contact name/number · 2020. 8. 24. · prime contractor: 3(1) every work site must have a prime...

Health and Safety Policy:

(Insert school authority here) is committed to the protection of our employees, contractors,volunteers and the students we serve.

In fulfilling this commitment, the school administration will provide and maintain a safe and healthful work environment in accordance with industry standards and in compliancewith legislative requirements, and will strive to eliminate any foreseeable hazards whichmay result in injury, illness or damage.

We are all responsible for preventing incidents within our facilities and are each expected to comply fully with all applicable health and safety laws, rules and regulations.

Incidents can be prevented through good management in combination with active employeeinvolvement. Participation in the safety and health program is the direct responsibility of all employees. All employees will perform their jobs in compliance with established safework practices.

The information in this policy does not take precedence over OHS legislation. All employeesshould be familiar with the OHS Act, Regulation and Code. A copy of the legislation is available in every school office.

To ensure that this policy continues to meet our needs, this school authority will review it each year.

Signed:

Superintendent, headmaster or equivalent

School authority

Date

APPENDIX 1: Sample Occupational Health and Safety Policy and Responsibilities Statement 1/7

Position school board logo

here

SCHOOL OR WORK SITE:

ADDRESS/CITY/POSTAL CODE:

CONTACT NAME/NUMBER:

Out of

date

Responsibilities:

Everyone within the operations of the (insert school authority here) has responsibilities to help create and maintain a safe working environment for themselves and others. Clearexpectations are necessary to ensure that everyone is aware of their rights and obligations.This will enable the (insert school authority here)’s health safety management system tooperate effectively.

Everyone has the right to work in a safe and healthy environment.

Therefore, the (insert school authority here) will clearly describe the roles and responsi-bilities of all levels within the operations, including the Board or Authority, Management(Principal or System Administrators), workers, volunteers, contractors and students.

These expectations will be a condition of employment and must be followed.

Board or Authority Responsibilities:

> Provide a safe workplace

> Inform all employees of their OHS rights and obligations

> Ensure that the health and safety program is created, operating and maintained as intended by actively overseeing, participating in and maintaining control of the program

> Establish policies and procedures for the health and safety management system

> Ensure adequate resources are available to successfully build and implement this system



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Out of

date

Principals and System Administrator Responsibilities:

> Implement a heath and safety program in their facilities

> Inform all employees of their OHS rights and obligations

> Inform employees of any hazards specific to their location or nature of their work

> Ensure all employees perform their duties in accordance with applicable legislation

> Ensure all employees are aware of and comply with all aspects of the health and safety program

> Ensure all employees are competent by continuously providing adequate and necessarytraining in a timely manner

> Regularly inspect and correct substandard conditions

> Ensure all incidents and near misses are reported and investigated

> Ensure proper maintenance of equipment and tools

> Ensure all contractors and workers are aware of (insert school authority here)’s expectations

> Identify troubled or impaired workers and ensure they are looked after appropriately

Worker Responsibilities:

> Know and follow all aspects of the health and safety program

> Report all incidents, near misses, injuries, unsafe acts or conditions and infractions, no matter how small

> Wear all personal protective equipment required by safe job procedures, regulations or policies

> Take every reasonable precaution to ensure the safety of yourself, other workers and students

> Refuse to perform work when unsafe conditions exist or when not properly trained to do the job, in accordance with Section 35 of the OHS Act

> Know the locations and operations of the emergency safety equipment

> Be familiar with emergency response protocol



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Contractor Responsibilities:

> Present proof of good standing with the Workers’ Compensation Board of Alberta and provide proof of insurance before working on any (insert school authority here)job location

> Follow all aspects of (insert school authority here)’s health and safety program

> Take work hazards seriously and protect yourself and others from danger

> Report all hazards, near misses, injuries or incidents that occur while working at a(insert school authority here) facility

> Comply with all legislated requirements pertaining to your scope of work

Visitors, Parents, Guests and Volunteer Responsibilities:

> Report to the main office prior to entering the facility

> Wear personal protective equipment when required and follow the instructions andrules of the location

> Provide all clearances required for the position

Key Legislation Requirements:

Obligations of employers, workers, etc.:

2(1) Every employer shall ensure, as far as it is reasonably practicable for the employer to do so,

(a) the health and safety of

(i) workers engaged in the work of that employer, and

(ii) those workers not engaged in the work of that employer but present at the worksite at which that work is being carried out, and

(b) that the workers engaged in the work of that employer are aware of their responsibilities and duties under this Act, the regulations and the adopted code

(2) Every worker shall, while engaged in an occupation,

(a) take reasonable care to protect the health and safety of the worker and of other workers present while the worker is working, and

(b) co-operate with the worker’s employer for the purposes of protecting the health and safety of

(i) the worker,

(ii) other workers engaged in the work of the employer, and

(iii) other workers not engaged in the work of that employer but present at the work site at which that work is being carried out



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Out of

date

(3) Every supplier shall ensure, as far as it is reasonably practicable for the supplier to do so, that any tool, appliance or equipment that the supplier supplies is in safe operating condition.

(4) Every supplier shall ensure that any tool, appliance, equipment, designated substanceor hazardous material that the supplier supplies complies with this Act, the regulationsand the adopted code.

(5) Every contractor who directs the activities of an employer involved in work at a work site shall ensure, as far as it is reasonably practicable to do so, that theemployer complies with this Act, the regulations and the adopted code in respect of that work site.

Prime contractor:

3(1) Every work site must have a prime contractor if there are two or more employersinvolved in work at the work site at the same time

(2) The prime contractor for a work site is

(a) the contractor, employer or other person who enters into an agreement with the owner of the work site to be the prime contractor, or

(b) if no agreement has been made or if no agreement is in force, the owner of the work site.

(3) If a work site is required to have a prime contractor under subsection (1), the primecontractor shall ensure, as far as it is reasonably practicable to do so, that this Actand the regulations are complied with in respect of the work site.

(4) One of the ways in which a prime contractor of a work site may meet the obligationunder subsection (3) is for the prime contractor to do everything that is reasonablypracticable to establish and maintain a system or process that will ensure compliancewith this Act and the regulations in respect of the work site.

Multiple obligations:

4(1) In this section, “function” means the function of prime contractor, contractor, employer, supplier or worker.

(2) If a person has two or more functions under this Act in respect of one work site, the person must meet the obligations of each function.

Refusal of unsafe work:

All workers have a legislated responsibility and an obligation to refuse unsafe work. “Unsafe Work” is defined as a task that is not normal for that occupation and/or a dangerthat would not normally be present as a part of the tasks that a person in that occupationhas been deemed “competent” to perform (see 35(2) below).



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Existence of imminent danger:

35(1) No worker shall

(a) carry out any work if, on reasonable and probable grounds, the worker believesthat there exists an imminent danger to the health or safety of that worker,

(b) carry out any work if, on reasonable and probable grounds, the worker believesthat it will cause to exist an imminent danger to the health or safety of that workeror another worker present at the work site, or

(c) operate any tool, appliance or equipment if, on reasonable and probable grounds,the worker believes that it will cause to exist an imminent danger to the health or safety of that worker or another worker present at the work site.

(2) In this section, “imminent danger” means in relation to any occupation

(a) a danger that is not normal for that occupation, or

(b) a danger under which a person engaged in that occupation would not normallycarry out the person’s work.

(3) A worker who

(a) refuses to carry out work, or

(b) refuses to operate a tool, appliance or equipment

pursuant to subsection (1) shall, as soon as practicable, notify the worker’s employerat the work site of the worker’s refusal and the reason for the worker’s refusal.

