IIP Program For General Industry Employers With Intermittent Employees

XYZ Company
Injury and Illness Prevention Program

For
General Industry Employers

With
Intermittent Employees
Complies with Provisions of OSHA 29 CFR Part 1910 General Industry Standards OSHA 29 CFR Part 1926 Construction Industry Standards
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees)
Safety Office Depot. All rights reserved.
Table of Contents
Section 1 2 3 4 5 6 7 8 9 10 11 12 Description Page Program Policy & Requirement Program Responsibility Employee Compliance Safety Communication Hazard Assessment Accident/Exposure Investigation Hazard Correction Safety Training and Instruction Recordkeeping Policy Company Required Safety Programs Company Required Safety Training Courses Company Required Safety Forms & Checklists 3 4 5 6 7 9 10 11 13 15 16 18
Appendices A B C D E F List of Training Subjects Hazard Assessment Checklists Hazard Assessment and Correction Record Accident/Exposure Investigation Report Employee Training and Instruction Record Employee Acknowledgement Form 21 30 51 53 55 57
Section 1
Program Policy & Requirement

Program Policy It is intent of XYZ Company to comply with all laws. To do this, we must constantly be aware of conditions in all work areas that can produce injuries. No employee is required to work at a job he/she knows is not safe or healthful. Your cooperation in detecting hazards and, in turn, controlling them, is a condition of your employment. Inform your supervisor immediately of any situation beyond your ability or authority to correct. Program Requirement This program has been prepared for use by employers in industries which have been determined by OSHA to historically utilize intermittent or
seasonal workers. Intermittent or seasonal employment refers to controlling, directing, or directly supervising any worker other than permanent workers.
Employers in an industry which has been determined by OSHA as historically utilizing

intermittent or seasonal workers and who adopts and implements this program in good faith shall be deemed in compliance with IIP Program requirements, unless mandated otherwise
by a State law. Proper use of this program requires the IIP Program administrator to carefully review the requirements for each of the IIP Program elements found in this program, fill in the appropriate blank spaces and select those items that are applicable to your workplace. The recordkeeping section requires that the IIP Program administrator select and implement the category appropriate for your establishment.
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) This program must be maintained by the employer in order to be effective.
Section 2
Program Responsibility
Program Administrator The Injury and Illness Prevention Program (IIPP) administrator, Program Administrator has the authority and responsibility for implementing the provisions of this program. DECISION POINT Enter a name or position title (recommended) The Program Administrator for XYZ Company is _______________________________________. Managers and Supervisors All managers and supervisors are responsible for implementing and maintaining the IIP Program in their work areas and for answering worker questions about the IIP Program. A copy of this IIP Program shall be available from each manager and supervisor upon request.
Section 3
Employee Compliance
XYZ Company management is responsible for ensuring that all safety and health policies and procedures are clearly communicated and understood by all employees. Managers and supervisors are expected to enforce the rules fairly and uniformly.
All permanent and intermittent workers, including managers and supervisors, are responsible for complying with safe and healthful work practices. Our system of ensuring that all workers comply with these practices includes one or more of the following selected practices:
DECISION POINT Review and select the items that apply and delete those that do not
Our systems of ensuring that all workers comply with these practices include one or more of the following selected practices:
1. Informing workers of the provisions of our IIP Program; 2. Evaluating the safety performance of all workers; 3. Recognizing employees who perform safe and healthful work practices; 4. Providing training to workers whose safety performance is deficient; 5. Disciplining workers for failure to comply with safe and healthful work practices.
Section 4
Safety Communication
All managers and supervisors are responsible for communicating with all permanent and intermittent workers about occupational safety and health in a form readily understandable by all workers. Our communication system encourages all workers to inform their managers and supervisors about workplace hazards without fear of reprisal. Upon hiring, management will identify any intermittent workers with special communication needs. Management will ensure that such a worker understands the safety and health requirements before being assigned to duties exposing them to workplace hazards. Our communication system includes one or more of the following checked items DECISION POINT Review and select the items that apply and delete those that do not
Our communication system includes one or more of the following selected items:
1. New worker orientation including a discussion of safety and health policies and procedures. 2. Review of our IIP Program. 3. Workplace safety and health training programs. 4. Regularly scheduled safety meetings. 5. Effective communication of safety and health concerns between workers and supervisors, including translation where appropriate. 6. Posted or distributed safety information.
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) 7. A system for workers to anonymously inform management about workplace hazards. 8. Our establishment has less than ten employees and communicates with and instructs employees orally about general safe work practices and with respect to hazards unique to each employee's job assignment.
Section 5
Hazard Assessment
Periodic inspections of XYZ Company facilities, workplaces and sites to identify and evaluate workplace hazards shall be performed by the following competent observer(s) in the following areas of our workplace: DECISION POINT Complete the information requested in this table. A. Competent Observers
Competent Observer
Area
B. Periodic Inspections
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) Periodic inspections are performed according to the following schedule: DECISION POINT - State the frequency of inspections below (Daily, weekly, monthly, etc.) 1. ________________________________;
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) 2. When we initially established our IIP Program; 3. When new substances, processes, procedures or equipment which present potential new hazards are introduced into our workplace; 4. When new, previously unidentified hazards are recognized; 5. When occupational injuries and illnesses occur; and 6. Whenever workplace conditions warrant an inspection. Periodic inspections consist of identification and evaluation of workplace hazards utilizing applicable sections of the attached Hazard Assessment Checklist and any other effective methods to identify and evaluate workplace hazards. C. Identified Hazards
At XYZ Company, identified hazards will be corrected as soon as possible. For any that cant be immediately corrected, a target date will be set for correction based on such considerations as the probability and severity of an injury or illness resulting from the hazard; the availability of needed equipment, materials and/or personnel; time for delivery, installation, modification or construction; and training periods. We will provide interim protection to our employees who need it while correction of hazards is proceeding. A written tracking system such as a log may be used to help monitor the progress of hazard correction. The Program Administrator will review and prioritize based on the severity of the hazard.
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Section 6
Accident/Exposure Investigation
A. Accident Investigation XYZ Company procedures for investigating workplace accidents and hazardous substance exposures include: 1. Interviewing injured workers and witnesses; 2. Examining the workplace for factors associated with the accident/exposure; 3. Determining the cause of the accident/exposure; 4. Taking corrective action to prevent the accident/exposure from reoccurring; and 5. Recording the findings and corrective actions taken. B. Corrective Action Corrective action will be identified in terms of not only how it will prevent a recurrence of the accident or near miss, but also how it will improve the overall operation. This will assist the investigation in selling his/her solutions to management. The solution should be a means of achieving not only accident control, but also total operation control. DECISION POINT If you do not have a safety committee, delete this next section If you have a safety and health committee, its members should review investigations of all accidents and near-miss incidents to assist
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Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) in recommending appropriate corrective actions to prevent a similar recurrence. Thorough investigation of all accidents and near misses will help the investigator identify causes and needed corrections, and can help determine why accidents occur, where they happen, and any accident trends. Such information is critical to preventing and controlling hazards and potential accidents.
Section 7
Hazard Correction
Unsafe or unhealthy work conditions, practices or procedures at XYZ Company shall be corrected in a timely manner based on the severity of the hazards. Hazards shall be corrected according to the following procedures: 1. When observed or discovered; 2. When an imminent hazard exists which cannot be immediately abated without endangering employee(s) and/or property, we will remove all exposed workers from the area except those necessary to correct the existing condition. 3. Workers necessary to correct the hazardous condition shall be provided with the appropriate personal protective equipment for the hazardous condition.
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Section 8
Safety Training and Instruction

