Adjustments should not be made to power tools while tool is connected.

II. Power Actuated Tools

• Employees will be properly trained
• All defective tools should be immediately removed from service.
• Caution should be used when shooting pins into hard, brittle or easily penetrated
materials.
• Tools are not to be used in explosive or flammable atmosphere.
• Goggles and/or face shields are to be worn.
• Tools and charges shall be properly secured.
• ____________________________________________________________________
• ____________________________________________________________________
• ____________________________________________________________________
• ____________________________________________________________________

III. Woodworking Tools

• Fixed woodworking tools shall be installed with a switch that can be either tagged or
locked in the off position.
• Manufacturer installed safety devices shall be kept in place unless the equipment is
locked out for repair.
• ____________________________________________________________________
_

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• ____________________________________________________________________
_
• ____________________________________________________________________
_

IV. Abrasive Wheels & Tools

• Guards and safety devices are never to be removed.
• Work rests on stationary grinders should be no more than 1/8 in. from the grinding
wheel.
• Grinding wheels should be inspected for cracks or deformities and designed for the
proper use.

V. General
1. _________________________________________________________________
_
2. _________________________________________________________________
_

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 Respiratory Protection Program
I. Policy
Where effective engineering controls are not feasible to control breathing air
contamination such as harmful dusts, fumes, mists, gases or oxygen deficient
atmospheres, respiratory protection equipment shall be used to control exposure.

No employee shall be work in a contaminated or oxygen deficient atmosphere without

proper engineering controls or respiratory protection equipment.

The purpose of this program is to establish minimum operating procedures governing the
selection and use of respiratory equipment for all employees in tasks where such
protection is required.

This program covers all of the COMPANY employees. A contractor program may be
substituted for the company’s program, provided the contractor’s program is equivalent to
the company’s written Respiratory Protection Program and/or meets or exceeds the
minimum requirements of 29 CFR 1910.134, respiratory Protection Standard for General
Industry.

II. Responsibilities
A. Owner. The Owner is responsible for ensuring that the Respiratory Protection
Program is implemented according to these written policies and procedures.

B. Supervisor. The Supervisor shall be responsible for implementing the respiratory

protection program in the field. He shall be responsible for the following:
• Conduct a hazard assessment of the work and/or task is to be performed.
• Select the appropriate respiratory equipment for the task.
• Ensure the employees have been properly trained.
• Ensure the employees wear the required equipment.
• Ensure all respirators are being properly cleaned and disinfected after each use.
• Periodically inspect to ensure proper operation.

C. Employee. Use the respiratory equipment in the proper manner.

• Guard against damage to the respirator.
• Report any malfunction of the respirator.
• Inspect, clean, disinfect, and store his/her own respirator.
• Ensure proper fit of the respirator by conducting a self-test prior to every use.

III. Requirements
For the purpose of this program the Owner and Supervisor shall be trained to identify the
following respiratory hazards. The two basic types of respiratory hazards are oxygen
deficient air and air laden with contaminants.

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A. Oxygen Deficient Air: Current regulations require that the percentage of oxygen in
the workplace not be less than 19.5%. The normal content of oxygen in is 20.9% by
volume at sea level. At low oxygen concentration death can occur within minutes.

B. Air Contaminants/Particulate Hazards Air contaminants include particulate matter

in the form of discrete particles of solids or liquids, gaseous material in the form of a true
gas or vapor, or a combination of both gaseous and particulate matter.

IV. Types of Particulate Matter

• Dust
• Mist & Fog
• Fumes & Smoke

V. Types of Gaseous Contaminants

• Gaseous-such as sulfur dioxide, carbon monoxide, etc.
• Inert Gases-such as nitrogen, helium, argon etc. which produce an oxygen deficiency.
• Acidic Gases–such as chlorine, hydrogen sulfide, etc. which produce acid by reaction
with water.

