INJURY AND ILLNESS PREVENTION PROGRAM (IIPP) (School District) THE ETIWANDA SCHOOL DISTRICT will institute and administer a comprehensive and continuous occupational Injury and Illness Prevention Program (IIPP) for all employees. The health and safety of the individual employee takes precedence over all other concerns. Management’s goal is to prevent accidents, to reduce personal injury and occupational illness and to comply with all safety and health standards.

I. RESPONSIBILITY

The Program Administrator, LAURA ROWLAND, is the person with responsibility and authority for overall management and administration of the Injury and Illness Prevention Program. Each Supervisor and Site Administrator is responsible for implementing the IIPP in his/her work area. A copy of the IIPP shall be available from each Supervisor and Site Administrator. Questions regarding the program should be directed to him/her.

II. EMPLOYEE COMPLIANCE

Employees who follow safe and healthy work practices will have this fact recognized and documented on their performance reviews. Employees who are unaware of correct safety and health procedures will be trained or retrained.

Willful violations of safe work practices may result in disciplinary action in accordance with district policies.

III. COMMUNICATION

Matters concerning occupational safety and health will be communicated to employees by written documentation, staff meetings, formal and informal training and posting. Communication from employees to supervisors and/or the safety representatives about unsafe or unhealthy conditions is encouraged and may be verbal or written, as the employee chooses. The employee may use the “Report of Safety Hazard” form in the IIPP and remain anonymous.

NO EMPLOYEE WILL BE RETALIATED AGAINST FOR REPORTING HAZARDS OR POTENTIAL HAZARDS OR FOR MAKING SUGGESTIONS RELATED TO SAFETY.

The results of the investigation of any employee safety suggestion or report of hazard will be distributed to all employees affected by the hazard or shall be posted on appropriate bulletin boards.

IV. INSPECTIONS

Each supervisor and/or safety representative will conduct an inspection/investigation to identify unsafe work conditions and practices:

1. ANNUALLY in all work areas; and

(State Frequency)

2. Whenever new substances, processes, procedures or equipment are introduced into the workplace that represent a new occupational safety and health hazard; and

3. Whenever the Supervisor/Safety Representative is made aware of a new or previously

unrecognized hazard.

The “Hazard Checklist” or “Hazard Assessment” form in this IIPP shall be used to document these inspections/investigations.

V. INJURY AND ILLNESS INVESTIGATION

Occupational injuries and illness will be investigated in accordance with established procedures and documented, as described in this IIPP.

VI. CORRECTION OF UNSAFE OR UNHEALTHY CONDITIONS

Whenever an unsafe or unhealthy condition, practice, or procedure is observed, discovered, or reported, the Program Administrator or designee will take appropriate corrective measures in a timely manner based upon the severity of the hazard. Employees will be informed of the hazard and interim protective measures taken until the hazard is corrected.

Employees may not enter an imminent hazard area, without appropriate protective equipment, training, and the prior specific approval of the Program Administrator or designee.

VII. TRAINING

A. The Program Administrator or designee shall assure that supervisors receive training to

familiarize them with the safety and health hazards to which employees under their immediate direction and control may be exposed.

B. Supervisors are responsible to see that those under their direction receive training on general

workplace safety as well as specific instructions with regard to hazards unique to any job assignment.

This training is provided:

1. To all employees and those given new job assignments for which training has not

previously been received. The “Employee Safety Checklist” in this IIPP should be used to document this training.

2. Whenever new substances, processes, procedures or equipment are introduced to the

workplace and represent a new hazard; and

3. Whenever the employer is made aware of a new or previously unrecognized hazard.

When a supervisor is unable to provide the required training he/she should request such Training be given to the employee by others through notification of the Program Administrator or designee

VIII. RECORDKEEPING

The program Administrator or designee shall keep records of inspections, including the name of the person(s) conducting the inspection, the unsafe conditions and work practices that have been identified and action taken to correct the identified unsafe conditions and work practices. These records shall be maintained for three (3) years.

The Program Administrator or designee shall also keep documentation of safety and health training attended by each employee, including employee name or other identifier, training dates, type(s) of training and training providers. The documentation shall be maintained for three (3) years.