(4) On being notified under subsection (3), the employer shall

(a) investigate and take action to eliminate the imminent danger,

(b) ensure that no worker is assigned to use or operate the tool, appliance or equipment or to perform the work for which a worker has made a notificationunder subsection (3), unless

(i) the worker to be so assigned is not exposed to imminent danger, or

(ii) the imminent danger has been eliminated,

(c) prepare a written record of the worker’s notification, the investigation and actiontaken, and

(d) give the worker who gave the notification a copy of the record described in clause(c).

(5) The employer may require a worker who has given notification under subsection (3)to remain at the work site and may assign the worker temporarily to other workassignments that the worker is reasonably capable of performing.



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Out of

date

(6) A temporary assignment under subsection (5), if there is no loss in pay, is not disciplinary action for the purposes of section 36.

(7) If a worker who receives a record under subsection (4)(d) is of the opinion that an imminent danger still exists, the worker may file a complaint with an officer.

(8) An officer who receives a complaint under subsection (7) shall prepare a writtenrecord of the worker’s complaint, the investigation and the action taken and shall give the worker and the employer a copy of the record.

(9) A worker or an employer who receives a record under subsection (8) may request a review of the matter by the Council by serving a notice of appeal on a Director of Inspection within 30 days from the date of receipt of the record.

(10) After considering the matter, the Council may by order

(a) dismiss the request for a review, or

(b) require the employer to eliminate the imminent danger.



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APPENDIX 2: Hazard Assessment and Control Process

1. Identify Work Groups

2. Identify Tasks (work inventory) for Each Group

3. Identify Hazards for Each Task

4. Assess the RiskAssociated with Each Hazard

5. Eliminate Hazards

6. Identify and DevelopHazard Controls

7. Implement Hazard Controls and Follow-up

Describe the type of work carried out in the work site and segregate working groups where possible.

List the work-related activities in each work group.

Assess the hazards for each task/work-related activity.> Consider associated people, equipment, tools, chemicals

and materials.> Consider all psychosocial, ergonomic, physical, chemical

and biological hazards.

Evaluate the risk factors of each hazard including the probability and severity.

Starting with the higher-risk hazards, eliminate hazards whenever it is reasonably practicable to do so.

Identify controls for the hazards that cannot be eliminated in the following order:> Engineering Controls> Administrative Controls> Personal Protective Equipment

> Put the controls in place to reduce the risk of each hazard to a level as low as reasonably achievable. Provide training and coaching in the use of the controls and communicate control measures to affected employees.

> Conduct regular work site inspections; monitor controls.> Investigate incidents and determine if controls are working.

Out of

date

BO

AR

D

AP

PEN

DIX

3:

Sa

mp

leO

rgan

izat

ion

al C

har

t–L

arg

er J

uri

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tion

Plan

ning

Hum

anRe

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Asso

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(Div

isio

ns 1

/2)

Asso

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isio

ns 3

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ion

Scho

ols

Busi

ness

Serv

ices

Tran

spor

tatio

nFa

cilit

ies

Out of

date

BO

AR

D

AP

PEN

DIX

4:

Sa

mp

leO

rgan

izat

ion

al C

har

t–In

dep

end

ent

Sch

ool

Stud

ent

Teac

her

Clas

sroo

mVo

lunt

eers

Head

of S

choo

l(C

EO)

CFO

Supp

ort

Volu

ntee

rs

for

Even

tsCo

ache

sEv

ents

Tour

nam

ents

Assi

stan

tsVo

lunt

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Man

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sVo

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Prin

cipa

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Adm

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Deve

lopm

ent

and

Mar

ketin

gPa

rent

Cou

ncil

Athl

etic

Dire

ctor

Mai

nten

ance

Out of

date

APPENDIX 5: Sample Job Inventory


here




PREPARED BY: DATE:

DEPARTMENT:

1. Board 9

2. C.F.O. 1

3. Head of School or Principal 1

4. Vice Principal 1

5. Administration 2

6. Development and Marketing 1

7. Support 1

8. Faculty 12

9. Parent Council 5

10. Volunteers 20

11. Athletic Director 1

12. Coaches 6

13. Assistant Coaches and Managers 12

14. Maintenance and Custodial 3

# Job Title Number of Employees Hazard Assessment Performing Task Completion Date

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date

APPENDIX 6: Sample Custodian Work Inventory


here




LOCATION:

DATE:

1. Maintain floor and carpets

2. Remove garbage and recyclables

3. Pressure wash walls and furniture

4. Clean and disinfect washrooms

5. Clean up hazardous spills, such as blood or body fluids, mouse or bird droppings and chemicals

6. Perform general cleaning of desks, walls, chalk or whiteboards, windows or glass etc.

7. Change or replace lights and ceiling tiles

8. Move furniture and equipment

9. Work on rooftops to check vents, retrieve balls, adjust flags, change security lights

10. Inspect and clean up buildings and grounds

11. Cut grass and maintain flower beds

12. Remove snow or ice and sand walkways

13. Perform routine maintenance and repair power equipment

14. Perform boiler water testing, treat boiler water, relight pilots

15. Monitor condition of building materials

16. Lubricate fan motor or bearings and replace filters

17. Prepare (take down) boilers for inspection

18. Conduct security checks and unlock or lock building

19. Assist in budget planning, prepare cleaning schedules, perform appraisals

20. Supervise or train custodial staff

21. Order stock and maintain custodial supplies

22. Obtain MSDS updates and label chemicals for WHMIS compliance

23. Prepare or monitor maintenance service requests

24. Monitor or assist with community use of building

25. Liaise with rental groups, facilities staff, contractors, regulatory agencies (e.g. fire or health inspectors)

26. Receive or pick up supplies using personal vehicle and stock items

27. Set up or dismantle stage equipment, move gym floor mats or tarps and desks or chairs for exams or special events

28. Change filters and dust collectors

TYPE OF WORK: CUSTODIAN

Out of

date

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

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1/7

Cleaning or Building Maintenance

Floo

r mai

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:sw

eep,

wet

mop

, str

ip,wa

x, sc

rub

burn

ish

and

buff

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and

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from

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wet

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ise

and

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azar

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(str

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43

336

High

Prov

ide

prop

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desi

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or m

aint

aine

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into

pal

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mac

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sw

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wet

mop

, str

ip,wa

x, sc

rub

burn

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and

buff

floor

s

43

448

High

Curr

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Mat

eria

l Saf

ety

Data

She

ets

( MSD

S) o

n si

te fo

r all

chem

ical

sSi

te w

orkin

g al

one

prot

ocol

in p

lace

WHM

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pla

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JOB

OR

POSI

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UMM

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Resp

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for

the

care

, cle

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d se

curit

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the

build

ing

and

grou

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saf

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and

mai

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of h

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dm

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of c

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the

build

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BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

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ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

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Haza

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neer

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3

Adm

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4

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Pro

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and

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t Haz

ard

Cont

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ss R

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and

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s

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P 1

1S

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22

STE

P 3

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of

Wor

kRe

late

d Ta

sks

or A

ctiv

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Envi

ronm

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Tool

s, E

quip

men

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Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

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A:Frequency of Exposure6

B:Hazard Probability7

C:Potential Consequence8

Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

Out of

date


Mai

ntai

n ca

rpet

s: c

lean

or va

cuum

, spo

t cl

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petit

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43

336

High

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into

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43

336

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Safe

wor

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iftin

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Prov

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43

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Rem

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site

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12

48

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Proc

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F G

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JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

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for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