VI. Types and Limitations of Respiratory Protection Equipment

Respiratory protection equipment falls into three basic classes:
• Air-Purifying Respirators (APR)
• Supplied-Air Respirators (SAR)
• Self-Contained Breathing Apparatuses (SCBA

VII. Air Purifying Respirator (APR)

3. Air purifying respirators cleanse the contaminated atmosphere by trapping or
absorbing the air contaminants when inhaled through a filter. The three basic
types are Half-Face Respirators, Full-Face Respirators and Powered Air-Purifying
Respirators (PAPR).
4. Air-purifying respirators do not protect against oxygen-deficient atmospheres or
against skin irritants and absorption by harmful airborne contaminants. These
respirators only purify the air from the potentially hazardous particulate and or
vapors and gases.
5. These respirators should never be used in confined spaces, below or above ground
where oxygen-deficient or high concentrations of air contaminants may occur.
6. There are two different types of air purifying respirator cartridges: Mechanical
and chemical
•Mechanical cartridge filters remove particulate matter such as dusts, mists
and fumes.
•Chemical cartridge filters remove specific gases and vapors from the air,
such as chlorine, ammonia, organic vapors, etc.

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VIII. Supplied-Air respirator (SAR)
Supplied-Air Respirators are designed to provide the worker with clean air to breathe
while the worker is performing a task. Connecting a hose from the full-face mask to a
generator or oxygen cylinder does this.

IX. Combination APR/SAR

Air Purifying and Supplied-Air Respirators can be used in combination with each other to
increase the protection factor and reduce the weight of required equipment. However,
some limitations must be taken into consideration when using this combo system.

These systems cannot be used in IDLH conditions and low oxygen atmospheres.

X. Self-Contained Breathing Apparatus (SCBA)

SCBA provides the highest protection factor against toxic gases, particulate and oxygen
deficiency.

XI. Selection of Respirators

The Supervisor or Owner shall select and specify the type of respiratory protection to be
used for each job. The selection of the proper type of respirator shall be based on:
• The type of respiratory hazard
• Effects of the body
• The quality of fit of the respirator to the employee
• The nature of the hazardous operation, process or work being done
• The activities of workers in the hazardous area.
• The period of time for which respiratory protection shall be worn.
• The location of the hazardous area in relation to the nearest area having breathable
air

Respirator selection shall be periodically reviewed and changed if necessary when

changes have been made in operations, processes, new machinery or monitoring results
show a change in the average workplace concentrations or at employee or Supervisor
request.

XII. Competent Person Training Requirements

• Review 29 CFR 1910.134-Respiratory Protection Standards for General Industry
• Basic respiratory protection practices
• Nature and extent of respiratory hazards to which persons under his/her supervision
may be exposed
• How to train respirator wearers
• Policies regarding the issuance, procurement and return of respiratory protective
equipment
• Respirator inspection and maintenance
• Use of respirators, including monitoring and evaluation of use
• Cleaning, disinfecting and storage of respirators

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• Regulations concerning respirator use

XII. Employee Training

All employees who may be required to wear respirators shall be instructed in the purpose
and limitations of respiratory protective equipment. All Supervisor personnel required to
manage employees who wear respiratory protection equipment shall attend this training.
Respiratory training shall include:
• The description of respirators
• Intent, safe and proper handling/use and limitations of the respirator
• Proper use, adjustment and fit testing
• Proper cleaning and storage methods
• Inspection and maintenance procedures
• Specific training for different types of respirators
• Specific hazards employees may encounter
• Procedures in the event of an emergency

Respiratory protection training should be completed before an employee is required to

wear respiratory protection. The training should also be conducted and evaluated
annually.

Respiratory fit testing shall be completed and documented on each respirator wearer. Fit
testing shall include, positive, negative, and qualitative testing.

XV. Employee Physical Capacity Requirements

Prior to an employee being trained or using a respirator, he/she must complete a physical
status questionnaire and receive and pass a pulmonary capacity test.