This IIPP contains a variety of sample forms for documentation training/communication.

IX. SAFETY AND HEALTH COMMITTEE

The district elects to use a safety and health committee. Membership is comprised of an appointee from each site/department. This appointee is responsible for communicating safety and health matters to all classified and certificated staff at their respective sites/departments. Duties are as follows:

1. Meet at least quarterly; 2. Maintain and distribute to affected employees a written record of meetings; 3. Review results of the periodic, scheduled worksite inspections; 4. Review incident and near-miss investigations, and where necessary, submit suggestions

for the prevention of future incidents; 5. Review investigations of alleged hazardous conditions brought to the attention of any

committee member; 6. Conduct own inspections and investigation to assist in remedial solutions; 7. Evaluate employee safety suggestions and submit recommendations. 8. Verify abatement action taken by the district as specified in CAL-OSHA citations when

requested by CAL-OSHA. 9. Perform a periodic review of student/third party accident, incident or claim reports to

identify adverse trends and risks for which corrective action is appropriate.

EMPLOYEE

COMMUNICATION

AND

COMPLIANCE

SAFETY AND HEALTH COMPLIANCE PROCESS Disciplinary measures are progressive and involve four steps:

1. Should a safety and health violation be noted, the supervisor is to informally discuss the behavior with

the employee, stating the potential dangerous result and outlining the correct procedure, then retrain the employee to ensure understanding.

2. A second violation should generate either a formal verbal warning or written warning to the employee,

depending on the severity.

3. The third infraction results in a formal written warning or suspension of the employee.

4. A fourth violation may lead to employee termination.

CONSTRUCTION SAFETY ORDERS

(APPLIES TO M&O EMPLOYEES)

CODE OF SAFE PRACTICES

GENERAL

1. All persons shall follow these safe practices rules, render every possible aid to safe operations, and

report all unsafe conditions or practices to their site administrator, supervisor or program administrator. 2. Foreman shall insist on employees observing and obeying every applicable District, State or Federal

regulation and order as is necessary to the safe conduct of the work, and shall take such action as is necessary to obtain compliance.

3. All employees shall be given frequent accident prevention instructions. Instructions shall be given at

least every 10 working days. 4. Anyone known to be under the influence of drugs or intoxicating substance which impair the employees

ability to safely perform the assigned duties shall not be allowed on the job while in that condition. 5. Horseplay, scuffling, and other acts which tend to have an adverse influence on the safety or well-being

of the employees shall be prohibited. 6. Work shall be well planned and supervised to prevent injuries in the handling of materials and in

working together with equipment. 7. No one shall knowingly be permitted or required to work while the employee’s ability or alertness is so

impaired by fatigue, illness, or other causes that they might unnecessarily expose the employee or others to injury.

8. Employees shall not enter manholes, underground vaults, chambers, tanks silos, or other similar places

that receive little ventilation unless it has been determined that it is safe to enter. 9. Employees shall be instructed to ensure that all guards and other protective devices are in proper places

and adjusted, and shall report deficiencies promptly to the foreman or superintendent. 10. Crowding or pushing when boarding or leaving any vehicle or other conveyance shall be prohibited.

11. Workers shall not handle or tamper with any electrical equipment, machinery, or air or water lines in a

manner not within the scope of their duties, unless they have received instructions from their foreman.

12. All injuries shall be reported promptly to the supervisor so that arrangements can be made for medical or first aid treatment.

13. When lifting heavy objects, the large muscles of the leg instead of the smaller muscles of the back shall be used.

14. Inappropriate footwear or shoes with thin or badly worn soles must not be worn.

15. Materials, tools, or other objects shall not be thrown from buildings or structures until proper

precautions are taken to protect others from the falling objects. 16. Employees shall cleanse themselves thoroughly after handling hazardous substances and follow special

instructions from authorized sources. 17. Hod carriers should avoid the use of extension ladders when carrying loads. Such ladders may provide

adequate strength, but the rung position and rope arrangement make such climbing difficult and hazardous for this trade.