All XYZ Company permanent and intermittent workers, including managers and supervisors, shall have training and instruction on general and job-specific safety and health practices. Training and instruction can be provided through a brief on-site safety meeting. Any training and instruction shall be provided as follows: A. Safety training and instruction shall be provided as follows: 1. When the IIP Program is first established; 2. To all new hires; 3. To all workers given new job assignments for which training has not previously provided; 4. Whenever new substances, processes, procedures or equipment are introduced to the workplace and represent a new hazard; 5. Whenever the employer is made aware of a new or previously unrecognized hazard; 6. To supervisors to familiarize them with the safety and health hazards to which workers under their immediate direction and control may be exposed; and 7. To all workers with respect to hazards specific to each employee's job assignment.
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Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) B. Workplace safety and health training practices for all industries include, but are not limited to, the following: 1. 2. 3. Implementation and maintenance of the IIP Program
Emergency action and fire prevention plan. Provisions for medical services and first aid including emergency
procedures.
4. 5.
Prevention of musculoskeletal disorders, including proper lifting techniques. Proper housekeeping, such as keeping stairways and aisles clear, work
areas neat and orderly, and promptly cleaning up spills.
6.
Prohibiting horseplay, scuffling, or other acts that tend to adversely
influence safety.
7.
panels.
Proper storage to prevent stacking goods in an unstable manner and
storing goods against doors, exits, fire extinguishing equipment and electrical
8. 9.
Proper reporting of hazards and accidents to supervisors. Hazard communication, including worker awareness of potential chemical
hazards, and proper labeling of containers.
10.
Proper storage and handling of toxic and hazardous substances including
prohibiting eating or storing food and beverages in areas where they can become contaminated.
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Section 9
Recordkeeping Policy
Every employer has certain mandatory records that they must keep and be prepared to provide to the appropriate agency when needed. The two primary types of records that must be kept are Occupational Safety and Health (OSHA) and Internal Revenue Service (IRS) information. A. Occupational Safety and Health (OSHA) Records Every employer covered by OSHA who has more than ten (10) employees, except for employers in certain low-hazard industries such as retail, finance, insurance, real estate, and some service industries, must maintain OSHA-specified records of job-related injuries and illnesses. There are two such records, the OSHA Form 300, and the OSHA Form 301. 1. OSHA Form 300 The OSHA Form 300 is an injury/illness log, with a separate line entry for each recordable injury or illness (essentially those workrelated deaths, injuries, and illnesses other than minor injuries that require only first aid treatment and do not involve medical treatment, loss of consciousness, restriction of work or motion, or transfer to another job). A summary section of the OSHA Form 300, which includes the total of the previous year's injury and illness experience, must be posted in the workplace for the entire month of February each year. 2. OSHA Form 301 The OSHA Form 301 is an individual incident report that provides added detail about each individual recordable injury or illness. An equivalent insurance or workers' compensation form that provides
Safety Office Depot. All rights reserved. 15
Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) the same details may be substituted for the OSHA Form 301. B. Company Recordkeeping Policy DECISION POINT Select one of the four categories below that applies to your company. Remove the other three categories that do not apply to your company. The recordkeeping policy for XYZ Company is as follows: Category 1: XYZ Company has Fewer Than 10 employees in Low
Hazard Industries XYZ Company has fewer than ten (10) workers and will modify our IIP Program as follows: 1. Communications about safety generally do not have to be in writing. 2. Inspection records do not need to be kept after a hazard is corrected. 3. Training records can be a simple log of training provided at hiring or when an employee is assigned to new duties. Category 2: XYZ Company has Fewer Than 20 employees in Low
Hazard Industries A. XYZ Company has fewer than twenty (20) workers and will modify our IIP Program if:
1. We are not on a designated high hazard industry list as
established by the Department of Industrial Relations, and the employer has a workers compensation experience modification rate of 1.1 or less; or
2.
We are on a designated list of low hazard industries as
established by the Department of Industrial Relations. and
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Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) have taken the following steps to implement and maintain our IIP Program: B. XYZ Company is on a designated list of low hazard industries. As such, our written recordkeeping documentation may be limited to the following: 1. The identity of the persons with authority and responsibility for implementing the plan 2. Scheduled periodic inspections to identify and correct workplace hazards and practices 3. Required training and instruction
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Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) Category 3: XYZ Company has More Than 20 employees in Low
Hazard Industries A. Our establishment has twenty (20) or more workers and will modify our IIP Program for the following reasons:
1. We have a workers' compensation experience modification
rate of greater than 1.1; and