XVI. Inspection & Maintenance of Respiratory Equipment

Inspections
• The user before and after each use and after cleaning shall check the condition of the
face piece, headbands, valves, hoses, canisters, cartridges and filters.
• Supervisor overseeing employees using respiratory equipment shall inspect all
respirators of their employees on at least a monthly basis. A log shall be maintained
of all inspections and shall be kept in the office.
• Respirators designated for emergency use shall be tagged noting the date of last
inspection and the initials of the Supervisor doing the inspection.

XVII. Maintenance
• The Supervisor shall ensure that employees follow maintenance procedures according
to manufacture recommendations.
• Respirators which do not pass inspection shall be replaced or repaired immediately
• Employees may conduct limited repairs to respirators. These repairs shall only be
limited to changing canisters, cartridges, filters, and head straps.

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• The Supervisor or individual experienced and knowledgeable shall perform all other
replacements or repairs with the parts designed for the respirator.

• Supervisor or any company employee should not attempt to replace components

or make adjustments, modifications or repairs beyond the manufacturer’s
recommendations and individual capabilities.

XVIII. Cleaning
Individually assigned respirators shall be cleaned and disinfected as frequently as
necessary to insure that proper protection is provided for the wearer. Respirators not
individually assigned and those for emergency use shall be cleaned and disinfected after
each use.

The following procedure shall be used for cleaning and disinfecting:

• Filters, cartridges or canisters shall be removed before washing the respirator and
discarded as necessary.
• Respirators shall be washed in a detergent solution, rinsed in clean water and allowed
to dry in a clean area. A brush may be used to scrub the respirator to remove any
soiled areas.

XIX. Storage
After inspection, cleaning, and necessary repairs, respirators shall be stored to protect
against dust, sunlight, heat extreme hot or cold temperatures, excessive moisture or
damaging chemicals.

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 Scaffolds
I. General

1. The following guidelines will be implemented when the use of scaffolding is

required on the job site.
2. Erected with a stable base.
3. A scaffold can only be erected, moved, dismantled or altered under the
supervision of a competent person.
4. If over 10 ft., guardrails and toe boards will be used.
5. Scaffolds 4 to 10 ft. in height and less than 45 in. in width will use standard
guardrails on all open sides.
6. When employees are required to pass or work below scaffolding an 18-gauge
1/2in-wire mesh screen will be installed between the toe board and guardrail.
7. Scaffolds and components must be capable of withstanding 4 times the maximum
intended load.
8. Planking will be clear scaffold grade lumber 2x10 or greater.
9. Planking will be secured or overlap 12 in.
10. Planking shall extend at least 6 in. and not more than 12 in. over the end supports.
11. Hard hats will be required when working or passing under scaffold.
12. _________________________________________________________________
_
13. _________________________________________________________________
_

II. Rolling Scaffold

1. Lock casters or wheels when in use.
2. Employees are not allowed on scaffold when being moved.
3. For more than 10 ft. in height a standard guardrail system shall be used.
4. A wire mesh screen will be used when employees are required to work or pass
under scaffold.
5. A ladder or stairway will be affixed to scaffold.
6. Diagonal bracing will be in place.
7. On freestanding scaffold the height will not exceed 4 times the minimum base
dimension.
8. _________________________________________________________________
_

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 Signs & Placards
General Requirements
1. Signs shall be visible and removed as conditions warrant.
2. Danger signs are to be used in areas of immediate hazards.
3. Caution signs are to be used to warn of potential hazards or unsafe practices.
4. Exit signs should be posted at all exits.
5. Traffic signs should be posted at all points of traffic hazards.
6. Accident Prevention tags are to be used to warn employees of defective tools,
equipment etc.
7. _________________________________________________________________
_
8. _________________________________________________________________
_