2/7

Out of

date


Chan

ge o

r rep

lace

ligh

ts,

ceilin

g til

esAs

best

os, w

orkin

g fr

om h

eigh

ts, l

adde

rs, g

eni-l

ifts

Risk

of e

lect

rocu

tion

22

416

Med

Safe

pro

cedu

res

for w

orkin

g fr

om h

eigh

tsin

clud

ing

proc

edur

e fo

r roo

ftop

wor

k

STAF

F G

ROUP

:H

ead

Cust

odia

n or

Cus

todi

an

JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

onsi

ble

for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

3/7

Mov

e fu

rnitu

re a

nd

equi

pmen

tTa

bles

, ben

ches

, des

ks, c

abin

ets,

TV’s

, ent

ranc

e m

ats,

floor

mac

hine

s et

c. P

hysi

cal i

njur

y fr

om a

wkwa

rd

post

ures

, Hea

vy li

ftin

g, o

vere

xert

ion,

repe

titive

mot

ions

, ben

ding

, twi

stin

g, c

arry

ing

up a

nd d

own

stai

rs, f

oot

or h

and

haza

rds

43

336

High

Adeq

uate

foot

pro

tect

ion

worn

Us

e st

rate

gies

to

min

imize

load

s an

d fr

eque

ncy

of m

anua

l han

dlin

g (e

.g. p

rovid

e ca

rts

and

dollie

s)

Wor

k on

roof

tops

: ven

tch

ecks

, bal

l ret

rieva

l, fla

g ad

just

men

ts,

chan

ging

sec

urity

ligh

ts

Falls

from

hei

ghts

or l

adde

rs o

r roo

ftop

s Sl

ips

or fa

lls o

n ic

e or

sno

wAw

kwar

d ac

cess

and

egr

ess

–fix

ed la

dder

s or

roof

hatc

hes

Awkw

ard

post

ures

car

ryin

g eq

uipm

ent

up la

dder

s

32

424

Med

Follo

w wo

rkin

g al

one

proc

edur

es

Esta

blis

h ch

eck

in p

roto

col w

ith o

ffice

Impl

emen

t sa

fe w

ork

proc

edur

es fo

r wo

rkin

g fr

om h

eigh

ts

Maintain Building or Grounds

Build

ing

or g

roun

dsin

spec

tions

, cle

an u

p Ne

edle

s, c

ondo

ms,

bro

ken

glas

sCu

ts o

r lac

erat

ions

, blo

od o

r bod

y flu

ids

Bitt

en b

y st

ray

anim

als,

inse

cts

Enco

unte

rs w

ith t

hrea

teni

ng s

tran

gers

31

412

Low

Appr

opria

te p

rote

ctive

equ

ipm

ent

avai

labl

e an

d us

edG

uide

lines

for b

lood

bor

ne d

isea

ses

Bloo

d Bo

rne

Path

ogen

s Tr

aini

ngFo

llow

work

ing

alon

e pr

otoc

ol

Gen

eral

cle

anin

g:

desk

s, w

alls

, cha

lk or

white

boar

ds, w

indo

ws

or g

lass

etc

.

Whi

tebo

ard

clea

ners

, neu

tral

and

gla

ss c

lean

ers

Awkw

ard

post

ures

, rep

etiti

ve m

otio

nsG

lass

cle

anin

g m

ay in

volve

wor

king

from

hei

ghts

or

ladd

ers

43

336

High

Whi

tebo

ard

clea

ning

gui

delin

es o

n si

teLa

dder

saf

ety

guid

elin

es o

n si

te

Out of

date

Maintain Building or Grounds

Gra

ss c

uttin

g, m

aint

ain

flowe

r bed

sLa

wn m

ower

, noi

se e

xpos

ure

pest

icid

es, s

un

expo

sure

, ins

ects

, sto

opin

g, b

endi

ng, k

neel

ing

Hand

or f

oot

haza

rds

from

con

tact

with

mov

ing

part

s

22

416

Med

Safe

ope

ratin

g pr

oced

ure

for l

awnm

ower

s G

asol

ine

stor

ed o

utdo

ors

in a

ppro

ved

shed

and

app

rove

d m

etal

con

tain

ers

Writ

ten

proc

edur

es fo

r dis

pens

ing

gaso

line

Win

ter s

now

or

ice

rem

oval

, san

ding

wa

lkway

s

Shov

els,

sno

w bl

ower

s, h

eavy

sno

w, fl

amm

able

m

ater

ials

Heav

y re

petit

ive li

ftin

g, b

endi

ng o

r awk

ward

pos

ture

s Pu

shin

g, p

ullin

g eq

uipm

ent

over

une

ven

terr

ain

Phys

ical

inju

ry fr

om fl

ying

debr

is, m

ovin

g m

achi

nery

part

sFa

tigue

and

tim

e co

nstr

aint

s, s

lips

or fa

lls, n

oise

33

436

Med

Follo

w sn

ow s

hove

ling

and

snow

blo

wer

guid

elin

es

STAF

F G

ROUP

:H

ead

Cust

odia

n or

Cus

todi

an

JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

onsi

ble

for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

4/7

Rout

ine

mai

nten

ance

on

pow

er e

quip

men

t or

initi

ate

repa

irs

Snow

blo

wers

, bur

nish

ers,

lawn

mow

ers,

con

tact

wi

th m

ovin

g pa

rts

12

48

Low

Send

to

Faci

litie

s M

aint

enan

ce fo

rre

pairs

Maintain PhysicalPlant

Perf

orm

boi

ler w

ater

test

ing,

tre

at b

oile

rwa

ter,

relig

ht p

ilots

Caus

tic o

r cor

rosi

ve c

hem

ical

s, b

urns

, hig

h te

mpe

ratu

res,

asb

esto

s, n

oise

, con

fined

spa

ces,

fir

e or

exp

losi

ons

42

432

High

Wea

r per

sona

l pro

tect

ive e

quip

men

t

Mon

itor c

ondi

tion

ofbu

ildin

g m

ater

ials

Ex

posu

re t

o as

best

os, m

ould

, con

fined

spa

ces

31

39

Low

Asbe

stos

Awa

rene

ss T

rain

ing

Asbe

stos

saf

e wo

rk p

roce

dure

s on

site

Curr

ent

Asbe

stos

Bui

ldin

g Su

rvey

Repo

rt o

n si

te a

nd u

p to

dat

e

Out of

date

Lubr

icat

e fa

n m

otor

or

bear

ings

and

repl

ace

filte

rs

Mov

ing

part

s, c

onfin

ed s

pace

s, d

ust,

wor

k fr

omhe

ight

s, la

dder

s va

cuum

s, b

rush

es fi

lters

, cut

s,

trip

s or

falls

12

48

Low

Conf

ined

Spa

ce C

ode

of P

ract

ice

Prep

are

(tak

e do

wn)

boile

rs fo

r ins

pect

ion

Ladd

ers,

hei

ghts

, dus

t, c

onfin

ed s

pace

s, s

uper

heat

-ed

wat

er, a

sbes

tos

13

412

Med

Safe

wor

k pr

actic

e fo

r ste

am b

oile

rs

on s

ite

STAF

F G

ROUP

:H

ead

Cust

odia

n or

Cus

todi

an

JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

onsi

ble

for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

5/7

Security

Cond

uct

secu

rity

chec

ks,

unlo

ck o

r loc

k bu

ildin

gCh

eck

secu

rity

and

fire

safe

ty a

larm

sys

tem

s

Intr

uder

s, v

iole

nt e

ncou

nter

s, s

lips

or fa

llsW

alkin

g ar

ound

the

bui

ldin

g, in

side

and

out

side

chec

ks, e

xpos

ure

to e

lem

ents

if o

utsi

de

43

448

High

Writ

ten

work

ing

alon

e pr

oced

ures

fo

r wor

k si

te in

pla

ceSe

curit

y ch

ecks

don

e fr

om in

side

the

build

ing

Com

mun

icat

ion

syst

em in

pla

ce

in t

he e

vent

of a

n em

erge

ncy

Administrative

Assi

st in

bud

get

plan

ning

, pre

pare

cl

eani

ng s

ched

ules

, pe

rfor

man

ce a

ppra

isal

s

Stre

ss a

ssoc

iate

d wi

th w

ork

dem

ands

11

11

Low

Empl

oyee

Ass

ista

nce

Prog

ram

Supe

rvis

e or

tra

in

cust

odia

l sta

ff 1

24

8Lo

w

Orde

r sto

ck, m

aint

ain

cust

odia

l sup

plie

s Us

e of

a c

ompu

ter,

star

s sy

stem

, tel

epho

ne1

11

1Lo

w

Obta

in M

SDS

upda

tes,

Labe

l che

mic

als

for

WHM

ISco

mpl

ianc

e

Use

of c

ompu

ter a

nd t

elep

hone

to

get

new

MSD

S

Poss

ible

exp

osur

e to

che

mic

als

11

44

Low

Prep

are

or m

onito

r m

aint

enan

ce s

ervic

ere

ques

ts

Com

pute

rs, S

TARS

31

13

Low

Maintain Physical Plant

Out of

date

Other

Mon

itor o

r ass

ist

with

com

mun

ity u

se

of b

uild

ing

Afte

r hou

rs o

r wee

kend

wor

k2

11

2Lo

w

Liai

se w

ith re

ntal

gr

oups

, fac

ilitie

s st

aff,

cont

ract

ors,

regu

lato

ryag

enci

es (e

.g. f

ire o

rhe

alth

insp

ecto

rs)

Build

ing

tour

s, w

alkin

g, s

peak

ing,

pos

sibl

e la

ngua

geba

rrie

rs3

11

3Lo

w

STAF

F G

ROUP

:H

ead

Cust

odia

n or

Cus

todi

an

JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

onsi

ble

for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

6/7

Rece

ive o

r pic

k up

su

pplie

s us

ing

pers

onal

vehi

cle,

stoc

king

item

s

Clea

ning

or b

oile

r che

mic

als,

gas

olin

e, he

avy

liftin

gM

otor

veh

icle

acc

iden

ts

33

327

Med

Set

up o

r dis

man

tlest

age

equi

pmen

t,

gym

floor

mat

s or

tar

ps

Set

up d

esks

or c

hairs

for e

xam

s or

spe

cial

eve

nts

Heav

y lif

ting,

repe

titive

mot

ions

24

324

Med

Mec

hani

cal a

ids

cart

s an

d do

llies

avai

labl

e. As

k fo

r ass

ista

nce

if re

quire

d

Chan

ge fi

lters

and

du

st c

olle

ctor

sCo

nfin

ed s

pace

s, p

ossi

ble

expo

sure

to

asbe

stos

,he

ight

s, c

limbi

ng la

dder

s1

24

8Lo

wCo

nfin

ed s

pace

tra

inin

g an

d pr

oced

ures

in

pla

ce if

app

licab

le

Out of

date

STAF

F G

ROUP

:H

ead

Cust

odia

n or

Cus

todi

an

ASSE

SSM

ENT

BY:

DATE

CO

MPL

ETED

:SC

HOO

L O

R W

ORK

SIT

E:

AP

PEN

DIX

7:

Sa

mp

leC

ust

odia

n H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

7/7

JOB

OR

POSI

TIO

N S

UMM

ARY:

Resp

onsi

ble

for

the

care

, cle

anin

g an

d se

curit

y of

the

build

ing

and

grou

nds,

saf

e op

erat

ion

and

mai

nten

ance

of h

eatin

g an

dm

echa

nica

l equ

ipm

ent a

nd o

vers

ight

of c

usto

dial

sta

ff fu

nctio

ns in

the

build

ing.

Revi

ew D

ates

STE

P 5

Revi

ew a

nd c

omm

unic

ate

asse

ssm

ent w

ith a

pplic

able

sta

ff (li

st s

taff

belo

w a

nd h

ave

staf

f ini

tial d

ocum

ent)

STE

P 6

Revi

ew a

sses

smen

t ann

ually

and

upd

ate

as n

eces

sary

1)Ty

pes

of w

ork

incl

ude

a de

scrip

tion

of th

e br

oad

gene

ral n

atur

e of

the

wor

k ca

rrie

d ou

t (e

.g. o

ffice

wor

k, c

lass

room

pre

para

tion,

cle

anin

g).

Wor

k-re

late

d ac

tiviti

esw

ould

be

the

spec

ific

activ

ities

car

ried

out w

ithin

eac

h ty

pe o

f wor

k st

artin

g w

ith a

n ac

tion

verb

(e.g

. ope

ratin

g of

fice

equi

pmen

t, us

ing

com

pute

rs, p

lann

ing

less

ons,

vacu

umin

g flo

ors)

.

2)H

azar

dsca

n be

iden

tifie

d us

ing

seve

ral m

etho

ds in

clud

ing

pers

onal

exp

erie

nce

or in

tuiti

on,

phys

ical

obs

erva

tions

, tas

k or

job

anal

ysis

or

inci

dent

inve

stig

atio

n.

3)En

gine

erin

g C

ontr

ols:

Pref

erre

d m

etho

d. R

educ

es e

xpos

ure

by r

emov

ing

or is

olat

ing

haza

rd

from

wor

ker.

Exam

ples

are

elim

inat

ion,

ven

tilat

ion,

sub

stitu

tion,

red

esig

n, g

uard

ing,

enc

losu

re,

auto

mat

ion,

mec

hani

cal a

ids.

4)Ad

min

istr

ativ

e C

ontr

ols:

Prac

tices

that

red

uce

likel

ihoo

d of

exp

osur

e by

alte

ring

the

time

or w

ay

a ta

sk is

per

form

ed (e

.g. t

rain

ing

or e

duca

tion,

saf

e w

ork

proc

edur

es, p

urch

asin

g st

ds, s

uper

visi

on,

sign

age,

job

rota

tion

or s

ched

ulin

g, h

ouse

keep

ing

etc.

).

5)Pe

rson

al P

rote

ctiv

e Eq

uipm

ent

(PPE

):N

ot to

be

used

as

prim

ary

cont

rol u

nles

s en

gine

erin

g or

adm

inis

trat

ive

cont

rols

are

not

feas

ible

. Exa

mpl

es a

re s

afet

y gl

asse

s, s

afet

y fo

otw

ear,

glov

es,

resp

irato

ry p

rote

ctio

n, h

earin

g pr

otec

tion.

6)Fr

eque

ncy

of E

xpos

ure

to H

azar

d:1

=Le

ss th

an o

nce

per

mon

th2

=At

leas

t onc

e pe

r m

onth

3=

At le

ast o

nce

per

wee

k4

=O

ne o

r m

ore

times

dai

ly

7)H

azar

d Pr

obab

ility

:Lik

elih

ood

haza

rd w

ill re

sult

in a

n in

cide

nt c

ausi

ng h

arm

. 1

=N

ot li

kely

2=

Rem

ote:

not l

ikel

y bu

t pos

sibl

e on

ce e

very

5 to

20

year

s3

=O

ccas

iona

l:lik

ely

to h

appe

n on

ce e

very

1 to

5 y

ears

4=

Prob

able

:exp

ecte

d to

hap

pen

one

or m

ore

times

per

yea

r

8)Po

tent

ial C

onse

quen

ce:S

ever

ity o

f los

s if

haza

rdou

s ev

ent o

ccur

s.

1=

Neg

ligib

le(n

o in

jury

, firs

t aid

, lim

ited

prop

erty

dam

age)

2=

Mar

gina

l(m

edic

al a

id, m

inor

inju

ry o

r illn

ess/

no lo

st ti

me)

3=

Cri

tical

(lost

tim

e in

jury

, tem

pora

ry d

isab

ility)

4=

Cat

astr

ophi

c(s

erio

us in

jury

or

illnes

s, p

erm

anen

t dis

abilit

y, d

eath

, ext

ensi

ve p

rope

rty

dam

age)

9)R

isk

Cla

ssifi

catio

n:1-

9=

Low

Ris

k:m

inim

al c

ontro

ls12

-27

=M

ediu

m R

isk:

take

sch

edul

ed a

ctio

n to

min

imiz

e32

-64

=H

igh

Ris

k/“C

ritic

al T

ask”

:tak

e im

med

iate

act

ion

to e

limin

ate

haza

rd o

r re

duce

deg

ree

of r

isk

10)

Docu

men

ts o

r pr

oced

ures

ref

eren

ced

in th

is te

mpl

ate

are

avai

labl

e fro

m O

ccup

atio

nal H

ealth

an

d Sa

fety

, Per

sonn

el S

uppo

rt S

ervi

ces.

Out of

date

AP

PEN

DIX

8:

Sa

mp

leT

each

er H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

1/6

Classroom Planning Preparation and Management

Upda

te c

urric

ulum

know

ledg

e an

d es

tabl

ish

prog

ram

goa

ls

Esta

blis

h cl

assr

oom

rule

s an

d ro

utin

esDe

velo

p in

divid

ual

prog

ram

pla

ns fo

r sp

ecia

l nee

ds s

tude

nts

Rese

arch

and

dev

elop

less

on, u

nit

and

stud

ent

grow

th p

lans

Use

com

pute

rs, I

nter

net

and

curr

icul

um re

sour

ces.

Prep

are

at h

ome

or w

ork

alon

e af

ter s

choo

l hou

rsan

d on

wee

kend

s Ey

e, ne

ck, s

houl

der,

arm

and

wris

t st

rain

from

pr

olon

ged

sitt

ing,

repe

titive

mot

ions

, awk

ward

po

stur

es a

nd p

oorly

des

igne

d an

d po

sitio

ned

furn

iture

and

wor

ksta

tions

Tran

spor

t ba

gs a

nd b

oxes

of m

ater

ials

from

hom

e,pe

rson

al v

ehic

les,

sto

rage

room

s et

c. b

y ha

nd o

rus

ing

cart

sPo

tent

ial f

or v

iole

nt e

ncou

nter

s wi

th in

trud

ers

if wo

rkin

g al

one

or in

isol

ated

sch

ool l

ocat

ions

Stre

ss fr

om c

hang

ing

work

and

gra

de a

ssig

nmen

tsth

at m

ay va

ry fr

om y

ear t

o ye

ar, i

nteg

ratio

n of

sp

ecia

l nee

ds c

hild

ren

12

36

Low

1. Ta

ke m

icro

-bre

aks:

alte

rnat

e fr

omst

andi

ng t

o se

ated

pos

ition

s re

gula

rly2.

W

orkin

g al

one

proc

edur

es fo

r sc

hool

sta

ff (in

clud

ing

secu

rity

and

door

lock

ing

proc

edur

es),

post

ing

of p

aren

t an

d st

uden

tex

pect

atio

ns fo

r beh

avio

ur3.

Em

ploy

ee A

ssis

tanc

e Pr

ogra

m ( E

AP)

4.

Safe

wor

k pr

actic

es fo

r lift

ing

and

hand

ling

load

s5.

Us

e m

echa

nica

l aid

s (d

olly)

for

tran

spor

ting

load

s6

. Re

view

ladd

er s

afet

y ch

eckli

st

7.

Basi

c He

alth

and

Saf

ety

Insp

ectio

nCh

eckli

st8.

Ar

twor

k an

d te

achi

ng a

ids

do n

ot

exce

ed 2

0% o

f wal

l or c

eilin

g su

rfac

e

Prep

are

clas

sroo

mm

ater

ials

and

uni

t di

spla

ys

Type

ass

ignm

ents

, use

com

pute

rs, p

hoto

copi

ers,

lam

inat

ors,

pap

er c

utte

rs, s

ciss

ors,

filin

g ca

bine

ts,

step

ladd

ers,

she

lves

etc.

Falls

from

por

tabl

e la

dder

s or

mak

eshi

ft c

limbi

ngai

ds, s

uch

as b

oxes

, cha

irs, d

esks

St

rain

s an

d sp

rain

s fr

om m

ovin

g de

sks

and

chai

rsor

tra

nspo

rtin

g bo

oks

from

reso

urce

room

sPh

ysic

al in

jury

from

uns

tabl

e fu

rnitu

re o

r lim

ited

stor

age

spac

e an

d cl

utte

red

work

are

asCu

ts a

nd b

ruis

es fr

om s

harp

edg

es o

n de

sks

and

cabi

nets

,uns

tabl

eshe

lving

,AV

equi

pmen

tand

unse

cure

dan

d im

prop

erly

stac

ked

or p

rotr

udin

g m

ater

ials

Fire

haz

ards

from

stu

dent

art

work

, tea

chin

g ai

dsan

d ot

her c

ombu

stib

le m

ater

ials

23

318

Med

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

Out of

date

AP

PEN

DIX

8:

Sa

mp

leT

each

er H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

2/6

Routine Classroom and Teaching Instruction

Deliv

er le

sson

pla

nsus

ing

varie

ty o

f lea

rnin

gto

ols

and

reso

urce

s

Use

audi

tory

, prin

t an

d vis

ual m

edia

, ove

rhea

d pr

ojec

tors

, cha

lkboa

rds,

white

boar

ds a

nd c

ompu

ters

Aw

kwar

d po

stur

es, m

uscl

e st

rain

and

fatig

ue

from

usi

ng e

quip

men

t an

d fr

om p

rolo

nged

sta

ndin

g an

d wa

lking

whe

n as

sist

ing

stud

ents

Trip

san

dfa

llsfr

omco

rds

and

exte

nsio

nco

rds

Elec

tric

al h

azar

ds fr

om c

ords

and

AV

equi

pmen

t Vo

ice

loss

from

repe

titive

use

of v

oice

Expo

sure

to

chal

k du

st, s

olve

nt m

arke

rs, w

hite

-bo

ard

clea

ners

, air

cont

amin

ants

and

alle

rgen

sfr

om b

uild

ing

mat

eria

ls a

nd o

ccup

ants

and

from

clea

ning

and

mai

nten

ance

or r

enov

atio

n ac

tiviti

es(e

.g. a

sbes

tos

and

mou

lds,

cle

anin

g pr

oduc

ts,

perf

umes

, pro

pane

exh

aust

em

issi

ons)

Unco

mfo

rtab

le t

empe

ratu

res

and

hum

idity

, odo

urs,

poor

ligh

ting

and

vent

ilatio

n Po

tent

ial e

xpos

ure

to c

omm

unic

able

dis

ease

s(v

iruse

s, b

acte

ria, l

ice

etc.

) and

con

tact

with

pe

sts

(e.g

. mic

e, an

ts, f

lies)

Stre

ss fr

om la

rge

clas

s si

zes,

lim

ited

spac

e an

d re

sour

ces,

lang

uage

bar

riers

with

stu

dent

s,pa

rent

s an

d in

tegr

atio

n of

spe

cial

nee

ds s

tude

nts

wher

e su

ppor

t sy

stem

s m

ay b

e lim

ited

Phys

ical

inju

ry fr

om u

nsta

ble

furn

iture

or s

harp

edge

s or

cre

ated

by

limite

d st

orag

e sp

ace

and

clut

tere

d wo

rk a

reas

Cuts

and

bru

ises

from

sha

rp e

dges

on

desk

s an

d ca

bine

ts, o

r uns

ecur

ed, i

mpr

oper

ly st

acke

d or

pro

trud

ing

mat

eria

lsPh

ysic

al o

r ver

bal a

buse

from

stu

dent

s

44

348

High

9.Us

e of

ant

i-fat

igue

mat

ting

or

cush

ioni

ng in

sole

s10

.El

ectr

ical

saf

ety

tips

11.FM

Soun

d Sy

stem

s fo

r voi

ce

proj

ectio

n12

.In

door

air

qual

ity t

ips

13.

Proc

edur

es fo

r blo

od a

nd b

ody

fluid

s14

.Fl

u im

mun

izatio

n pr

ogra

m15

.Pr

ompt

ly re

port

all

inci

dent

s of

wo

rkpl

ace

viole

nce

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

Out of

date

AP

PEN

DIX

8:

Sa

mp

leT

each

er H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

3/6

Physical Education

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

Set

up a

nd t

ake

down

and

insp

ect

vario

us

gym

equ

ipm

ent

Stra

ins

and

spra

ins

from

lift

ing,

car

ryin

g, m

ovin

ghe

avy

and

awkw

ard

gym

nast

ics

equi

pmen

t, m

ats,

benc

hes,

vol

leyb

all n

ets

etc.

Phys

icalin

jury

from

stru

ctur

alfa

ilure

ofwa

ll-m

ount

edeq

uipm

ent

(e.g

. bac

ksto

ps, c

limbi

ng w

alls

etc

.)Ex

posu

re t

o su

n an

d pe

sts

(e.g

. bee

s, w

asps

) du

ring

outd

oor a

ctivi

ties

and

field

eve

nts

13

39

Low

20.A

naph

ylaxis

han

dboo

k fo

r Sc

hool

Boa

rds

(Hea

lth C

anad

a)

21.

Sun

Safe

ty P

roce

dure

s

Set

up e

quip

men

t an

d in

stru

men

ts

Set

up ri

sers

for

asse

mbl

ies

Clea

n re

cord

ers

Stra

ins

and

spra

ins

from

mov

ing

pian

os, l

iftin

g an

dca

rryin

g in

stru

men

ts a

nd a

udio

equ

ipm

ent

etc.

on

and

offs

helve

s,m

ovin

gta

bles

and

benc

hes

and

riser

sUn

even

floo

r sur

face

s, t

rips

and

falls

on

stai

rs

and

riser

s.Ch

emic

al e

xpos

ure

to p

rodu

cts

used

to

clea

n an

d sa

nitiz

e in

stru

men

ts a

nd m

outh

piec

es

32

318

Med

22.S

ee #

423

.Sto

re h

eavie

r ins

trum

ents

on

shelv

esbe

twee

n kn

uckle

and

sho

ulde

r hei

ght

24.M

ater

ial S

afet

y Da

ta S

heet

s fo

rch

emic

al p

rodu

cts

Music Programs

Mus

ic in

stru

ctio

nUs

e rh

ythm

inst

rum

ents

, rec

orde

rs, p

iano

Voic

e fa

tigue

(sin

ging

, tal

king

) Po

ssib

le h

igh

nois

e ex

posu

re fr

om in

stru

men

tsM

uscle

str

ain

from

repe

titive

han

d an

d ar

m m

otio

ns(e

.g. c

ondu

ctin

g) a

nd m

ovin

g he

avy

inst

rum

ents

Awkw

ard

post

ures

wor

king

with

you

nger

stu

dent

son

floo

r

42

432

Med

25.N

oise

tes

ting

and

CSA

appr

oved

hear

ing

prot

ectio

n if

leve

ls e

xcee

doc

cupa

tiona

l exp

osur

e lim

its.

Dem

onst

rate

and

su

perv

ise

indo

or

and

outd

oor p

hysi

cal

activ

ities

and

spo

t st

uden

ts w

ho a

re

usin

g eq

uipm

ent

Expo

sure

to

high

noi

se le

vels

from

whi

stle

s, s

tude

ntac

tiviti

es

Pote

ntia

l for

phy

sica

l inju

ry (e

.g. b

ruis

es, l

acer

atio

ns,

stra

ins

and

spra

ins,

bac

k or

ove

rexe

rtio

n in

jurie

s)Ex

posu

re t

o bl

ood

and

body

flui

ds fr

om s

tude

ntin

quire

s

33

327

Med

16.

Hear

ing

prot

ectio

n 17

.Fi

rst

Aid

Trai

ning

18.

See

# 13

19.

Safe

ty G

uide

lines

for P

hysi

cal

Activ

ity in

Alb

erta

Sch

ools

(N

ov. 2

003)

Out of

date

Mar

k te

sts

and

assi

gnm

ents

Ente

r dat

a in

to

com

pute

r

Com

pute

rs, p

rolo

nged

sitt

ing,

wor

king

afte

r hou

rsan

d we

eken

ds a

t wo

rk o

r fro

m h

ome.

Exte

nsive

read

ing,

mus

cle

and

visua

l fat

igue

and

str

ain

Eye,

neck

, sho

ulde

r, ar

m a

nd w

rist

stra

in fr

om

prol

onge

d si

ttin

g, re

petit

ive m

otio

ns, a

wkwa

rd

post

ures

and

poo

rly d

esig

ned

and

posi

tione

d fu

rnitu

re a

nd w

orks

tatio

nsFa

tigue

and

str

ess

from

wor

king

exte

nded

hou

rs

and

inte

rrup

tions

to

fam

ily a

nd p

erso

nal t

ime

32

212

Med

26.S

ee #

1, 2

, 3, 1

1

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

AP

PEN

DIX

8:

Sa

mp

leT

each

er H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

4/6

Cond

uct

stud

ent

and

pare

nt c

onfe

renc

esLi

aise

with

socia

lse

rvice

s, sc

hool

cou

ncils

, co

lleag

ues,

cou

ncillo

rs,

heal

th c

are

prov

ider

s,ES

HIP,

etc

.

Use

tele

phon

es, e

-mai

l, st

uden

t ag

enda

s, in

terv

iews

Po

tent

ial v

erba

l abu

se, a

nd t

hrea

ts o

f phy

sica

lab

use

Pare

nts

may

cal

l tea

cher

s af

ter h

ours

at

thei

rho

me

num

bers

(ang

ry o

r thr

eate

ning

cal

ls)

32

318

Med

27.

Non-

viole

nt c

risis

inte

rven

tion

trai

ning

28.S

ee #

2, 3

StakeholderCommunication

Deliv

er m

inor

firs

t ai

dan

d m

edic

atio

ns

Poss

ible

con

tact

with

blo

od o

r bod

y flu

ids,

nee

dles

,ep

i-pen

s 2

14

8Lo

w29

.See

Stu

dent

Foc

used

Med

icat

ion

Gui

delin

esSe

e #

13, 1

4

Prov

ide

extr

acur

ricul

ar,

coac

hing

, vol

unte

er c

lubs

,sp

ecia

l eve

nts

(dan

ces,

choi

r, bi

ngos

, cas

inos

)Pi

ck u

p cl

assr

oom

su

pplie

s

Risk

of p

hysi

cal i

njur

y fr

om a

ctivi

ties

and

equi

pmen

t M

otor

veh

icle

acc

iden

ts fr

om u

se o

f per

sona

l an

d sc

hool

veh

icle

s to

att

end

even

ts o

r tr

ansp

ort

stud

ents

Expo

sure

to

seco

nd-h

and

smok

e, no

ise

Stra

nded

dur

ing

incl

emen

t we

athe

r

12

48

Low

30.D

efen

sive

Driv

ing

Prep

are

inte

rim re

port

san

d re

port

car

ds

13

39

Low

OtherStudentAssessment

Out of

date

OtherA

PP

END

IX 8

:S

am

ple

Tea

cher

Haz

ard

Ass

essm

ent

and

Con

trol

For

m5/

6

Prov

ide

supe

rvis

ion

outd

oors

, in

lunc

hroo

m,

befo

re o

r aft

er s

choo

lac

tiviti

es, f

ield

trip

s

Tem

pera

ture

ext

rem

es, s

un e

xpos

ure,

inse

cts,

tr

ips

and

falls

from

slip

pery

or u

neve

n su

rfac

es,

burn

s fr

om m

icro

wave

ove

ns

32

318

Med

31.

Bulle

tin M

icro

wave

Saf

ety

Ente

ring

or le

avin

g th

ebu

ildin

g, u

nloc

king

door

stu

rnin

g bu

ildin

g se

curit

ysy

stem

s of

f and

on

Pote

ntia

lfor

violen

tenc

ount

ers

with

peop

leor

anim

als

Slip

s an

d fa

lls o

n sn

ow a

nd ic

e or

une

ven

surf

aces

Park

ing

stal

ls lo

cate

d fa

r awa

y fr

om e

ntra

nce

44

46

4Hi

gh32

.See

# 2

, 27

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

List

Typ

es o

f Wor

k an

d W

ork-

rela

ted

Activ

ities

Iden

tify

Exis

ting

or P

oten

tial

Haza

rd S

ourc

es o

r Ty

pes

Engi

neer

ing

Cont

rols

3

Adm

inis

trat

ive

Cont

rols

4

Pers

onal

Pro

tect

ive

Equi

pmen

t5Co

rrec

tive

Actio

n

STE

P 4

Iden

tify

and

Impl

emen

t Haz

ard

Cont

rols

Asse

ss R

isk

and

Prio

ritiz

e Ha

zard

s

STE

P 1

1S

TEP

22

STE

P 3

Type

of

Wor

kRe

late

d Ta

sks

and

Activ

ities

Envi

ronm

ent,

Tool

s, E

quip

men

t, Pe

ople

Haza

rd T

ypes

:Ph

ysic

al, C

hem

ical

, Bi

olog

ical

, Erg

onom

ic, P

sych

osoc

ial




Risk Level: AxBxC

Risk Priority9

Sum

mar

y of

Rec

omm

ende

d Ha

zard

Con

trols

10In

Pla

ce

YES

NO

Com

men

ts

SCHO

OL

OR

WO

RK S

ITE:

Assi

st w

ith s

ettin

g up

ass

embl

ies

and

spec

ial e

vent

s

Lift

ing

and

carr

ying,

pus

hing

and

pul

ling

heav

yst

age

equi

pmen

t, c

hairs

, pia

nos,

scr

eens

Awkw

ard

post

ures

, str

ains

and

spr

ains

, foo

t ha

zard

s, w

oode

n sp

linte

rs

22

312

Med

33.S

ee #

4, 5

Disc

iplin

e st

uden

ts o

rre

stra

in v

iolen

t st

uden

tsVe

rbal

abu

se a

nd p

hysi

cal i

njur

y, vio

lent

stu

dent

s or

par

ents

(hit,

kic

ked,

bitt

en)

Poss

ible

con

tact

with

blo

od o

r bod

y flu

ids

43

448

High

34. S

ee #

2 , 1

3, 2

7

Colle

ctio

n an

d re

tent

ion

of c

ash

from

stu

dent

sfo

r fie

ld t

rips,

spe

cial

fees

etc

.

Risk

of r

obbe

ry2

14

16M

ed35

.Rob

bery

pre

vent

ion

proc

edur

es (s

eeW

orkin

g Al

one

Com

plia

nce

Gui

delin

e)

Out of

date

AP

PEN

DIX

8:

Sa

mp

leT

each

er H

azar

d A

sses

smen

t an

d C

ontr

ol F

orm

6/6

STAF

F G

ROUP

:Te

ache

r (E

lem

enta

ry)

JOB

OR

POSI

TIO

N S

UMM

ARY:

Educ

atio

n of

stu

dent

s fo

llow

ing

the

“Gui

de to

Educ

atio

n” a

nd “

Teac

hing

Qua

lity

Stan

dard

."AS

SESS

MEN

T BY

:DA

TE C

OM

PLET

ED:

SCHO

OL

OR

WO

RK S

ITE:

Revi

ew D

ates

STE

P 5

Revi

ew a

nd c

omm

unic

ate

asse

ssm

ent w

ith a

pplic

able

sta

ff (li

st s

taff

belo

w a

nd h

ave

staf

f ini

tial d

ocum

ent)

STE

P 6

Revi

ew a

sses

smen

t ann

ually

and

upd

ate

as n

eces

sary

1)Ty

pes

of w

ork

incl

ude

a de

scrip

tion

of th

e br

oad

gene

ral n

atur

e of

the

wor

k ca

rrie

d ou

t (e

.g. o

ffice

wor

k, c

lass

room

pre

para

tion,

cle

anin

g).

Wor

k-re

late

d ac

tiviti

esw

ould

be

the

spec

ific

activ

ities

car

ried

out w

ithin

eac

h ty

pe o

f wor

k st

artin

g w

ith a

n ac

tion

verb

(e.g

. ope

ratin

g of

fice

equi

pmen

t, us

ing

com

pute

rs, p

lann

ing

less

ons,

vacu

umin

g flo

ors)

.

2)H

azar

dsca

n be

iden

tifie

d us

ing

seve

ral m

etho

ds in

clud

ing

pers

onal

exp

erie

nce

or in

tuiti

on,

phys

ical

obs

erva

tions

, tas

k or

job

anal

ysis

or

inci

dent

inve

stig

atio

n.

3)En

gine

erin

g C

ontr

ols:

Pref

erre

d m

etho

d. R

educ

es e

xpos

ure

by r

emov

ing

or is

olat

ing

haza

rd

from

wor

ker.

Exam

ples

are

elim

inat

ion,

ven

tilat

ion,

sub

stitu

tion,

red

esig

n, g

uard

ing,

enc

losu

re,

auto

mat

ion,

mec

hani

cal a

ids.

4)Ad

min

istr

ativ

e C

ontr

ols:

Prac

tices

that

red

uce

likel

ihoo

d of

exp

osur

e by

alte

ring

the

time

or w

ay

a ta

sk is

per

form

ed (e

.g. t

rain

ing

or e

duca

tion,

saf

e w

ork

proc

edur

es, p

urch

asin

g st

ds, s

uper

visi

on,

sign

age,

job

rota

tion

or s

ched

ulin

g, h

ouse

keep

ing

etc.

).

5)Pe

rson

al P

rote

ctiv

e Eq

uipm

ent

(PPE

):N

ot to

be

used

as

prim

ary

cont

rol u

nles

s en

gine

erin

g or

adm

inis

trat

ive

cont

rols

are

not

feas

ible

. Exa

mpl

es a

re s

afet

y gl

asse

s, s

afet

y fo

otw

ear,

glov

es,

resp

irato

ry p

rote

ctio

n, h

earin

g pr

otec

tion.

6)Fr

eque

ncy

of E

xpos

ure

to H

azar

d:1

=Le

ss th

an o

nce

per

mon

th2

=At

leas

t onc

e pe

r m

onth

3=

At le

ast o

nce

per

wee

k4

=O

ne o

r m

ore

times

dai

ly

7)H

azar

d Pr

obab

ility

:Lik

elih

ood

haza

rd w

ill re

sult

in a

n in

cide

nt c

ausi

ng h

arm

. 1

=N

ot li

kely

2=

Rem

ote:

not l

ikel

y bu

t pos

sibl

e on

ce e

very

5 to

20

year

s3

=O

ccas

iona

l:lik

ely

to h

appe

n on

ce e

very

1 to

5 y

ears

4=

Prob

able

:exp

ecte

d to

hap

pen

one

or m

ore

times

per

yea

r

8)Po

tent

ial C

onse

quen

ce:S

ever

ity o

f los

s if

haza

rdou

s ev

ent o

ccur

s.