18. Work shall be arranged so that employees are able to face a ladder and use both hands while climbing.

19. Gasoline shall not be used for cleaning purposes.

20. No burning, welding, or other source of ignition shall be applied to any enclosed tank or vessel, even if

there are some openings, until it has first been determined that no possibility of explosion exists and authority for the work is obtained from the supervisor.

21. Any damage to scaffolds, falsework, or other supporting structures shall be immediately reported to the

supervisor.

USE OF TOOLS AND EQUIPMENT 22. All tools and equipment shall be maintained in good condition.

23. Damaged tools or equipment shall be removed from service and tagged “DEFECTIVE”.

24. Pipe or Stillson wrenches shall not be used as a substitute for other wrenches.

25. Only appropriate tools shall be used for a specific job.

26. Wrenches shall not be altered by the addition of handle-extensions or “cheaters”.

27. Files shall be equipped with handles and not used to punch or pry.

28. A screwdriver shall not be used as a chisel.

29. Wheelbarrows shall not be pushed with handles in an upright position.

30. Portable electric tools shall not be lifted or lowered by means of the power cord. Ropes shall be used. 31. Electric cords shall not be exposed to damage from vehicles.

32. In locations where the use of a portable power tool is difficult, the tool shall be supported by means of a

rope or similar support of adequate strength.

MACHINERY AND VEHICLES 33. Only authorized persons shall operate machinery or equipment.

34. Loose or frayed clothing, long hair, dangling ties, finger rings, etc., shall not be worn around moving

machinery or other area where they may become entangled. 35. Machinery shall not be serviced, repaired, or adjusted while in operation, nor shall oiling of moving

parts be attempted, except on equipment that is designed or fitted with safeguards to protect the person performing work.

36. Where appropriate, lock-out procedures shall be used.

37. Employees shall not work under vehicles supported by jacks or chain hoists without protective blocking

that will prevent injury if jacks or hoists should fail. 38. Air hoses shall not be disconnected at compressors until the hose line had been bled.

39. All excavations shall be visually inspected before backfilling to ensure that it is safe to backfill.

40. Excavating equipment shall not be operated near tops of cuts, banks, or cliffs if employees are working

below. 41. Tractors, bulldozers, scrapers and carryalls shall not operate where there is possibility of overturning in

dangerous areas like edges of fills, cut banks, and steep slopes. 42. When loading where there is a probability of dangerous slides or movement of materials, the wheels or

treads of loading equipment, other than that riding on rails, should be turned in the direction which will facilitate escape in case of danger, except in situation where this position of the wheels or treads would cause a greater operational hazard.

CODE OF SAFE PRACTICES

General Work Areas It is our policy that everything possible will be done to protect employees, students and visitors from accidents. Safety is a cooperative undertaking requiring participation by every employee. Failure by any employee to comply with safety rules will be grounds for corrective discipline. Supervisors shall insist that employees observe all applicable District, State and Federal safety rules and practices and take action as is necessary to obtain compliance.

To carry out this policy employees shall:

1. Report all unsafe conditions and equipment to their supervisor or safety coordinator.

2. Report all accidents, injuries and illnesses to their supervisor or safety coordinator immediately.

3. Anyone known to be under the influence of intoxicating liquor or drugs shall not be allowed on the job

while in that condition.

4. Horseplay, scuffling, and other acts which tend to have an adverse influence on the safety or well-being of the employees are prohibited.

5. Means of egress shall be kept unblocked, well lighted and unlocked during work hours.

6. In the event of fire, sound alarm and evacuate.

7. Upon hearing fire alarm, stop work and proceed to the nearest clear exit. Gather at the designated

location.

8. Only trained workers may attempt to respond to a fire or other emergency.

9. Exit doors must comply with fire safety regulations during business hours. Deadbolt locks on exits must never be used.

10. Stairways should be kept clear of items that can be tripped over and all areas under stairways that are

egress routes should not be used to store combustibles.

11. Materials and equipment will not be stored against doors or exits, fire ladders or fire extinguisher stations.

12. Aisles must be kept clear at all times.

13. Work areas should be maintained in a neat, orderly manner. Trash and refuse are to be thrown in proper waste containers.