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 Stairways & Ladders
I. Ladders
1. Used around electrical hazards are to be insulated.
2. May not be spliced.
3. Should be free of oil, mud and grease.
4. Use the belt buckle rule: Keep your belt buckle inside the side rails.
5. Inspect ladder before use. Tag and take out of service defective ladders.
6. Keep both hands free when climbing or descending.
7. Employee should face ladder when climbing.
8. Top of ladder should extend a minimum of 3 ft. above landing surface.
9. Portable ladders should be pitched 1 foot out for every 4 feet of height.
10. The maximum length for single metal extension ladders is 30 ft., two-section
ladders 48 ft., and multi section 60 ft.
11. Ladders should be securely tied off.
12. Do not move or shift while in use.
13. Do not place in front of door, unless door has been locked or secured.
14. Never stand on the top step of any stepladder.
15. Stepladders should be fully open when in use.
16. A stepladder should not be used as a straight ladder.
17. _________________________________________________________________
_
18. _________________________________________________________________
_

II. Stairways
1. All stairways should have at least one handrail and if over 44 inches in width the
standard requires two.
2. Unprotected sides of landing should be protected with a guardrail system with a
top rail 42 inches high and a mid rail and toe board.
3. _________________________________________________________________
_
4. _________________________________________________________________
_

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 Warehouse Safety

General

Warehouse – An industrial facility that receives and stocks many types of products; then
transports or ships them to various locations. The warehouse evokes the image of a
simple operation moving materials around with forklifts, powered hand jacks, conveyors,
or by hand. Thanks to this image, warehouse employees often develop a false sense of
security. With no dangerous machines or high-risk operations to consider, many fail to
see the need for a sound safety program. This section offers some practical suggestions
for improving overall warehouse safety.

Key Areas of Focus

Statistics indicate that certain areas or operations within a warehouse present greater
hazards than others. The following operations have significantly contributed to significant
numbers of injuries and are considered to be the most hazardous: docks, powered
industrial trucks, conveyors, materials storage, manual lifting/handling, and
charging stations. To improve warehouse safety, employers should focus on these areas
and take steps to improve employee training, enforce safe practices, and implement
appropriate corrective action.

Overview of Hazards

Loading Docks – According to the National Safety Council, injuries that occur at docks
are responsible for 10-25% of all workplace injuries. Employees and visitors can easily
fall off a deck. Due to operator error, a piece of powered equipment (such as a lift truck)
may drive off a dock. If a tractor prematurely pulls out with a trailer, the lift truck and
operator may crash to the dock floor, which could result in serious injury or death. A lift
truck could also skid off the dock as a result of contact with a slippery surface.
Products stored or being moved can easily fall and injure someone if not stacked
properly. In addition, sprinkler heads may be struck by loads being lifted; the resulting
water flow may damage products.
To enhance dock safety, management can take several steps. Paint the dock edge yellow
to provide a better visual perception of the hazard. Require wheel choking at every bay
door. If a trailer creeps or pulls out prematurely, the lift truck may fall between the trailer
and the dock floor, leading to serious injury or death.
Automatic trailer restraints are another alternative. With these devices, the operator
secures the trailer from inside the building by simply pushing a control button. A flashing
green light inside the building indicates that the trailer restraint is engaged, while a
flashing red light outside alerts the tractor-trailer operator that it is not safe to pull away.
Wheel chock signs (with backwards print) may be posted on the outside wall of the dock.

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Verify that ladders from dock surface to dock well meet OSHA specifications. In
addition, management MUST prohibit dock jumping, which can lead to serious ankle,
knee, and back injuries.
Provide proper illumination for exit doors. Such doors should also be equipped with
emergency lighting.
Allow only trained, authorized employees to operate hand trucks or hand jacks (walkies).
Although these devices appear easy to operate, they actually pose hazards similar to those
of forklifts. These units turn in a small radius, which can trap the operator’s hand between
the operating handle and a fixed object (such as storage racks).
Inspect the dock area daily to ensure fire extinguishers are not blocked or damaged. Make
sure the dock plates are designed for the loads and lift trucks that will use them. Attempts
to manually place portable dock plates can lead to back injury. Some portable docks have
built-in handles and can be mechanically lifted using lift trucks. Install dock plates with
non-skid surfaces. Use yellow edging on fixed plates to help operators gain perspective
on distance while driving on them. Color highlighting also helps prevent operators from
driving off the side. When dock plates need repair, rope off the surrounding area and post
appropriate warning signs to prevent accidents.
Clean out dock areas periodically to remove accumulated debris and discarded materials.
Paper, wood, and other combustible materials may fall into holes along the open sides of
dock plates, which pose a fire hazard. Water drainage must also be maintained to prevent
standing water.
Identify overhead pipes and highlight them with color.