2. We are not on a designated low hazard industry list.
B. XYZ Company has taken the following steps to implement and maintain our IIP Program: 1. Records of hazard assessment inspections, including the person(s) conducting the inspection, the unsafe conditions and work practices that have been identified and the action taken to correct the identified unsafe conditions and work practices, are recorded on a hazard assessment and correction form; and 2. Documentation of safety and health training for each worker, including the worker's name or other identifier, training dates, type(s) of training, and training providers are recorded on a worker training and instruction form. Category 4: XYZ is a local government entity
We are a local governmental entity (county, city, district, or and any public or quasi-public corporation or public agency) and we are not required to keep written records of the steps taken to implement and maintain our IIP Program.
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Section 10
Company Required Safety Programs

Due to the nature of work and operations performed by XYZ Company, it is necessary that the following regulatory programs are included in our Injury and Illness Prevention Program: For convenience, programs listed in the table below are alpha sorted. DECISION POINT Review and select those programs that apply or included others not listed
Company Required Safety and Health Plans & Programs

Accident Prevention Program Asbestos Management Plan Bloodborne Pathogens Program Chemical Hygiene Plan Confined Space Entry Program Control of Hazardous Energy Program Cranes and Derricks Safety Program Electrical Safety Program Emergency Action Plan Excavation and Trenching Program Fall Protection Program Fire Prevention Work Plan Flammable Storage / Compressed Gas Forklift Safety Program Hazard Communication Program Hearing Conservation Program Hot Work Permit Program Ladders and Stairways Work Plan Laser Safety Program Lead Safety Program Personal Protective Equipment Plan Powered Industrial Truck Program Radiation Protection Program Respiratory Protection Program Scaffolding Safety Program Welding Safety Program
Table 1
All Safety Plans & Programs are available through Safety Office Depot www.SafetyOfficeDepot.com
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Section 11 Company Required Safety Training Courses

Due to the nature of work and operations performed by XYZ Company, it is necessary that the following safety training courses are included in our Injury and Illness Prevention Program: For convenience, courses listed in the 3 tables below are alpha sorted. DECISION POINT Review and select those courses that apply or included others not listed
Company Required Safety Training Courses Sorted A-E

Accident Investigation Accident Prevention Signs & Tags Asbestos Safety Bloodborne Pathogens Initial/Refresher Bloodborne Pathogens Train-theTrainer Chemical Spills Competent Persons Compressed Gas Cylinder Concrete & Masonry Confined Space Entry Construction Safety Management Crane Safety Refresher Cranes & Derricks in Construction Electrical Safety Emergency Exit Routes Emergency Response Team Ergonomics Basic Human Factors Ergonomics Advanced Human Factors Excavation Safety Eye & Face Protection
Table 2
All Safety Training Courses are available through Safety Office Depot www.SafetyOfficeDepot.com
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Company Required Safety Training Courses Sorted F-L

Fall Protection Portable Fire Extinguisher Flammable & Combustible Liquids Forklift Safety Classroom (English) Forklift Safety Classroom (Spanish) Hand & Power Tools Hazard Communication Hazard Vulnerability Hazardous Materials Management Hearing Protection Hexavalent Chromium Hot Work Permit Safety Indoor Air Quality Introduction to OSHA Job Hazard Analysis Laser Safety Lead Exposure Liquid Nitrogen Lockout-Tagout
Table 3
Company Required Safety Training Courses Sorted M-W

Machine Guarding Material Handling Office Safety Awareness Pandemic Preparedness Personal Protective Equipment Powered Industrial Truck Radiation Safety Respirator Protection Safe Lifting Awareness Back Safety Safety Audit Training Safety Representative Training Safety Supervisor Training Scaffolding Slip, Trip & Fall Prevention Stairway & Ladder Safety TB Respiratory Protection Walking & Working Surfaces Warehouse Safety Workplace Violence Prevention Healthcare Workplace Violence Prevention Retail
Table 4
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Section 12
Company Required Safety Forms & Checklists