14. All spills shall be wiped up promptly.

15. Always use the proper lifting technique. Never attempt to lift or push an object which is too heavy. You

must contact your supervisor when help is needed to move a heavy object. 16. Never stack material precariously on top of lockers, file cabinets or other relatively high places.

17. When carrying material, caution should be exercised in watching for and avoiding obstructions, loose

material, etc. 18. Do not stack material in an unstable manner.

19. Report exposed wiring and cords that are frayed or have deteriorated insulation so that they can be

repaired promptly. 20. Never use a metal ladder where it could come in contact with energized parts of equipment, fixtures or

circuit conductors. 21. Maintain sufficient access and working space around all electrical equipment to permit ready and safe

operations and maintenance. 22. Do not use any portable electrical tools and equipment that are not grounded or double insulated.

23. All electrical equipment should be plugged into appropriate wall receptacles or into an extension of only

one cord of similar size and capacity. Three-pronged plugs should be used to ensure continuity of ground.

24. All cords running into walk areas must be taped down or inserted through rubber protectors to preclude

them from becoming tripping hazards. 25. Inspect motorized vehicles and other mechanized equipment daily or prior to use.

26. Shut off engine, set brakes and block wheels prior to loading or unloading vehicles.

27. Inspect pallets and their loads for integrity and stability before loading or moving.

28. Do not store compressed gas cylinders in areas which are exposed to heat sources, electric arcs or high

temperature lines. All cylinders must be secured to prevent them from falling. 29. Do not use compressed air for cleaning off clothing unless the pressure is less than 10 psi.

30. Identify contents of pipelines prior to initiating any work that affects the integrity of the pipe.

31. Wear hearing protection in all areas identified as having high noise exposure. 32. Goggles or face shields must be worn when grinding.

33. Do not use any faulty or worn hand tools.

34. Guard floor openings by a cover, guardrail, or equivalent.

35. Do not enter into a confined space unless tests for toxic substances, explosive concentrations, and

oxygen deficiency have been taken. 36. Always keep flammable or toxic chemicals in closed containers when not in use.

37. Do not eat in areas where hazardous chemicals are present.

38. Be aware of the potential hazards involving various chemicals stored or used in the workplace. All

flammables should be stored in an approved flammables storage cabinet. 39. Cleaning supplies should be stored away from edible items on kitchen shelves.

40. Cleaning solvents and flammable liquids should be stored in appropriate containers.

41. Solutions that may be poisonous or not intended for consumption should be kept in well labeled

containers. 42. When working with a VDT, have all pieces of furniture adjusted, positioned and arranged to minimize

strain on all parts of the body. 43. Never leave lower desk or cabinet drawers open that present a tripping hazard. Use care when opening

and closing drawers to avoid pinching fingers. 44. Do not open more than one upper drawer at a time; particularly the top two drawers on tall file cabinets.

45. Individual heaters at work areas should be kept clear of combustible materials such as drapes or waste

from waste baskets. Newer heaters which are equipped with tip-over switches should be used. 46. Appliances such as coffee pots and microwaves should be kept in working order and inspected for signs

of wear, heat or fraying of cords. 47. Fans used in work areas should be guarded. Guards must not allow fingers to be inserted through the

mesh. Newer fans are equipped with proper guards.

CODE OF SAFE PRACTICES

General Office and Classrooms It is our policy that everything possible will be done to protect employees, students and visitors from accidents. Safety is a cooperative undertaking requiring participation by every employee. Failure by any employee to comply with safety rules will be grounds for corrective discipline. Supervisors shall insist that employees observe all applicable District, State and Federal safety rules and practices and take action as is necessary to obtain compliance.

To carry out this policy employees shall:

1. Report all unsafe conditions and equipment to their supervisor of safety coordinator.

2. Report all accidents, injuries and illnesses to their supervisor or safety coordinator immediately.

3. Means of egress shall be kept unblocked, well lighted and unlocked during work hours.

4. In the event of fire, sound alarm and evacuate.

5. Upon hearing the fire alarm, stop work and proceed to the nearest clear exit. Gather at the designated

location.

6. Only trained workers may attempt to respond to a fire or other emergency.

7. Exit doors must comply with fire safety regulations during business hours. Deadbolt locks on exits must never be used.

8. Stairways should be kept clear of items that can be tripped over and all areas under stairways that are

egress routes should not be used to store combustibles.

9. Materials and equipment will not be stored against doors or exits, fire ladders or fire extinguisher stations.

10. Aisles must be kept clear at all times.

11. Work areas should be maintained in a neat, orderly manner. Trash and refuse are to be thrown in proper

waster containers.

12. All spills shall be wiped up promptly.

13. Files and supplies should be stored in such a manner as to preclude damage to the supplies or injury to personnel when they are moved. Heaviest items should be closet to the floor and lightweight items stored above.

14. All cords running into walk areas must be taped down or inserted through rubber protectors to preclude them from becoming tripping hazards.

15. Never stack material precariously on top of lockers, file cabinets or other high places.

16. Never leave lower desk or cabinet drawers open that present a tripping hazard. Use care when opening

and closing drawers to avoid pinching fingers. 17. Do not open more than one upper drawer at a time; particularly the top two drawers on tall file cabinets.

18. Always use the proper lifting technique. Never attempt to life or push an object which is too heavy. You

must contact your supervisor when help is needed to move a heavy object. 19. When carrying material, caution should be exercised in watching for and avoiding obstructions, loose

material, etc. 20. All electrical equipment should be plugged into appropriate wall receptacles or into an extension of only

one cord of similar size and capacity. Three-pronged plugs should be used to ensure continuity of ground.

21. Individual heaters at work areas should be kept clear of combustible materials such as drapes or waste

from waste baskets. Newer heaters which are equipped with tip-over switches should be used. 22. Appliances such as coffee pots and microwaves should be kept in working order and inspected for signs

of wear, heat or fraying of cords. 23. Fans used in work areas should be guarded. Guards must not allow fingers to be inserted through the

mesh. Newer fans are equipped with proper guards. 24. Equipment such as scissors, staples, etc., should be used for their intended purposes only and should not

be misused as hammers, pry bars, screwdrivers, etc. Misuse can cause damage to the equipment and possible injury to the user.

25. Cleaning supplies should be stored away from edible items on kitchen shelves.

26. Cleaning solvents and flammable liquids should be stored in appropriate containers.

27. Solutions that may be poisonous are not intended for consumption should be kept in well labeled

containers. 28. Use appropriate climbing equipment such as stepstools or ladders in lieu of desks, chairs and

countertops.

ACCIDENT

INVESTIGATION

BASIC RULES FOR ACCIDENT INVESTIGATION*

- The purpose of an investigation is to find the cause of an accident and prevent further occurrences, not to fix the blame. An unbiased approach is necessary to obtain objective findings.

- Visit the accident scene as soon as possible while the facts are fresh and before witnesses

forget important details

- If possible, interview the injured worker at the scene of the accident and ‘walk” with him or her through a re-enactment.

- All interviews should be conducted as privately as possible. Interview witnesses one at a

time. Talk with anyone who has knowledge of the accident, even if they did not actually witness it.

- Consider taking signed statements in cases where facts are unclear or there is an element

of controversy.

- Document details graphically. Use sketches, diagrams and photos as needed, and take measurements when appropriate.

- Focus on causes and hazards. Develop an analysis of what happened, how it happened

and how it could have been prevented. Determine what caused the accident itself, not just the injury.

- Every investigation should include an action plan. How will you prevent such accidents

in the future?

- If a third party or defective product contributed to the accident, save any evidence. It could be critical to the recovery of claims costs.

* Every employer shall report immediately (within 8 hours) by telephone or telegraph to the nearest District Office of the Division of Occupational Safety and Health any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment (see CCR Title 8, Section 342).

VEHICLE ACCIDENT REPORT

What to do in Case of Vehicular Accident 1. Warn other motorist. Use flashlight, flares or car

lights. SCHOOL DISTRICT: 2. ADDRESS: 3. PHONE: 4.