Powered industrial trucks – Powered industrial trucks are the key component of the
material handling process in a warehouse. These vehicles are also dangerous. About 100
employees are killed and 95,000 are injured each year while operating powered industrial
trucks. A lift truck has a high center of gravity, turns more sharply than an auto, and may
weight three to four times more than a common car. All this factors contribute to forklift
tipover, which, according to OSHA statistics, is responsible for 24% of all fatal injuries to
operators.
OSHA developed operator guidelines, which states that only trained, authorized
employees will be allowed to operate lift trucks. Training programs must include:
classroom lecture, visual aids, operator testing, hands-on driving skills evaluation,
equipment-specific training and certificates of completion. Install back-up alarms on
trucks, which can prevent many struck-by or caught-between injuries. Flashing lights
may also add to the safety of employees working or moving nearby.

Conveyors – Conveyors are common in warehouse and distribution industry. Inspect

conveyors on a regular basis. Color code On / Off buttons and ensure easy accessibility.
These buttons should be available at various intervals along conveyors. Develop a means
of locking out the conveyor and train employees in these procedures. Install netting or
other protective guarding (to prevent product from falling) on the sides or under
conveyors in areas where workers or visitors may walk. If employees must cross over a
conveyor, provide stairs and railing or enable one section of the conveyor to fold up in
order to accommodate access. Climbing onto or over conveyor MUST be prohibited.
Install a shutoff device (electronic sensors or sensitivity wires) to prevent over-stacking

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and falling product at the ends of conveyors. Post signs and install alarms and warning
lights to alert employees when the system starts and stops. Provide proper lighting and
working surfaces in the area surrounding the conveyor. Special floor mats can enhance
employee comfort. Verify that conveyor height is adjustable at both the feeding and
removal end to accommodate employee height. Adjustable pallet stackers further reduce
the need for bending and lifting.

Material Storage – A warehouse provides a building where product and materials are
brought in, stored and later retrieved for shipment to another location. Product
movement and storage pose risk to all present. To improve safety and productivity,
employees should take the following steps.
Visually inspect pallets as they arrive and remove those in poor condition. Loads can fall
from racking or storage if a pallet breaks. Also, lifting a bad pallet that is loaded can
cause product to unexpectedly fall on employees.
Stack loads straight and evenly. Place loads directly on racking. Correct loads that look
out of balance.
Where possible, shrink-wrap loads or place plastic or metal banding around them. A
secure load helps protect lift trucks operators.
Place yellow protective posts or barriers at the ends of racking to prevent damage caused
by lift truck movement.
Space racks so that pallets being handled cannot damage other loads. Spotting a load on
one side of a rack could easily push the adjacent load in the next aisle, perhaps onto
unsuspecting employees.
Provide sufficient space so lift trucks can turn properly and safely, without damaging
storage racks.
Make sure the floor surfaces and aisles are smooth and free of ruts, debris, and slippery
surfaces (e.g. oil, chemicals, fluids, water), which may hinder operator’s ability to stop
powered equipment. In addition, the jarring motion of a forklift operating on a poorly
maintained floor can seriously injure operator’s legs and back.
Store product on shelving, not in aisles or on the floor.
Store low-sales (infrequently handled) product out of the way. Place product that is
regularly handled (manually) on shelves that are knee high and not above shoulder
height.