Due to the nature of work and operations performed by XYZ Company, it is necessary that the following safety forms and checklists are included in our Injury and Illness Prevention Program: For convenience, forms listed below are subject sorted. DECISION POINT Review and select those forms that apply or included others not listed
CONFINED SPACE Confined Space Entry Permit Confined Space Class A & B Permit Confined Space Class C Permit List of Authorized Entrants Permit Required Confined Space Inventory Log CONSTRUCTION INDUSTRY - SAFETY MANAGEMENT Construction Industry Inspection Checklist Job Start-Up Checklist Contractors Job Site Checklist Contractor Safety Performance Report Construction Equipment Checklist Forklift Service Checklist Operator Performance Evaluation Checklist Safety Nets Inspection Checklist Body Harness & Lanyard Inspection Report Competent Person Evaluation Fall Protection CRANE OPERATIONS Cranes, Derricks or Material Handling Devices Worksheet Crane Inspection Checklist Crane Pre-Lift Checklist Sling (Chain) Inspection Report Monthly Hoist Rope Inspection Report Monthly Hoist Hook Inspection Report EMERGENCY ACTION AND RESPONSE Crisis Management Response Team - Contact Log Safety Representatives - Contact Log External Resources Contact Log Vulnerability Analysis Chart Bomb Threat Checklist Employee Evacuation - Accounting Log Physically Challenged Employee List
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Command Post Equipment Inventory Log Press Information Log Post Exercise Evaluation Report
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EMPLOYEE SAFETY RECORDS Employee Acknowledgement Form Employee Orientation Checklist Construction Employee PPE Assessment Form Employee PPE Issue Form Employee Safety Training Record Ergonomic Workstation Analysis Form Employee Ergonomic Workstation Questionnaire Employee Safety Suggestion Form EXCAVATION OPERATIONS Pre-Excavation Checklist Trenching Design Checklist Trench Safety Daily Field Report Competent Person Evaluation Excavation FIRE PREVENTION Hot Work Permit Fire Safety Inspection Checklist Fire Drill Post Response Report Emergency HAZMAT Inventory Log Hazardous Waste Disposal Request Form GENERAL INDUSTRY SAFETY MANAGEMENT General Industry Safety Inspection Checklist Office Safety Inspection Checklist Job Safety Analysis Worksheet & Instructions Accident Prevention Program Analysis Forklift Service Checklist Hearing Conservation Program Log Scaffolding Safety Checklist Site Safety Meeting Record Supervisors Monthly Meeting Record Report of Safety Hazard Form Property Security Survey INCIDENT REPORTING FORMS OSHA 300 Log Employee Injury & Illness Report Employee Injury Cost Accounting Matrix Vehicle Accident & Property Damage Report Compiling Direct and Indirect Costs OCCUPATIONAL HEALTH FORMS Medical Evaluation Questionnaire Respirator Use Respirator Fit Testing Record Hepatitis B Vaccine - Accept/Decline Form Bloodborne Pathogens Risk Classification Flowchart BBP Employee Annual Training Record BBP Source Patient Consent Form RADIATION PROGRAM FORMS Radioactive Material Use Log Pregnancy Declaration Form Laboratory Contamination Survey Record Radiation Producing Device - Authorization Form Training Guide for Radiation Workers Training Guide for Ancillary Radiation Works
TRAINING RECOGNITION CERTIFICATE Certificate of Completion
All Subject Form Groups are available through Safety Office Depot www.SafetyOfficeDepot.com
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Appendix A
List of Training Subjects

XYZ Company trains our workers about the following selected training subjects:
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AGRICULTURE PRODUCTION AND FARM LABOR AND MANAGEMENT SERVICES

(SIC Codes: 0111-0119, 0131-0139, 0161, 0171-0179, 0191, 0721-0724, 0761-0762)
Safe practices for operating any agricultural equipment, including procedures for cleaning, repairing, servicing and adjusting
Electrical hazards
Heat stress
Ergonomic hazards, including proper lifting techniques and working on ladders or in a stooped posture for prolonged periods at one time.
Hazardous chemical exposures
Other job-specific hazards, such as _______________________________________________________________________ _______________________________________________________________________
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HEAVY CONSTRUCTION AND SPECIAL TRADES CONTRACTORS

(SIC Codes: 1611, 1721, 1751-1755, 1761, 1771)
The employer's Code of Safe Practices.
Good housekeeping, fire prevention, safe practices for operating any construction equipment, including procedures for cleaning, repairing, servicing and adjusting.
Safe access to working areas
Protection from falls
Electrical hazards, including working around high voltage lines
Crane operations
Trenching and excavation work
Proper use of powered tools
Ergonomic hazards, including proper lifting techniques
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PRESERVED FRUITS AND VEGETABLES MANUFACTURING AND SUGAR AND CONFECTIONERY PRODUCTS
(SIC Codes: 2032-2038, 2061-2068)
Guarding of belts and pulleys, gears and sprockets, and conveyor nip points
Machine, machine parts, and prime movers guarding
Lock-out/tag-out procedures
Materials handling
Noise
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GENERAL MERCHANDISE, FOOD AND APPAREL STORES AND PHOTOGRAPHIC AND TAX PREPARATION
(SIC Codes: 5311, 5399, 5441, 5499, 5632, 5651, 7221, 7291)
Materials handling
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LOGGING
(SIC Code: 2411)
Chainsaw and other power tool operation
Tree falling/bucking procedures and precautions, including procedures for recognizing and working with hazard trees, snags, lodged trees, and unsafe weather conditions
Yarding operations, including skidding, running lines, unstable or rolling logs, use of rigging and communication
Landing and loading areas, including release of rigging, landing layout, moving vehicles and equipment, and log truck locating, loading and wrapping
30
MOTION PICTURE PRODUCTION AND SERVICES AND THEATRICAL PRODUCERS

(SIC Codes: 7812-7819, 7922-7929)
Fall protection from elevated locations
Use of elevated platforms, including condors and scissor lifts
Electrical safety
Safe use of explosives
Slips, falls, and back injuries
Noise
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RECREATIONAL PARKS AND CAMPS AND MUSEMENT AND RECREATION SERVICES

(SIC Codes: 7032-7033, 7941-7948, 7996, 7999)
Design, maintenance, operation, repair, inspection, assembly and disassembly of amusement rides or sports equipment
Electrical hazards
Bloodborne pathogens (for medical personnel and first aid provide)
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SCHOOL BUSES, SCHOOLS, COLLEGES AND UNIVERSITIES AND JOB TRAINING AND RELATED SERVICES
(SIC Codes: 4151, 8211, 8221-8222, 8331)
Driver safety
Hazard communication
Laboratory safety
Bloodborne pathogens (for medical personnel and first aid provider)
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Appendix B
Hazard Assessment Checklist

