General Safety Plan Template

From: Staffing

General Safety Plan Template

Introduction

This sample safety plan template must be customized for each company location to reflect the unique exposures related to your business. Resources to assist you, along with best practice tips, are noted throughout this template to help you accomplish this goal.

Review the copy here, but we recommend that you download the customizable Word version of this form here.

Note: As of February 2017, 26 states, Puerto Rico, and the U.S. Virgin Islands have Occupational Safety and Health Administration (OSHA) approved State Plans. Twenty-two State Plans (Alaska, Arizona, California, Hawaii, Indiana, Iowa, Kentucky, Maryland, Michigan, Minnesota, Nevada, New Mexico, North Carolina, Oregon, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington, Wyoming, and Puerto Rico) cover both private and state and local government workplaces. The remaining six State Plans (Connecticut, Illinois, Maine, New Jersey, New York, and the U.S. Virgin Islands) cover state and local government workers only. Each State Plan on the list includes information regarding state standards and what elements differ from the federal regulations. Be sure your safety plan is customized to meet those state standards.

Links to the OSHA state-approved plan information and state offices is available here.

Important tips:

  • Any improvements to safety processes or the overall program should be tracked internally and communicated to your insurance broker and/or carrier. This could help the company with more favorable rates and additional options at policy renewal time.
  • Validate positive safety behaviors (and where possible reward with incentives). This will help spread a positive safety culture for other associates to imitate.
  •  Include the frequency and types of training that your company provides to employees.
NOTE: When using the general safety plan template as a guide to create your company safety plan, be sure to delete the tips and best practice suggestions that are included in the template from your final draft of the safety plan.

 

Sample Template

Section 1:  Management Commitment to Safety and Health

(Insert company name) strives to have the safest possible place of employment for our employees.

The goals for our Safety Program are to:

  • Develop, implement, and maintain a safe workplace for our employees consistent with all applicable state and federal regulations.
  • Control the costs related to workers’ compensation insurance coverage.
  • Consistently improve the safety program to minimize incidents, therefore ensuring our employees’ long-term safety and wellness.
  • Have zero incidents and celebrate a great safety record.

The person responsible for implementing and monitoring the Safety Program at this location is (name of company safety representative).

A copy of this Safety Program is located here: (indicate where copy is located)

 

CEO/President/Safety Director: ________________________________________________

Date: _____________________________

 

Section 2: Roles and Responsibilities

Employer Responsibilities

Under the Occupational Safety and Health Act (OSH Act), it is the employer’s responsibility to provide employees with a workplace free recognized hazards that may cause illness or serious physical harm and to comply with standards, rules, and regulations issued under the OSH Act.

Management must lead by using a variety of techniques to demonstrate the company’s commitment to workplace safety and health.

Managers may demonstrate their commitment in a variety of ways, such as:

  • Attending safety meetings.
  • Participating in volunteer groups promoting various safety topics.
  • Setting an example by following safety rules and regulations.
  • Allowing employees free access to tools and equipment necessary to do a job safely.
  • Providing employees with training on specific safety issues and equipment.
  • Attending employee training programs if appropriate to reinforce employee training.
  • Participating in or leading safety and health committees.
  • Making presentations on safety and health topics.
  • Regularly emphasizing to the community the organization’s concern with safety and health.
  • Conducting regular inspections.
  • Following up after safety incidents with thorough accident investigations, correcting problems and post-accident employee training.
  • Recognizing and rewarding employees with the best safety and health suggestions and practices.

The Company will provide the necessary medical examinations for employees as required by OSHA standards to maintain a healthy workforce. All testing results will be kept on file and maintained in accordance with federal rules and regulations relating to safety and privacy.

Employee Responsibilities

As much as it is (insert company name) responsibility to provide a safe work environment for everyone, each employee plays a critical role in the success of the safety program. We ask employees to accept this important responsibility and commit to work in the safest manner possible to ensure their own individual health and wellness for the future. We encourage all employees to communicate freely about safety concerns and offer suggestions to improve safety conditions without the fear of reprisal.

Employee rights are protected under the OSH Act and the law’s anti-retaliation protections.