Manual Lifting and Handling – Manual materials handling can easily produce back and
hand injuries. In fact, back injuries result in the most expensive claims within the
industry. NSC offers several tips for safe manual lifting.
Develop employee’s awareness regarding pinch points. Hand traps can occur while
setting down heavy boxes, working near pulleys in conveyor belts, adjusting lift truck
forks, operating walkies, shutting trailer doors, and manually handling product. Proper-
fitting gloves provide additional protection.
Identify fixed pinch points (e.g. the two horizontal doors that come together on a freight
elevator) with yellow paint or black and yellow striped tape. Post appropriate signs as
well.
Place guards on any moving gears or hazardous rollers to protect hands and other body
parts.

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To ease manual lifting, add handles to containers. Train employees in proper lifting
techniques bend at the knees, keep close to the load, and use the arms and legs to lift.
They should also know how to shift feet not to twist at the waist when turning with a
load.

Charging Stations – To allow powered equipment to function, a fueling or recharging

area is needed. Units may be powered by gasoline, diesel, liquid petroleum gas (LPG),
compressed natural gas (CNG), or battery. Management must exercise special care to
reduce risk of fire or explosion in areas where vehicles are refueled or recharged.
Ensure that refueling systems are professionally designed for the specific risk. The
manufactured should provide specific guidelines regarding the system design and safety
features.
Prohibit smoking or open flames in and around charging stations and post signs
reinforcing these restrictions. Ensure that fire extinguishers are readily available, fully
charged, and are for the type of fire hazard present. Dry chemical or CO2 are the most
effective extinguisher types in addition to an automated fire suppressant discharging
system to facilitate an effective response during an emergency.
Consult with the local fire department to determine the required distance between the
charging station and a building structure.
Verify that safety devices for vapor recovery, flash arrestors, automatic shut-off, etc are in
place and in good operating condition.
Equip battery-charging areas with an eyewash unit that will provide at least 15
continuous minutes of running water. Depending on the potential for exposure, a full
drench shower may be required.
Post information about the fire extinguisher placement and job hazard analysis near the
chargers, along with an informational placard from the battery manufacturer.
Provide equipment to protect against battery acid (e.g. rubber gloves, apron, goggles, face
shield, and boots).
Mount an emergency shut-off valve/button near the charging station and enforce
lockout/tagout procedures.

Fire Safety – Many warehouses are protected by automatic sprinkler systems. As noted,
management must be sure that the product stored can be extinguished by this system
should a fire occur.
Inspect sprinkler system and conduct flow and alarm testing each month. Document
these inspections and tests. Store all flammables according to fire code.
Inspect fire hoses and extinguishers regularly. Remove any obstructions and make sure
these items are readily available. Only employees trained in appropriate firefighting
techniques should handle this equipment.
Perform annual fire drills and practice emergency drills. Post large emergency
evacuation maps throughout the facility.
Develop and emergency plan that assigns specific tasks to specific employees.
Train all employees in basic principle of firefighting, including how to identify fire types
and use extinguishers. Local fire departments can provide on-the-job training.
Maintain fire alarms, smoke detectors, and emergency lighting improper operation
condition.

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Chemical Exposure – Provide MSDS for each chemical in the facility. This is best
achieved by filing MSDS sheets in binders and storing binders in key locations.
Maintain a master chemical inventory. Provide spill clean-up kits in any area where
chemicals are stored. Develop and implement a written spill control plan. Train
employees to clean up spills, protect themselves and properly dispose of used materials.

Lockout / Tagout – Various machines, devices, and operations in a warehouse present

the need for a zero-energy state and, thus, the need for a lockout/tagout (LOTO) program.
Employees required to perform LOTO should be thoroughly trained, and all employees
should have, at least, working knowledge of the program.
Forklift minor repairs: Safely park the forklift in an approved area, remove the key and
add a tag that identifies who locked it out, when, and why. For additional safeguarding,
turn off the propane valve or disconnect the battery as appropriate, chock the wheels, and
ensure the forks are on the ground.
Identify circuit breakers boxes (on the outside) by number or letter code; this makes it
easier to locate. Inside each box, test individual switches to verify what they control,
then label them accordingly. Ensure that the panel contains no openings which expose
employees to live current, and install barriers (rails or guards) to protect power panels
and boxes against impact by powered equipment.