The following checklists contain safety and health hazard assessment items commonly found in the workplace. It is the employer's responsibility to identify, evaluate and control job-specific safety and health hazards in the workplace, and to meet all applicable OSHA requirements. The following checklists are to be used as guides in identifying safety and health hazards in your workplace. Answer the questions contained in the General Workplace checklist and then identify and answer the questions contained in the checklist that applies to your specific industry.
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GENERAL WORKPLACE
(SIC Codes: All)
Is the OSHA poster Safety and Health Protection on the Job displayed in a prominent location where all employees are likely to see it?
Do you have a written, effective Injury and Illness Prevention Program?
Are all work areas properly illuminated?
Are employees instructed in proper first aid and other emergency procedures?
Do you have a fire prevention plan?
Are all worksites clean and orderly?
Are all spilled materials or liquids cleaned up immediately?
Do you have eye wash facilities and a quick drench shower within the work area where employees are exposed to injurious corrosive materials?
When lunches are eaten on the premises, are they eaten in areas where there is no exposure to toxic materials or other health hazards?
Are aisles and passageways kept clear?
Are the directions to exits, when not immediately apparent, marked with visible signs?
Are hazardous substances identified which may cause harm by inhalation, ingestion, skin absorption or contact?
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Are employees aware of the hazards involved with the various chemicals they may be exposed to in their work environment, such as ammonia, chlorine, epoxies, caustics?
Is personal protective equipment provided, used and maintained wherever required?
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Are there written standard operating procedures for the selection and use of respirators where needed?
Are restrooms and washrooms kept clean and sanitary?
Are employees instructed in the proper manner of lifting heavy objects?
Is there a list of hazardous substances used in your workplace?
Is there a written hazard communication program dealing with Material Safety Data Sheets (MSDS) labeling, and employee training?
Is each container for a hazardous substance (i.e. vats, bottles, storage tanks,) labeled with product identity and a hazard warning (communication of the specific health hazards and physical hazards)?
Is there a Material Safety Data Sheet readily available for each hazardous substance used?
Is there an employee training program for hazardous substances?
Can the work be performed without eye strain or glare to the employees?
Does the task require prolonged raising of the arms and does the neck and shoulders have to be stooped to view the task?
Are there pressure points on any parts of the body (wrists, forearms, back of thighs)?
Are there sufficient rest breaks, in addition to the regular rest breaks, to relieve stress from repetitive-motion tasks?
Are tools, instruments and machinery shaped, positioned and handled so that tasks can be
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performed comfortably?
Are you keeping the required records and documentation?
Have arrangements been made to maintain required records for the legal period of time?
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AGRICULTURE PRODUCTION AND FARM LABOR AND MANAGEMENT SERVICES

(SIC Codes: 0111-0119, 0131-0139, 0161, 0171-0179, 0191, 0721-0724, 0761-0762)
Where workers do not understand English, are safety instructions and warnings presented in a language the workers understand?
Are adequate first-aid materials are immediately available at the farm headquarters and/or on worker transportation buses?
At remote locations, are provisions made in advance for prompt medical attention and are there is there at least 1 employee for every 20 employees trained for the administering of first aid?
Is all agricultural equipment is properly guarded to prevent accidental contact by workers?
Are safe practices for operating agricultural equipment, including procedures for cleaning, repairing, servicing and adjusting, being followed?
Is all machinery or equipment capable of movement, required to be de-energized or disengaged and blocked or locked out during cleaning, servicing, adjusting or setting up operations, whenever required?
Are safe work practices being followed during operation of self-propelled equipment? Where mobile farm equipment is towed by a tractor or truck and the tractor or truck driver cannot see the employees on the towed equipment, is there a positive signaling device installed on the towed equipment that can stop the towing equipment in case of an emergency?
Are portable screw conveyors located seven feet or less above the work level substantially covered or guarded?
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Are augers guarded with either grating type guards or solid baffle style covers according to OSHA?
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Are ladders, steps, or other suitable climbing means provided where and when workers are required to work in or about farm structures such as permanent pools, ponds, water tanks, or reservoirs 4 feet or more in actual depth and where the slope and construction would make exit difficult?
Are machines, aircraft, or applicators decontaminated in a safe area before they are overhauled or placed in storage?
Are safety precautions as required by Title 3, Article 23 of the California Code of Regulations followed when using aircraft for crop dusting and spraying?
Are safe work practices followed when using applicator rigs, tanks, and vessels containing fertilizer, insecticide, pesticide, and other chemical solutions of a hazardous nature?
Is potable water provided, and access to permitted, at all times, during working hours and placed in locations readily accessible to all workers?
Is potable water for drinking dispensed in single-use drinking cups or by fountains, and the water is fresh, pure, and suitably cool?
Are adequate toilet and handwashing facilities available and do they meet OSHA requirements?
Are all ladders maintained in good condition, and are employees instructed to face the ladder when ascending or descending and prohibited from using ladders that are broken, missing steps, rungs, or cleats, broken side rails or other faulty equipment?
Are employees instructed not to use the top 2 steps of ordinary stepladders as a step? Are employees made aware of the hazards caused by faulty or improperly used hand tools?
Is each van, bus or truck used regularly to transport employees, equipped with an adequate number of seats, and equipped with the proper safety devices?
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Can the work be done without twisting or overly bending the lower back?
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Are hazardous substances identified which may cause harm by inhalation, ingestion, skin absorption or contact?
Are employees aware of the hazards involved with the various chemicals they may be exposed to in their work environment, such as ammonia, chlorine, and caustics? Is heat stress being evaluated and controlled?
Are employees screened before assignment to areas of high heat to determine if their health condition might make them more susceptible to having an adverse reaction?
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HEAVY CONSTRUCTION AND SPECIAL TRADES CONTRACTORS

(SIC Codes: 1611, 1721, 1751-1755, 1761, 1771)
Are workers knowledgeable about and complying with the employer's Code of Safe Practices?
Are safe practices for operating construction equipment, including procedures for cleaning, repairing, servicing and adjusting, being followed?
Is good housekeeping maintained in all work areas, passageways, and stairs in and around buildings or other structures?
Are all personal protective devices maintained in a safe, sanitary condition, and in accordance with manufacturer's instructions?
Are approved safety glasses required to be worn at all times in areas where there is a risk of eye injuries such as punctures, abrasions, contusions or burns?
Are hard hats provided and worn where danger of falling objects exists?
Are hard hats inspected periodically for damage to the shell and suspension system?
Is appropriate foot protection required where there is the risk of foot injuries from hot, corrosive, poisonous substances, falling objects, crushing or penetrating actions?
Are all applicable safety precautions, practices, being used prior to and during entry into any excavation?
Are appropriate protective devices utilized where applicable in the excavation?
Are competent and qualified personnel used when blasting is required?
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Are workers protected from electrical hazards?
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Are the minimum number of toilets and washing facilities provided and are they clean and sanitary?Are portable metal ladders legibly marked with signs reading "CAUTION" "Do Not Use Around Electrical Equipment" or equivalent wording?
Are all ladders maintained in good condition, and are employees instructed to face the ladder when ascending or descending and not to use the top 2 steps of ordinary stepladders as a step?
Are employees prohibited from using ladders that are broken, missing steps, rungs, or cleats, broken side rails or other faulty equipment?
Are floor openings guarded by a standard railing and toeboards or cover?
Are elevator shafts in which cages are not installed and which are not enclosed with solid partitions and doors guarded on all open sides by standard railings and toeboards?
Are workers adequately protected when working on temporary floors?
Are scaffolds provided for all work that cannot be done safely by employees standing on permanent or solid construction at least 20 inches wide, except where such work can be safely done from ladders?
When scaffolds are used, are they properly constructed in accordance with Cal/OSHA Article 22?
When work is performed from thrustouts or similar locations, such as trusses, beams purlins, or plates of 4-inch nominal width, or greater, at elevations exceeding 15 feet above ground, water surface, or floor level below and where temporary guardrail protection is impracticable, are employees using approved safety belts or harnesses with attached lanyards?
Are all tools and equipment (both, company and employee-owned) used by employees at their workplace in good condition?
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Are power tools used with the correct shield, guard or attachment recommended by the manufacturer, portable circular saws equipped with guards above and below the base shoe and checked to assure they are not wedged up, thus leaving the lower portion of the blade unguarded?\
Are all cord-connected, electrically-operated tools and equipment effectively grounded or of the approved double insulated type?
Are ground-fault circuit interrupters provided on all temporary electrical 15 and 20 ampere circuits, used during periods of construction?
Are only authorized and trained personnel permitted to use welding, cutting or brazing equipment?
If cranes are used are they visually inspected for defective components prior to the beginning of any work shift and is a preventive maintenance program established?
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PRESERVED FRUITS AND VEGETABLES MANUFACTURING AND SUGAR AND CONFECTIONERY PRODUCTS
(SIC Codes: 2032-2038, 2061-2068)
Is sufficient clearance provided around and between machines to allow for safe operations, set up and servicing, material handling and waste removal and is there a power shut-off switch within reach of the operator's position at each machine?
Are all pulleys and belts, moving chains and gears and conveyor nip points that are within 7 feet of the floor or working level properly guarded ?
Are revolving drums, barrels and containers required to be guarded by an enclosure that is interlocked with the drive mechanism, so that revolution cannot occur unless the guard enclosure is in place, so guarded?
Is all machinery or equipment capable of movement, required to be de-energized or disengaged and blocked or locked out during cleaning, servicing, adjusting or setting up operations, whenever required?
Does the lock-out procedure require that stored energy (i.e. mechanical, hydraulic, air,) be released or blocked before equipment is locked-out for repairs?
Are only authorized and trained personnel permitted to use welding, cutting or brazing equipment?
Are only trained personnel allowed to operate industrial trucks and does each industrial truck have a warning horn, whistle, gong, or other device which can be clearly heard above the normal noise in the area where operated?
Before entering a confined space, are all appropriate tests conducted, precautions observed, permits obtained, and work practices followed?
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Are employees aware of the hazards involved with the various chemicals they may be exposed to in their work environment?
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Can the work be done without twisting or overly bending the lower back? Are there sufficient rest breaks, in addition to the regular rest breaks, to relieve stress from repetitive-motion tasks?
Are there areas in the workplace where continuous noise levels exceed 85 dBA and if so, are engineering controls being considered to reduce the noise and/or is a hearing conservation program in effect?
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GENERAL MERCHANDISE, FOOD AND APPAREL STORES AND PHOTOGRAPHIC AND TAX PREPARATION
(SIC Codes: 5311, 5399, 5441, 5499, 5632, 5651, 7221, 7291)
Does the task require prolonged raising of the arms?
Do the neck and shoulders have to be stooped to view the task?
Can the work be done without twisting or overly bending the lower back?
Are tools, instruments and machinery shaped, positioned and handled so that tasks can be performed comfortably?
Are all pieces of furniture adjusted, positioned and arranged to minimize strain on all parts of the body?
Are there pressure points on any parts of the body (wrists, forearms, back of thighs)?
Are motorized vehicles and mechanized equipment inspected daily or prior to use?
Are hand trucks maintained in safe operating condition?
Are materials stacked or stored in a manner to prevent tipping or falling?
Are aisles and passageways kept clear?
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Are spilled materials cleaned up immediately?
Do employees complain about dizziness, headaches, nausea, irritation or other factors of discomfort when they use solvents or other chemicals?
Is there a dermatitis problem - do employees complain about skin dryness, irritation, or sensitization?
52
Are electrical appliances such as vacuum cleaners, polishers, vending machines grounded?
Do extension cords being used have a grounding conductor?
Are multiple plug adaptors prohibited?
Are flexible cords and cables free of splices or taps?
53
LOGGING
(SIC Code 2411)
Has first aid, communication and transportation been provided for?
Do all employees have appropriate personal protective equipment?
Is all equipment, including rigging, prime movers, winches, chain saws, and hand tools, inspected, maintained and safely operated?
Are required distances maintained between falling, bucking, and other operations?
When falling, are fallers located so that they will not endanger other employees?
Are suitable warning signs or other controls provided where needed to prevent foot or vehicle traffic from entering danger areas?
Are tree falling/bucking procedures and precautions, including procedures for recognizing and working with hazard trees, snags, lodged trees, being followed?
Are yarding operations using effective communication systems, and are safe procedures being followed insetting and unhooking chokers?
Are landing and loading operations, including release of rigging, landing layout, moving vehicles and equipment, and log truck locating, loading and wrapping, being safely performed by workers?
Are landings of adequate size for the operations, properly prepared and laid out, and reasonably clear of debris?
Is mobile equipment in suitable condition and provided with seat belts, backup alarms where required?
54
Do tractors have suitable roll-over protection, canopies, and Jill-Poke protection? Is the yarder rigging, butt-rigging, guylines, and stumps being properly inspected, maintained and used?
55
Are approved containers and tanks used for the storage and handling of flammable liquids?
Is the transfer/withdrawal of flammable or combustible liquids performed by trained personnel?
56
MOTION PICTURE PRODUCTION AND SERVICES AND THEATRICAL PRODUCERS