All employees are responsible to comply with all OSHA standards (federal and state) as well as with the company’s safety and health rules, including the following:

  • Handling equipment and work processes in accordance with established procedures and documented protocols.
  • Reporting any unsafe conditions, deficiencies in equipment, or injuries (no matter how minor) to management immediately.
  • Complying with all management instructions for safe conduct.
  • Attending accident prevention and safety training and instruction, including practice drills.
  • Obtaining permission and training before operating machinery or equipment unless part of the employee’s regular duties. Employees must be trained/certified prior to using any powered industrial trucks, such as forklifts.
  • Following the company’s safe working rules and policies at all times.
  • Wearing necessary safety and protective equipment at all times in specified work locations.
  • Asking for clarification or assistance if unsure about the safety of a particular task and stopping the work immediately until there is clear guidance to proceed.
  • Never participating in horseplay, scuffling, and other acts that endanger the safety or well-being of the work team.
  • Not reporting to work under the influence of alcohol and/or drugs or being impaired by fatigue, illness, or other causes that may expose the employee or others to injury or unsafe working conditions.
  • Lifting heavy objects using proper lifting techniques to prevent injuries.

All employees have the right to access safety records maintained by the Company that document the employee’s exposure to hazardous substances and individual medical records relating to evaluations, testing or exposures with certain exceptions.

Employee Injury and Illness Reporting

All injuries should be reported promptly to the supervisor, manager, or company emergency response team (if available) so that arrangements can be made for medical and/or first-aid treatment.

First-aid materials are located in __________________; emergency, fire, ambulance, rescue squad, and doctors’ telephone numbers are located __________________; and fire extinguishers are located at __________________.

Emergency clinic location: (insert clinic name)

In case of a fire, accident, or other emergency, employees should gather at this location: ___________________________________________________. See your location evacuation maps for more details.

Report any hazards immediately to your supervisor, manager, or safety committee representative.

Manager/Supervisor Name: ______________________

Phone Number: _________________________

Email: ________________________

After hours/weekends: (include contact information if applicable)

Important tip: Include this information so any potential incidents can be reported promptly, hazardous equipment or conditions can be repaired, and the incident can be investigated in a timely manner. For example, an incident might happen on a Saturday when the main office is not open. The injured employee and the workplace investigation will need attention that day/weekend.

OSHA Inspections: Employee Responsibilities

It is our policy to fully comply and cooperate with any OSHA location inspection. Inspections typically occur due to an employee complaint, referral, or program inspections in certain industries or locations. The designated Company safety representative will communicate and work directly with the OSHA inspectors. Immediately contact safety or executive management if OSHA inspectors arrive at the work location.

The Company safety representative responsible for handling location inspections is:

Name: ______________________

Phone Number: _________________________

Email:  ________________________

If the Company safety representative is not available, contact your location manager, safety manager, or human resources department.

Phone Number: _____________________________

 

Section 3:  Incident Investigation

It is company policy to investigate all injuries and illnesses in order to understand why the incident occurred and how it can be prevented from recurring. It will also serve to continuously improve our processes/procedures to create a safer workplace for all associates.

Important tip: Sometimes a full investigation and report cannot be done right away and there is limited information about the incident. In these instances, you should always submit a quick report with basic facts (employee name, short description, date, and any other details) about the incident so it can be submitted to the insurance carrier in a timely fashion. More information can always be added after the fact, but the report should always be submitted in a prompt manner.

The procedure for investigating employee incidents is outlined below:

  1. In an emergency situation, remember to dial 911 immediately.
  2. The immediate supervisor or manager should report any injury or illness immediately (or when safe to do so) and complete the appropriate paperwork for safety team follow up, human resources actions, and insurance carrier needs. All injuries and illnesses should be reported, no matter how large or small.
  3. Use the company Incident Reporting Form or the  OSHA reporting form that includes the employee’s report, the supervisor’s report, and the investigation report. Document the injury/illness completely while doing a thorough root cause analysis of the incident so that corrective action can be determined to prevent future incidents.
  4. Review the incident investigation report with the safety committee and/or management to determine appropriate corrective action, training, or other changes in the safety program in that work area. Any corrective actions should be communicated clearly, with responsibility for follow up tasks assigned to the appropriate person(s), and adjustments made to the job hazard analysis if needed.
  5. Part of the safety corrections may include employee coaching and counseling to correct unsafe behaviors, prevent injuries, and improve safety. Follow the company procedure for corrective action and focus on changing behavior instead of punishment. However, in some instances, after consultation with human resources and legal counsel, egregious or willfully negligent behavior may be cause for immediate disciplinary action up to and including termination of employment.

Injury and Illness Reporting

In the case of serious injuries or fatalities, there are time-sensitive reporting requirements. Any serious injury should be reported as soon as possible in order to comply with OSHA’s reporting rules or the company may face severe penalties. The company safety manager or human resources manager will handle OSHA reporting; however, if needed to meet the OSHA deadlines, you can call the OSHA reporting line at 1-800-321-6742, TTY 1-877-889-5627:

  • For work-related fatalities, report within eight hours.
  • For work-related inpatient hospitalizations, all amputations, and all losses of an eye, report within 24 hours.
Important tip: Be sure to check the state OSHA program for other safety and reporting requirements for additional reporting requirements.

 

Section 4: Hazard Identification and Assessment

Part of our ongoing commitment to the Safety Program includes hazard identification and assessment. It is our responsibility under the OSHA general duty clause to assess any potential hazards our employees may encounter through the normal course of their workdays. Our company follows the federal OSHA guidelines (listed below) for evaluating potential hazards in the workplace and will review the information as needed to prioritize action items for completion.

OSHA recommends that employers collect, organize, and review information with employees to determine what types of hazards may be present and which employees may be exposed or potentially exposed. Information available in the workplace may include:

  • Equipment and machinery operating manuals.
  • Safety data sheets (SDS) provided by chemical manufacturers.
  • Self-inspection reports and inspection reports from insurance carriers, government agencies, and consultants. Note:Include the frequency your company conducts self-inspections with the documented reports. Frequency may vary and could be daily, weekly, monthly, or at other intervals depending upon the environment.
  • Records of previous injuries and illnesses, such as OSHA 300 and 301 logs and reports of incident investigations.
  • Workers’ compensation records and reports.
  • Patterns/trends of frequently occurring injuries and illnesses.
  • Exposure monitoring results, industrial hygiene assessments, and medical records (appropriately redacted to ensure patient/worker privacy).
  • Existing safety and health programs, such as lockout/tagout, confined spaces, process safety management, personal protective equipment, and others. See list of programs below.
  • Input from workers, including surveys or minutes from safety and health committee meetings. Documenting that input and including copies of your safety suggestion and hazard correction forms is a best practice.
  • Results of job hazard analyses, also known as job safety analyses.

Information about hazards may be available from outside sources, such as:

  • OSHA, National Institute for Occupational Safety and Health (NIOSH), and Centers for Disease Control and Prevention (CDC) websites, publications, and alerts.
  • Trade associations.
  • Labor unions, state and local occupational safety and health committees/coalitions, and worker advocacy groups.
  • Safety and health consultants.

The following list includes general safety programs that may be required based on your company exposures and any assessments. Additional information is available for those programs listed below that are typically the areas with the most OSHA citations annually.

Job Hazard Analysis

A job hazard analysis will be conducted as needed and will outline the steps and tasks of a job and any controls that are in place to avoid the potential hazard(s). They may also be used to build, update, and maintain the safety training and education program. Company safety representatives should identify the work process, list the steps used in performing the process, identify the possible hazards within each of those steps, and then develop an action plan for the correction of any hazards, prioritizing the list with the most critical items first.

Job Hazard Analysis for (List Job or Work Process)

Date of evaluation: __________________

Steps to perform the job/work process Description of the hazards in each step Action plan for hazard control Degree of importance

(Low, Med, High)

 Other comments
Step 1        
Step 2        
Step 3        

 

Job hazard analyses will be updated at the following times:

  • When occupational injuries and illnesses occur that may warrant a review.
  • When new substances, processes, procedures, or equipment are introduced into the workplace that may be hazardous.
  • When new or previously unidentified hazards are recognized.
  • When employees provide feedback/suggestions that will lead to safety improvements.

Personal Protective Equipment, Tools, and Hazard Communications

All personal protective equipment (PPE) and tools to safely perform the work will be provided to employees and properly maintained in accordance with manufacturer guidelines.

(Insert Company PPE plan if applicable.)

All employees will be trained on the personal protective equipment that is required to do their jobs effectively. The Company will review any employee feedback on the use of this equipment and potential improvements that can be made.

Copies of the Company’s Hazard Communication Program and other information will be kept on file in the appropriate departments for employees to review any time. The SDS/chemical “right-to-know locations” are located here: (list all locations).

Important tip: According to OSHA’s hazard communications standards that provide employees with the right to know and understand the potential hazards in their work environment, employers with hazardous chemicals in the workplace must develop and implement a written hazard communication program and train employees on the hazards they are exposed to and proper precautions, including copies of accessible safety data sheets (SDS).

 

Section 5: Hazard Prevention and Control

Regular inspections and surveys, along with employee reports/feedback, allow us to keep hazard information current. With hazards continuously identified, they can be controlled or prevented using the following standard methods:

  • Safe Work Practices. Implementation of special workplace rules may be necessary to continue to protect employees from hazards. Such special rules include specific procedures regarding the use of potentially hazardous equipment or materials, identification of safe acts or behaviors, lockout/tagout procedures, requirements for personal protective devices, and good housekeeping practices. The supervisor or safety representative will make sure that these special safety and health rules are written, posted, and discussed with affected employees.
  • Engineering Controls. The Company strives to ensure the work environment and the job itself are designed to eliminate or reduce employee exposure to hazards. This can be done by completely removing the hazard from facilities, equipment, or processes through design whenever possible. When hazards cannot be eliminated or replaced with less-hazardous alternatives, they may be enclosed. For example, moving parts of machinery or heat-producing processes may be enclosed with special materials. Finally, if hazards cannot be removed or enclosed, barriers will be put between employees and the hazards in the form of machine guards, ventilation hoods, or isolation of a process. These engineering controls will be regularly reviewed with affected employees.
  • Training. Employees are taught to identify and avoid hazards during orientation as well as ongoing safety training based on their position within the company and any potential hazards they may encounter during the course of their job. Managers and safety representatives will highlight safe work procedures and recognizing employees or groups of employees though our “catch me at my best” program, which demonstrates and enforces positive safety behaviors. Examples of these types of best safety practices include rewards for employees who are lifting properly, wearing the proper safety equipment, or making suggestions that are implemented and/or improve safety.
  • Enforcement. Safe work practices are a condition of employment and any violation of workplace safety and health rules will be cause for corrective action, discipline, or termination of employment based on the seriousness of the violation. Enforcement will be based on letting employees know what is expected of them regarding workplace safety and health and giving them a chance to correct their own behavior.
  • Personal Protective Equipment. Engineering controls and safe work practices may not completely eliminate hazards. Personal protective equipment — such as face shields, steel-toed boots, safety glasses, or hardhats — may be required, and will be provided at no cost to the employees. Employees will be trained in the need for and proper use of such equipment and the limitations of this equipment will be made clear to all employees.
  • Administrative Controls. Administrative controls such as lengthened rest breaks, additional relief workers, exercise breaks to various body motions, and rotation of workers through different jobs to reduce exposure to hazards may also be employed to help with the continuing control of hazards. Administrative controls should be used in conjunction with other controls that work to eliminate hazards and control exposure more directly.
  • Preventive Maintenance. Preventive maintenance is designed to eliminate possible equipment problems and plays a major role in ensuring that hazard controls continue to function effectively and that equipment malfunctions do not cause additional hazards. Our preventive maintenance is continuous and performed in accordance with manufacturer’s recommendations. Records of all maintenance performed will be maintained by the appropriate designated safety personnel in their respective departments and kept on file in (list location), either by a computerized system or simply by dating the posted work schedule.
Important tip: Reward programs should always be designed to incent the right safety behaviors, such as proper equipment operation and immediate reporting of injuries or illnesses. Accidents do happen, even with the most diligent safety protocols and training. Programs that incent employees not to report injuries or illnesses, such as incentives for hours worked without injury or no lost time accidents, may create employer problems with OSHA and insurance carriers.

 

Section 6: Communication

Communication on safety issues is vital for the success of the program. Here are some of the ways the Company communicates with employees:

  • Review of the safety program upon hiring or during onboarding orientation.
  • Training topics covered in classroom or tailgate talks/standup meetings.
  • Posters/signage/distributed content for compliance with all applicable state and federal regulations as well as company-specific exposures.
  • Safety meetings are held at least every _______________ (list days/month/quarter). The meetings may take place at different intervals if the occurrence of injuries and/or illnesses prompts immediate action. Copies of the safety meeting minutes are reviewed with follow up action planning.
  • If applicable, include other means used to ensure safety communications with employees.

