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Division of Labor Standards
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Managing Worker Safety and Health

APPENDIX 12-1

EXAMPLE OF A SELF-EVALUATION CHECKLIST FOR SMALL BUSINESSES

Instructions: Fill out the last five columns after judging the effectiveness of each part of your safety and health program.  If the part of your program indicated in the first column is fully effective enter "YES" in the second column.  If not fully effective enter "NO".

  • Explain the deficiencies n the "Comments/Improvements" column and list any specific, planned improvements.

  • Indicate the persons responsible for these improvements in the next column.

  • Enter the target date for these improvements.

  • Finally, when the improvements are actually completed enter the completion date in the last column.

ELEMENT I.  MANAGEMENT LEADERSHIP AND EMPLOYEE INVOLVEMENT

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

Policies and objectives are established and communicated to all employees

         

Top management is visibly involved in safety and health

         

Employees are involved in identifying and solving safety and health problems

         

All safety and health responsibilities are clearly assigned

         

Adequate authority and resources are provided to those with responsibility

         

Managers, supervisors and employees are held accountable

         

Program operations are reviewed at least annually to evaluate success in meeting goals and objectives and to prepare new objectives

         

ELEMENT II.  WORKSITE ANALYSIS

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

A baseline comprehensive survey of hazards has been done or updated within the last three years

         

Change analysis is done for every change of facility, equipment, process or material

         

Job hazard analysis is done on an ongoing basis

         

Self-inspections are conducted regularly by adequately trained supervisors in their work areas

         

Broad, regular site inspections are conducted periodically by adequate trained personnel

         

Employees know how and whom to notify about hazards, without fear of reprisal and receive timely and appropriate responses

         

Accidents and near-miss incidents are investigated to identify all contributing causes and to prevent future occurrences

         

Reviews are done of injury and illness experience over a period of time long enough for patterns of potentially common causes to appear.

         

ELEMENT II.  WORKSITE ANALYSIS (CON’T)

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

Reviews are done of injury and illness experience over a period of time long enough for patterns of potentially common causes to appear

         

ELEMENT III.  HAZARD PREVENTION AND CONTROL

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

All identified hazards are prevented or controlled in the best feasible manner

         

Safe work procedures based on job hazard analyses have been established

         

Supervision reinforces safe work through positive feedback and training

         

Enforcement of safe work procedures and safety and health rules is accomplished fairly and efficiently through a disciplinary system that all employees understand

         

New or repeat hazards are identified and corrected in a timely manner

         

The facility and equipment are regularly maintained to prevent hazardous breakdowns

         

Arrangements have been made for occupational health specialists to provide medical services, including assistance in health problem identification

         

ELEMENT III.  HAZARD PREVENTION AND CONTROL (CON’T)

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

First aid and CPR-trained employees are available on every shift

         

Preparations have been made for all types of emergencies

         

Exits, evacuation routes and emergency telephone numbers are prominently displayed

         

ELEMENT IV.  SAFETY AND HEALTH TRAINING

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED

Employees can explain how and why they do the job safely and healthfully

         

Employees use all required PPE properly

         

Employees can explain why PPE is used, how to use it and maintain it and what the limits of its protection are

         

Supervisors can explain safety rules and procedures for hazard control, how they teach this to employees and how they enforce it

         

Managers can explain their safety and health responsibilities

         

SPECIAL OBJECTIVES (LIST AND EVALUATE INDIVIDUALLY)

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED