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Injury & Illness Prevention Program
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Injury & Illness Prevention Program

Hazard Description
Satisfactory
Needs
Attention
Target Date
for Completion
 
Date
Completed
Do you have a written, effective Injury and Illness Prevention Program?
 Yes o No o
 Yes o  No o
 
 
 
 
Do you have a person who is responsible and has authority for overall activities of the Injury and Illness Prevention Program?
 Yes o   No o
 Yes o No o
 
 
 
 
Do you have a system of identifying and evaluating your workplace hazards?
 Yes o   No o
 Yes o   No o
 
 
 
 
Do you systematically correct these hazards in a timely manner?
 Yes o   No o
 Yes o  No o
 
 
 
 
Do you provide training in both general and specific safe work practices?
 Yes o   No o
 Yes  No o
 
 
 
 
Do you encourage employee participation in health and safety matters?
 Yes o   No o
 Yes o  No o
 
 
 
 
Do you maintain an ongoing safety training program?
 Yes o   No o
 Yeso   No o
 
 
 
 
Do you have a system in place that ensures employees will be recognized for safe and healthful work practices?
 Yes o  No o
 Yes o  Noo
 
 
 
 
Will employees be disciplined for unsafe safety or health acts?
 Yes o  No o
 Yes o   No o
 
 
 
 
Is there a safety committee?
 Yeso   No o
 Yes o   No o
 
 
 
 
If there is no safety committee, is there in place a system for communicating safety and health concerns to employees?
Yes o   No o
Yes o   No o
 
 
 
 
On construction sites, is a Code of Safe Practices posted?
Yes o   No o
Yes o  No o
 
 
 
 
Are “toolbox “ meetings conducted every 10 days, or sooner if appropriate?
Yes o   No o
Yes o   No o
 
 
 

 
Comments:
 
 
 
                                                                                                                 
Name __________________________________________________________________
 

Department _______________________________________________

 
Date _______________________________________