The Company has instituted a procedure to communicate any hazards or safety issues without the fear of reprisal (anonymously if needed). In addition to communicating safety concerns with management or safety committee representatives directly, employees may submit their concerns through (list the types of communications methods you make available to your employees, such as the following:

  • Safety suggestion boxes (include a list of locations).
  • Telephone “care line.”
  • Online safety site on the Internet.
  • Third-party hotline.)
Important tip: All forms of safety communications must be in the language and vocabulary understandable to employees. Use color codes, posters, labels, or signs to warn employees of potential hazards. Provide employees with multiple ways to share concerns about unsafe working conditions, including standardized methods to document hazards, such as this form developed by Cal/OSHA. Please note that OSHA has strong protections for employees who raise safety concerns, and you can review OSHA’s guidance on the topic here.

 

Section 7: Training and Education Programs

Initial and ongoing safety training and education is necessary to ensure the safety of our employees. Our safety orientation is the backbone of our program and introduces new employees to our culture and commitment to safety. Ongoing training will also be conducted based on the employee department/position and any requirements, such as personal protective equipment, controls, and medical testing, etc.

The purpose of our training program is to provide employees with:

  • Knowledge and skills needed to do their work safely and avoid creating hazards that could place themselves or others at risk.
  • Provide awareness and understanding of workplace hazards and how to identify, report, and control them.
  • Specialized training, when their work involves unique hazards.

Safety training will be provided for employees:

  • During new hire onboarding.
  • When beginning new job assignments.
  • When cross training on new types of machinery/equipment.
  • When new substances, processes, procedures, or equipment are introduced to the workplace and represent a new hazard.
  • Periodically, in the form of refresher training (this may be following a near miss or incident, which can be required).

Depending upon the topic, the training may be conducted with one of the following methods:

  • Tailgate talks.
  • Classroom training.
  • Peer to peer training/shadowing.
  • Online training.
  • Coaching/counseling.
  • Safety observations/evaluations.
Important tip: Effective training and education can be provided outside a formal classroom setting. Peer-to-peer training, on-the-job training, and worksite demonstrations can be effective in conveying safety concepts, ensuring understanding of hazards and their controls, and promoting good work practices. OSHA’s recommendations for employee training is available here.

Section 8: Program Evaluation and Improvement

The main goal of our safety program evaluation is to ensure that the Company is providing a safe workplace to meet and exceed our safety goals while continuously improving our safety culture. At regular intervals (list when, such as biannually, annually, or when necessary), we will review the safety program or individual programs with those goals in mind and to remain compliant with all applicable regulations/laws.

The evaluation may also:

  • Verify that the core elements of the program have been fully implemented.
  • Involve employees in some aspects of program evaluation, including reviewing information (such as incident reports and exposure monitoring results), establishing and tracking performance indicators, and identifying opportunities to improve the program.
  • Ensure that the following key processes are in place and operating as intended:
    • Reporting injuries, illnesses, incidents, hazards, and concerns.
    • Conducting workplace inspections and incident investigations.
    • Tracking progress in controlling identified hazards and ensuring that hazard control measures remain effective and is completed promptly.
    • Collecting and reporting any data needed to monitor progress and performance.
  • Review the results of any compliance audits to confirm that any program shortcomings are being identified and that actions are being taken that will prevent recurrence.
  • Review and update plans/processes based on the company’s loss history.

The person tasked with the overall responsibility to evaluate the Company’s safety program and processes is:

Name: ____________________________________

Contact Information: ________________________________________

Important tip: The OSHA self-audit tool is an effective template to evaluate the safety program and create action plans for any needed improvements.

Section 9: Recordkeeping

The Company is responsible for maintaining records of all applicable safety-related programs. The records will be kept on file at (list location) by (Company representative name).

The OSHA Form 300 log of work-related injuries and illnesses will be posted annually in the areas where other notices are posted from February 1 through April 30.

Important tip: The following list includes the typical OSHA general industry standards that may require an employer to create, retain, and produce certain documents to the OSHA compliance officer during an inspection. The need for these documents and programs will depend on the nature of the work at that location.

Be sure to ask the compliance officer to provide a written request for the documents during the inspection so that all parties are clear about the documentation and there is no confusion later if a citation is issued for failure to provide all documentation. It is important to remember that an employer has no absolute duty to produce certain documents, such as insurance audits, hazard assessments, employee personnel files or post-accident investigations, and requests should be reviewed by your legal counsel to ensure that you are providing only the documents required by law.

A partial list of the most common regulations where document retention is required include:

Lockout/Tagout: Certify that periodic inspections have been performed at least annually and retain those certifications until a new one is created. It is a best practice to keep the employee training records for the entire duration of employment.

Noise/Hearing Conservation and Respiratory Programs: Provide a hearing conservation program with annual audiograms for employees exposed to noise levels equal to or exceeding an eight-hour time-weighted average of 85 decibels on the A scale and assess potential respiratory hazards from air particulates, evaluate employees and develop a program. Retain employee medical tests/evaluations for the duration of employment plus 30 years, hearing evaluations for two years, and keep individual employee test records for the duration of the employment.

Personal Protective Equipment (PPE): Retain written certifications of hazard assessments and employee training for the duration of employment for all employees exposed to identified hazards.

Hazard Communication: Unless there is another record of the chemical hazard, retain SDSs for each of the hazardous chemicals in the workplace for employees working with the chemicals for the duration of employment plus 30 years for all employees exposed to the applicable chemicals. Make sure you have copies of all current SDSs for chemicals used in the business at all times. Keep employee training on chemical hazards for each employee’s duration of employment.

Bloodborne Pathogens: If employees are expected to have work exposure to bloodborne pathogens, you are required to develop a written program and training to protect employees. Keep employee training records for at least three years from the training. Three years is the requirement, and safety experts recommend keeping all training records for the duration of employment. Retain employee exposure records for the duration of employment plus 30 years.

Employee Exposure/Medical Records: Retain employee exposure/medical records for the duration of employment plus 30 years.

OSHA Form 300, 300A, and 301 Reports: The OSHA Form 300 log of work-related injuries, illnesses and fatalities, the OSHA Form 300A summary of work-related injuries and illnesses, and the Form 301 injury and illness incident reports must be maintained for employers with 11 or more employees, unless there is an exemption based on the NAICS code (for certain low-hazard industries). The OSHA 300 log must be maintained and certified annually with the OSHA 301 Incident Report form, or the company’s injury report form, if applicable. The OSHA 300 forms should be retained on file for five years following the year the records cover.

Note: Effective January 1, 2017, two categories of employers must electronically submit injury and illness data to OSHA that they are already required to record on their onsite OSHA injury and illness forms (Form 300A, Form 300, and Form 301). OSHA will provide employers with a secure site for data submission that is scheduled to go live in February 2017. The new reporting requirements will be phased in over two years as follows:

  • Establishments with 250 or more employees during the calendar year in industries covered by the recordkeeping regulation must submit information from their 2016 Form 300A by July 1, 2017. These same employers will be required to submit information from all 2017 forms (300A, 300, and 301) by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.
  • Establishments with 20 – 249 employees during the calendar year in certain high-risk industries must submit information from their 2016 Form 300A by July 1, 2017, and their 2017 Form 300A by July 1, 2018. Beginning in 2019 and every year thereafter, the information must be submitted by March 2.

OSHA will provide a secure website for the electronic submission of this information. Employers that are not in either of these two categories must submit information from the injury and illness records to OSHA only if OSHA notifies them to do so for an individual data collection. OSHA will provide this notification by mail.

 

Employee Acknowledgement Form

SAFETY PROGRAM RESPONSIBILITIES: I have received and read the Company’s safety rules and understand that I must abide by these rules at all times. I have been given a copy of these safety rules and instructed to refer to them on a regular basis. Whenever I see an unsafe work condition, I must report it immediately to my supervisor, safety committee representative, or management.

REPORTING ACCIDENTS AND UNSAFE CONDITIONS: I have been informed and fully understand that it is my responsibility to report all work-related incidents of injuries or accidents, both my own and other employee incidents, at the time of the incident. I also understand that it is my responsibility to notify my supervisor, safety committee representative, or management of any unsafe working conditions immediately so that the potential hazards can be assessed and corrected.

 

Employee Signature: ____________________________________________________________

Printed Name: __________________________________________ Date: __________________