DATE OF ACCIDENT: TIME: 5. LOCATION OF COLLISION: POLICE REPORT #: 6.

VIOLATIONS/CITATIONS: 7.

Call police. If someone is injured, summon ambulance. Write down facts. Get as much information as possible. Obtain names, addresses and telephone numbers of all witnesses. This is very important. DON’T ADMIT LIABILITY, but give other party your name and address. Advise the Risk Services Department. Notify your supervisor of the accident immediately. Complete vehicular accident report form immediately.

DISTRICT/

VEHICLE #

YEAR

MAKE

MODEL

PERSONAL DRIVER OWNER DRIVER'S LICENSE VEHICLE SUPERVISOR WORK PHONE

DAMAGES

OTHER VEHICLE # YEAR MAKE MODEL

VEHICLE DRIVER OWNER D.O.B.

DRIVER'S LICENSE

OR ADDRESS PHONE # PROPERTY INSURANCE CO./POLICY #

DAMAGES

AGENT'S PHONE #

INJURIES

NAME DOB ADDRESS PHONE #

DIST. AUTO

OTHER AUTO PED

WITNESSES NAME DOB ADDRESS PHONE #

USE SYMBOL & NUMBER YOUR CAR #1, OTHER CAR #2. MARK STOP SIGNS AND STOP LIGHTS. GIVE STREET NAMES OR NUMBERS OF OF HIGHWAYS. SHOW POSITION OF CAR BEFORE, AT, AND AFTER IMPACT. DESIGNATE THE NUMBER OF TRAFFIC LANES FOR EACH DIRECTION.

EXPLAIN FULLY THE MANNER IN WHICH ACCIDENT OCCURRED:

DIAGRAM OF

ACCIDENT N

DRIVER SIGNATURE SUPERVISOR SIGNATURE

DATE DATE

RETURN FORM TO RISK SERVICES DEPARTMENT

HAZARD

EVALUATION

AND

ABATEMENT

EMPLOYEE SAFETY INFORMATION CHECKLIST

NOTE: This checklist is to be completed by the Site Administrator or Supervisor within 30 days after employment. The employee shall, upon 30 days post hire, schedule with his/her supervisor or the Site Administrator to receive training on the below-listed items. After completion, this checklist is to be returned to the Personnel Department.

EMPLOYEE NAME HIRE DATE SITE ASSIGNED TO JOB TITLE

THE FOLLOWING SAFETY SUBJECTS WERE DISCUSSED WHERE APPLICABLE

Review of IIPP and District Safety and Health Committee N/A Date and

Reviewer's Initials

SPECIFIC AND GENERAL SAFE WORK PRACTICES (i.e. proper lifting, chemical usage, ladders, etc.)

District safety rule enforcement and disciplinary procedures.

Employee responsibility for the prevention of accidents

Importance of good housekeeping practices

Workers' Compensation benefits for work-related injuries

Procedures for medical treatment (i.e. location of clinic and use of medical service order)

How, where and when to report work-related injuries

Use of tools and equipment

Proper guarding of equipment

Protective equipment required (i.e. steel tow shoes, safety glasses, goggles, etc.)

Training on use of chemicals

Operation of District vehicles

Use of hand trucks, carts, etc.

Student safety issues (i.e. playgrounds, shops, supervision and accident reporting procedures)

Emergency procedures

Supervisor Signature Date

Employee Signature Date

INSPECTION HAZARD SUMMARY (DISTRICT NAME)

LOCATION (SITE NAME)

INSPECTED BY

DATE

Indicate urgency for correction on 1-5 scale 1=Immediate 5=Prioritize & Schedule Repair

SAFETY HAZARD IDENTIFIED

CORRECTIVE ACTION TO BE TAKEN

Safety items identified during inspection/investigation will be submitted to (date)

(name) for review, and an action plan will be developed to resolve

each specific safety item (hazards, needed policies, etc.) by a set completion date by those assigned responsibility. This form will be used to document identified problems, steps to be taken, and urgency of the hazard.

GENERAL HEALTH AND SAFETY CHECK LIST

Check mark next to any item on this list which indicates a potential safety or health hazard that should be corrected. ELECTRICAL

Use of unnecessary extension cords

FLAMMABLE LIQUIDS AND OTHER CHEMICALS

Containers are not clearly labeled Electrical cord tripping hazard

Access to the electrical panel is obstructed Electrical cords run through wall openings or doorways Electrical cords are under rugs or mats Electrical plugs are defective Electrical equipment is not grounded "Live" connections in electrical equipment are exposed

Flammable liquids or other chemicals are stored in open containers Excess quantities of flammable liquids are stored in the building Flammable liquids are stored near exits, in aisles, or on stairways Safety Data Sheets (SDS) are not readily

EXITS AND AISLES

Locks or latches are on doors equipped with "panic

available to office employees HEAT PRODUCING APPLIANCES

Combustible material is stored in the heater area or hardware" Obstructions are present in aisles or exits, or on stairways Exits are locked while room is in use "Panic hardware" is not present on exit doors "Panic hardware" is not working on exit doors Directions to exit or exits are not clearly marked Lack of adequate lighting for aisles, exits, or stairways Emergency lighting is not present or not working Fire escape is not kept clear Exits don't open on a public way Not enough exits

near another source of ignition Flammable liquids are stored in the heater room All portable heaters are not "UL" listed, and do not

have tip-over shut-off switches

WORK AREAS/REST AREAS

Plumbing fixtures (fountains, sinks, urinals, etc.) leak

Floor mats are not slip-resistant

Stairways don't have anti-slip treads or handrails Slip-resistant preparation is not used on highly polished floors Lack of adequate space between desks and furniture to provide for safe passage Desks or cabinets are arranged so that drawers open into passage areas Inadequate lighting Damaged floor surfaces Ladders are not available to reach overhead storage areas Ladders are damaged or broken Riser heights on stairways are not uniform Glass walls or doors are not impact resistant Glass walls or doors are not clearly marked Heavy objects are placed on top of cabinets or partitions Lack of adequate ventilation in areas with photocopies or other similar machines Video display terminal operators complain of headaches, stress, or eyestrain Noise level is too high Temperature level is too high or too low Lack of adequate ventilation in areas where there is the use of potentially toxic materials, chemicals, or fluids Noticeable dust or odors in the air (especially in "energy-efficient" buildings)

FIRE ALARM SYSTEM

Fire alarm system is not tested regularly

Lack of evacuation plan

Employees are not familiar with evacuation plan or their responsibilities in case of emergency Evacuation plan is not posted

FIRE EXTINGUISHERS

Locations of extinguishers are not clearly marked

Required types or number are not readily accessible Extinguishers are not serviced or tagged at least yearly Employees are not trained in the use of extinguishers Extinguishers are not checked monthly and initialed on

back of tag FIRE PROTECTION INSTALLATIONS

Access to standpipes, fire hoses, or sprinkler control valves

is not kept clear Sprinkler system is not tested regularly Sprinkler valves are not kept in "open" position Decorations or other material is attached to sprinkler system Sprinkler heads are damaged, corroded, or have been painted over

INJURY / ILLNESS PREVENTION PROGRAM Training Meeting

DATE TIME AM/PM

CONDUCTED BY TITLE

SUBJECT DISCUSSED (INCLUDING VIDEOS USED)

SIGNATURES OF EMPLOYEES IN ATTENDANCE

NAME JOB TITLE SITE

NOTE: This form should be filed with the Program Administrator or Site Administrator when completed. A special safety training file should be used for this purpose.

REPORT OF SAFETY HAZARD

DATE REPORTED SITE NAME

NAME (OPTIONAL)

Note: This form must be submitted to the IIPP Program Administrator for follow up action.

Received By: Date:

WHITE: RETAIN AT SITE

YELLOW:DISTRICT COPY

PINK: SITE COPY

(AFTER RESOLUTION) (AFTER RESOLUTION)

UNSAFE CONDITION OR ACT (BY EMPLOYEE) BEING REPORTED:

SUGGESTIONS FOR CORRECTION:

RESOLUTIONS OF SAFETY HAZARD (DISTRICT USE ONLY):