(SIC Codes: 7812-7819, 7922-7929)
Are workers protected against accidental falls from elevated locations?
Is the use of elevated platforms, including condors and scissors lifts, in accordance with safety regulations?
Is the use of pyrotechnics in accordance with safe work practices?
Are only authorized personnel allowed to handle pyrotechnic devices and material?
Are work areas free from slipping, tripping, and falling hazards?
Are your workplace electricians familiar with the Cal/OSHA Electrical Safety Orders?
Do extension cords have a grounding conductor?
Are all temporary circuits protected by suitable disconnecting switches or plug connectors at the junction with permanent wiring?
Is exposed wiring and cords with frayed or deteriorated insulation repaired or replaced promptly?
Is sufficient access and working space provided and maintained about all electrical equipment to permit ready and safe operations and maintenance?
Are workers trained in proper lifting techniques?
Are work surfaces kept dry or appropriate means taken to assure the surfaces are slip-
57
resistant?
Is there safe clearance for equipment through aisles and doorways?
Are employees trained in the use of fire extinguisher?
Are there areas in the workplace where noise levels may exceed the permissible exposure limits?
Is approved hearing protective equipment available to employees exposed to excessive noise levels?
Are combustible scrap, debris and waste materials (i.e. oily rags) stored in covered metal receptacles and removed from the worksite promptly?.
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RECREATIONAL AND AMUSEMENT PARKS AND CAMPS AND RECREATION SERVICES

(SIC Codes: 7032-7033, 7941-7948, 7996, 7999)
Do amusement rides have the required testing, emergency brakes, anti-rollback devices, and speed limiting devices?
Is the amusement ride inspected and maintained each day before use?
Do only authorized persons perform or supervise the assembly or disassembly of amusement rides?
Are your workplace electricians familiar with the Cal/OSHA Electrical Safety Orders?
Are employees instructed to make preliminary inspections and/or appropriate tests to determine what conditions exist before starting work on electrical equipment or lines?
Do extension cords being used have a grounding conductor?
Are all temporary circuits protected by suitable disconnecting switches or plug connectors at the junction with permanent wiring?
Are flexible cords and cables free of splices or taps?
Are employees providing first-aid or medical services trained in infection control procedures?
Is personal protective equipment provided to employees, and in all appropriate locations?
Has medical surveillance including HBV evaluation, antibody testing and vaccination been made available to potentially exposed employees?
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Are there pressure points on any parts of the body (wrists, forearms, back or thighs)?
Are employees instructed in proper lifting techniques?
Have emergency escape procedures and routes been developed and communicated to all employees?
Are all work areas properly illuminated?
Are employees trained in the safe handling practices of hazardous chemicals?
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SCHOOL BUSES, SCHOOLS, COLLEGES AND UNIVERSITIES AND JOB TRAINING AND RELATED SERVICES
(SIC Codes: 4151, 8211, 8221-8222, 8331)
Are employees who operate vehicles on public thoroughfares instructed in safe driving practices?
Is there a list of hazardous substances used in your workplace?
Is each container for a hazardous substance labeled with product identity and a hazard warning (communication of the specific health hazards and physical hazards)?
Is there an employee training program for hazardous substances?
Are incompatible laboratory chemicals separated in storage?
Have standard operating procedures been established and are they being followed when cleaning up chemical spills?
Is a Chemical Hygiene Plan developed and implemented?
Are employees providing first-aid or medical services trained in infection control procedures?
Is personal protective equipment provided to employees, and in all appropriate locations?
Have infection control procedures been instituted where appropriate, such as ventilation, universal precautions, workplace practices, personal protective equipment?
Has medical surveillance including HBV evaluation, antibody testing and vaccination been
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made available to potentially exposed employees?
Are all pieces of furniture adjusted, positioned and arranged to minimize strain on all parts of the body?
Can the work be performed without eye strain or glare to the employees?
62
Do employees complain about dizziness, headaches, nausea, irritation or other factors of discomfort when they use solvents or other chemicals?
63
Appendix C Hazard Assessment and Correction Record
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Hazard Assessment and Correction Record
Date of Inspection: ________________________________________ Person Conducting Inspection: _______________________________ Unsafe Condition or Work Practice: __________________________________________________________________________ ____ __________________________________________________________________________ ____ __________________________________________________________________________ ____
Corrective Action Taken: __________________________________________________________________________ ____ __________________________________________________________________________ ____ __________________________________________________________________________ ____
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Appendix D Accident/Exposure Investigation Report
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Accident/Exposure Investigation Report

Date of Accident: _____________________________ Time of Accident: __________________ Location of Accident: ___________________________________________________________ Accident Description: __________________________________________________________________________ ____ __________________________________________________________________________ ____ __________________________________________________________________________ ____ Employees Involved: __________________________________________________________________________ ____ __________________________________________________________________________ ____ Preventive Action Recommendations: __________________________________________________________________________ ____ __________________________________________________________________________ ____
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Injury & Illness Prevention Program (For General Industry Employers with Intermittent Employees) Corrective Actions Taken: __________________________________________________________________________ ____ __________________________________________________________________________ ____ Manager Responsible: ________________________________________ Date Corrective Actions Completed: _____________________________
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Appendix E Employee Training and Instruction Record
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Employee Training and Instruction Record

Employee Receiving Training:
(First Name)
(Middle Initial)
(Last Name)
(Safety Training Topic) Select one: Initial Periodic Annual/Refresher Special
This employee has received specific safety & health training in the following subject areas:
Person conducting the training: (First Name) Trainers Signature (Middle Initial) (Last Name) Date
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Qualification or Job Title of Trainer
Trainees Signature
Date
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Appendix F Employee Acknowledgement Form
72
Employee Acknowledgement Form

I hereby acknowledge that I have had the opportunity to read, review and ask questions on the contents of the companys Injury and Illness Prevention Program. I also acknowledge that the provisions of this program and company safety and health policies are part of the terms and conditions of my employment and agree to abide by them. Furthermore, I understand that failure to comply with any part or parts of this program and any company safety and health policies may be grounds for termination of my employment. Additionally, I understand that failure to comply with the companys Drug-Free Workplace Policy shall also be grounds for termination of my employment.
Employee - Print Your Name Social Security Number
Signature of Employee
Date
As an employee representative of the company, I hereby attest that the employee named here was given the opportunity to read, review and ask questions about the companys Injury and Illness Prevention Program and company safety and health policies.
Witness Print Your Name
Duty Title of Witness
Signature of Witness
Date
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Safety Office Depot Disclaimer Notice While we have made every attempt to ensure that the information contained in this document is reliable, Safety Office Depot is not responsible for any errors or omissions, or for the results obtained from the use or non-use of this information. All information in this document is provided "as is", with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use or nonuse of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance, merchantability and fitness for a particular purpose. In no event will Americana Safety Associates, Safety Office Depot, or the partners, agents or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information in this document or for any consequential, special or similar damages, even if advised of the possibility of such damages. Given the changing nature of laws, rules and regulations, there may be omissions or inaccuracies in information contained in this document. Accordingly, the information in this document is provided with the understanding that the authors and publishers are proving guidance with respect to the information contained herein and that the performance or non-performance of this guidance shall be the responsibility of the user of this information.
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IIP Program For General Industry Employers With Intermittent Employees

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Injury and Illness Prevention Program

General Industry Employers

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Program Policy & Requirement

Employers in an industry which has been determined by OSHA as historically utilizing

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Safety Training and Instruction

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areas neat and orderly, and promptly cleaning up spills.

Prohibiting horseplay, scuffling, or other acts that tend to adversely

Proper storage to prevent stacking goods in an unstable manner and

hazards, and proper labeling of containers.

Proper storage and handling of toxic and hazardous substances including

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We are on a designated list of low hazard industries as

established by the Department of Industrial Relations. and

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rate of greater than 1.1; and

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Company Required Safety Programs

Company Required Safety and Health Plans & Programs

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Section 11 Company Required Safety Training Courses

Company Required Safety Training Courses Sorted A-E

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Company Required Safety Training Courses Sorted F-L

Company Required Safety Training Courses Sorted M-W

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Company Required Safety Forms & Checklists

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TRAINING RECOGNITION CERTIFICATE Certificate of Completion

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List of Training Subjects

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AGRICULTURE PRODUCTION AND FARM LABOR AND MANAGEMENT SERVICES

Hazardous chemical exposures

Other job-specific hazards, such as _______________________________________________________________________ _______________________________________________________________________

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HEAVY CONSTRUCTION AND SPECIAL TRADES CONTRACTORS

The employer's Code of Safe Practices.

Safe access to working areas

Protection from falls

Electrical hazards, including working around high voltage lines

Trenching and excavation work

Proper use of powered tools

Ergonomic hazards, including proper lifting techniques

Other job-specific hazards, such as _______________________________________________________________________ _______________________________________________________________________

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Machine, machine parts, and prime movers guarding

Ergonomic hazards, including proper lifting techniques

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _

Other job-specific hazards, such as _ _