Personal Protective Equipment – Management must conduct a site hazard assessment

to determine what Personal Protective Equipment (PPE) must be worn based on hazards
present. In addition, employees must be trained regarding proper PPE selection, use, and
maintenance.
Provide hard hats to all personnel. Product can easily fall off racks or shelves and strike
an employee’s head. While moving product under racking, an employee can easily strike
his/her head on the rack.
Require foot protection where appropriate. Steel-toe shoes protect feet against falling
product or when caught between tow objects. Such shoes also protect the feet while
operating powered pallet jacks, stock chasers, or similar equipment.
Provide appropriate gloves to protect against sharp, hot, heavy, and chemically unstable
products. Depending on the hazard, gloves may be leather, rubber, cotton, or other
material. Glove selection should be based on the type of exposure.
When necessary, provide hearing protection (e.g. earplugs or ear muffins). Since worker
acceptance of this equipment depends on the comfort it provides, workers should be
involved in its selection.

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 Warehouse / Materials Handling Safety Checklist

Site: _____________________________________ Date: ________________________

Work Area: _______________________________ Inspector: ____________________

Aisles are clearly identified

Aisles have adequate clearance to assure safe movement and handling of materials

Floor drainage is adequate to prevent water accumulation in traffic areas

Signs are posted warning of clearance limits

Tiered materials are stacked in a manner to assure stability

Storage racks are secured

Storage levels over 7ft high and loading docks have guard rails along the open edge

Joisted floors are clearly identified as to floor loading capacity

Ramps have non-slip coatings

NO SMOKING signs are clearly posted

Posters and other materials identifying correct lifting and materials handling
techniques are posted

Aisles are clear of obstructions

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 Welding & Cutting
I. Personal Protective Equipment
1. Use appropriate shaded lens.
2. Use approve leather gloves
3. Wear a long sleeve cotton shirt/not synthetic
4. Never cut or weld in a confined space without the proper testing and permits.
5. Adequate ventilation should be provided for welding, cutting or brazing
6. Set up ventilation so air is blown across face and away from the worker.
7. Do not work directly over top of work.
8. Do not roll up sleeves or cuffs of pants.
9. Pants should overlay tops of shoes.

II. Arc Welding

1. Hood should be in place before striking an arc.
2. Use welding screens if bystanders will be exposed to arc.
3. Never look at an electric arc.
4. Cables should be completely insulated. Remove cable with exposed wire.
5. The frames of welding machines should be properly grounded.
6. Do not dip hot electrode holders in water.
7. Do not strike arc against cylinder or combustible container.

III. Cutting
1. Always stand to the side when cracking valve(s).
2. Do not crack valve if close to an ignition source.
3. Do not use fuel gas from a cylinder without a pressure regulator.
4. Before removing regulator close cylinder valves and release the pressure from the
regulator.
5. Valve caps should be in place before transporting cylinders.
6. If a cart is not available move cylinders by tilting and rolling.
7. Cylinders should be transported in a vertical position.
8. Cylinders should be stored either 20 feet apart or separated by a 5 foot high, one-
half hour fire rated divider.
9. Keep cylinders isolated from actual welding or cutting operations.
10. Cylinders containing oxygen, acetylene or other fuel gas should not be taken into
a confined space.
11. Cylinders should be placed and stored in a well-ventilated area.
12. Hoses should be periodically checked for damage or leakage.
13. Fuel gas and oxygen hoses shall be properly marked and identified.

IV. General Procedures

• A fire watch will be provided when welding and/or cutting is being performed around
combustible materials.
• A suitable fire extinguisher shall be immediately available in the work area.

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