1=

Neg

ligib

le(n

o in

jury

, firs

t aid

, lim

ited

prop

erty

dam

age)

2=

Mar

gina

l(m

edic

al a

id, m

inor

inju

ry o

r illn

ess/

no lo

st ti

me)

3=

Cri

tical

(lost

tim

e in

jury

, tem

pora

ry d

isab

ility)

4=

Cat

astr

ophi

c(s

erio

us in

jury

or

illnes

s, p

erm

anen

t dis

abilit

y, d

eath

, ext

ensi

ve p

rope

rty

dam

age)

9)R

isk

Cla

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Out of

date

APPENDIX 10: Sample Hazard Report Form


here




LOCATION OF HAZARD:

DATE:NAME:

EQUIPMENT:

Description of hazard:

Suggested corrective action:

SIGNATURE OF WORKER:

DATE:SUPERVISOR NAME/SIGNATURE:

Supervisor’s remarks:

Corrective action taken:Out of

date

APPENDIX 11: Sample Employee Health and Safety Orientation Checklist

NAME:

LOCATION:

DATE:

POSITION:

Health and Safety Policy

Roles and Responsibilities

General Rules

Job Specific Hazards

Health and Safety Training

Inspections/Audits

Refusal of Unsafe Work

Incident Reporting and Investigations

Emergency Response Process

ORIENTATION ELEMENTS

ADDITIONAL INFORMATION

Completed Initials

Emergency Contact Information

Location of PPE

Location of First Aid and Emergency Supplies

Questions:

Comments:

Notes:

Completed Initials


here




SUPERVISOR NAME/SIGNATURE: DATE:

WORKER NAME/SIGNATURE: DATE:

DATE FOR ORIENTATION FOLLOW-UP:

Out of

date

APPENDIX 12: Sample Inspection Checklist 1/3


here




LOCATION:

DATE:INSPECTED BY (STAFF):

SECTION A – Slipping, Tripping and Falling Yes/No Priority Comment

Are hallways and classrooms free of obstructions to pedestrians?

Are classroom aisles free from debris and obstruction?

Are cords (phone/electrical) secured out of aisles, work areas?

Are there any spills that require cleaning?

Are stepladders available for staff to use to reach and hang decorations?

Are stepladders in good condition?

SECTION B – Falling Objects Yes/No Priority Comment

Are materials in classrooms stacked so that they cannot fall to a lower level?

Are shelves and cabinets free of overload?

SECTION C – Electrical Yes/No Priority Comment

Is there insulation on electrical cords?

Are appropriate plugs equipped with grounding prongs?

Are covers and cover plates in place?

Are equipment and lights free of loose connections?

Are electrical panels labelled and shut?

Are outlets free of overloads?

Priority Index: 1. Imminent Danger 2. Serious 3. Minor 4. Acceptable 5. Not Applicable (N/A)

INSPECTED ITEMS

Out of

date

SECTION D – Fire Prevention Yes/No Priority Comment

Are flammable liquids in approved containers if present?

Is waste disposed of properly?

Is equipment shut off at the end of the day?

Do employees know evacuation procedures?

Are all exit signs visible from your door illuminated?

If there are personal space heaters, electric hot plates or coffee makers, are they clear of flammable or combustible material and from contact with people?

SECTION E – First Aid and Emergency Response Yes/No Priority Comment

Are you aware of Emergency Response Plan?

Do you know where the first aid kits are located?

Do you know where the eyewash stations are located?

Are emergency equipment and exits free of obstruction?

SECTION F – Miscellaneous Yes/No Priority Comment

Is the classroom void of abrasion hazards such as sharpedges or corners of furniture or wall mounted fixtures?

Are the aisles free of any blind corners?

Is adequate light available?

Are computer screens/consoles positioned properly (no glare)?

Are computer stations equipped with wrist rests?

Do staff know where to access the Health and Safety policy?

Are there other concerns with your general working environment?



here




LOCATION:


Priority Index: 1. Imminent Danger 2. Serious 3. Minor 4. Acceptable 5. Not Applicable (N/A)

INSPECTED ITEMS

Out of

date

Description of Deficiency Corrective Action Responsible Person Due Date CompletionDate



here




LOCATION:


CORRECTIVE ACTION SUMMARY (TO BE COMPLETED BY ADMIN)

MANAGEMENT REVIEW AND SIGN OFF

DATE:SIGNATURE:

TITLE:NAME:

Out of

date

APPENDIX 13: Sample Incident Report Form 1/2


here




LOCATION OF INCIDENT:

DATE OF INCIDENT:NAME OF WORKER:

TIME OF INCIDENT:POSITION:

DATE REPORTED:PHONE:

Witnesses? YES NO

If YES, list and submit witness statements:

Type of incident:

Near Miss Property Damage Environmental/Spill

Injury (First Aid, Medical Aid, Lost Time) Other

Was there an injury? YES NO

If YES, describe (type and location) and submit First Aid Report and WCB forms:

Description of of incident (including events leading up to incident):

Immediate action taken:

Suggestions to prevent recurrence:

DATE:SIGNATURE:

DATE:MANAGER/PRINCIPAL NAME/SIGNATURE:

Out of

date

APPENDIX 13: Sample Incident Report Form 2/2


here




Draw out the Incident Scene. Be sure to include the locations of all witnesses, equipment, machinery, buildings, etc. in relationto the incident site.

Please describe the details of your drawing.Out of

date

APPENDIX 14: Sample Incident Investigation Form 1/2


here




LOCATION OF INCIDENT:

DATE OF INCIDENT:NAME OF WORKER:

TIME OF INCIDENT:POSITION:

DATE REPORTED:PHONE:

Witnesses? YES NO

If YES, list and submit witness statements:

Type of incident:

Near Miss Property Damage Environmental/Spill

Injury (First Aid, Medical Aid, Lost Time) Other

Was there an injury? YES NO

Injured worker’s name, position and experience:

Describe (type and part/location of injury) and attach First Aid Report and WCB forms:

Description of of incident (including events leading up to incident):

Out of

date

APPENDIX 14: Sample Incident Investigation Form 2/2


here




Direct or immediate causes (Substandard Acts or Conditions):

Indirect or underlying causes (Personal or Work Factors):

Immediate action taken:

CompletionRecommended corrective measures: By Whom Date

COMMENTS:

Status: COMPLETE MONITOR REQUIRES FURTHER INVESTIGATION

DATE:SIGNATURE:Reviewed by:

COMMENTS:

DATE:SIGNATURE:Investigated by: Out of

date

APPENDIX 15: Sample Witness Statement 1/2


here




Please state in your own words what happened.

DATE OF INCIDENT:NAME OF WITNESS:

CONTACT INFORMATION:POSITION:

DATE:SIGNATURE:

Out of

date

Draw out the Incident Scene. Be sure to include the locations of all witnesses, equipment, machinery, buildings, etc. in relationto the incident site.

APPENDIX 15: Sample Witness Statement 2/2


here




Please describe the details of your drawing.Out of

date

APPENDIX 16: Sample First Aid Report Form


here




FIRST NAME:LAST NAME:

Employee Information

Employee Incident/Injury Information (to be completed by the employee)

DEPT. NAME:WORKSITE:

DEPT. PHONE:

Date incident/injury occurred: Year: Month: Day: Time: AM or PM:

Date reported to supervisor: Year: Month: Day: Time: AM or PM:

Description of injury or illness:

Location where the injury or illness occurred or began:

Cause of the injury or illness:

First Aid Treatment Information (to be completed by the First Aid Provider)

Was first aid treatment provided? YES NO If YES, complete the following

Description of First Aid Treatment provided:

This record must be kept in the employee’s file for a minimum of three years from the date of the injury or illness.

First Aid Provider #1:

Qualifications: Emergency First Aid Standard First Aid Advanced First Aid





DATE:SIGNATURE:

DATE:SIGNATURE:

DATE:SIGNATURE:

Out of

date

APPENDIX 17: Sample WCB Employer’s Report Form 1/6

Out of

date


Out of

date

APPENDIX 18: Sample WCB Worker’s Report Form 1/3

Out of

date


Out of

date

contact name/number · 2020. 8. 24. · prime contractor: 3(1) every work site must have a prime...

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