Written Safety and Health Program

Written Safety and Health Program For XYZ Company Required for all Hawaii Businesses with 25 or More Employees Incorporates Provisions of Hawaii Administrative Rules Title 12, Subtitle 8, Part 2, Chapter 60

Table of Contents Section Description Page 1 Management Commitment 3 2 Assignment of Responsibilities 4 3 Employee Participation 10 4 Hazard Recognition 13 5 Hazard Prevention and Control 23 6 Emergency Planning 33 7 Safety and Health Training 42 8 Company Required Safety Programs 46 9 Company Required Safety Training Courses 47 10 Company Required Safety Forms & Checklists 49 Appendices Appendix A List of Training Subjects 51 Appendix B Hazard Assessment Checklist (Alpha sorted) 53 Appendix C Hazard Assessment and Correction Record 54 Appendix D Accident/Exposure Investigation Report 56 Appendix E Employee Training and Instruction Record 58 Appendix F Employee Acknowledgement Form 60

Section 1 Management Commitment Program Policy Statement XYZ Company shall comply with all occupational safety and health laws of the State of Hawaii. To accomplish this, we must constantly be aware of unsafe acts and conditions in all work areas that can produce injuries. No employee is required to work at a job they know is not safe or healthful. As employees of XYZ Company, your cooperation in detecting hazards and, in turn, controlling them, is a condition of your employment. Inform your supervisor immediately of any situation beyond your ability or authority to correct. Program Requirement This written program is required for all businesses with 25 or more employees within the State of Hawaii. This program incorporates and complies with Hawaii Administrative Rules Title 12, Subtitle 8, Part 2, Chapter 60 Proper use of this program requires the Program Administrator to carefully review the requirements for each of the program sections, appendices and to modify, where necessary, to accurately reflect specific company requirements as it relates to its operation and workforce. This program must be maintained by the employer in order to be effective.

Section 2 Assignment of Responsibilities 1. Program Administrator Written Safety and Health Program administrator, Program Administrator has the authority and responsibility for implementing the provisions of this program. DECISION POINT Enter a name or position title (recommended) The Program Administrator for XYZ Company is. 2. Company Responsibilities XYZ Company responsibilities shall including the following: a. Provide support from the top level down to first line supervisors in terms of time, effort, and money. b. Resolve scheduling and personnel conflicts. c. Provide realistic dates for correcting safety and health concerns. d. Support training for safety committee members. e. Provide leadership and direction. f. Participate in safety committee meetings. g. "Talk up" the positive effects of safety committee activities, on a one-on-one basis or ingroup meetings. h. Respond to recommendations in a timely manner. i. Ensure lines of communication are open and non-threatening. j. Consider expanding the safety committee's responsibilities and authority to better serve the company.

Section 3 Employee Participation DECISION POINT - If one is not established, state reason and/or justification, then edit the text in this section as appropriate to your business. 1. Occupational Safety and Health Committee XYZ Company has formed a safety committee to help employees and management work together to identify safety problems, develop solutions, review incident reports and evaluate the effectiveness of our safety program. The committee is made up of management-designated representatives and employee-elected representatives. A. The committee shall: 1) Promote a safe and healthy work environment at all times. 2) Encourage communication between employees and management. 3) Serve as an oversight committee on all issues relative to safety and health. 4) Make recommendations to the Safety Representative. B. Functions: The committee has four principal functions: 1) Identify potential hazards; 2) Evaluate these potential hazards; 3) Recommend corrective action; and 4) Follow up implemented recommendations. To carry out its functions, the committee is required to hold meetings and carry out regular inspections of the workplace.

Section 4 Hazard Recognition 1. Recordkeeping and Review A. Employees will: Employees will report any injury or work-related illness to their immediate supervisor regardless of how serious. Minor injuries such as cuts and scrapes can be entered on a Minor Injury Log posted in a conspicuous location. The employee must use an Employee s Injury/Illness Report Form to report more serious injuries. B. Supervisors will: DECISION POINT a. Investigate a serious injury or illness using procedures in the Incident Investigation section. b. Complete an Incident Investigation Report form. c. Give the Employee s Report and Incident Investigation Report to the company Safety Representative. 2. Hazard Recognition Methods Hazard recognition is a vital element in the program. It is a system to identify any existing or potential dangers in the workplace, then following through to eliminate or control them. If dangers occur (or reoccur), there is a breakdown in the danger control system, and in turn the safety and health program. The danger control system also serves as the basis for developing safe work procedures and safety and health training.

Section 5 Hazard Prevention and Control 1. Eliminating Workplace Hazards XYZ Company is committed to eliminating or controlling workplace hazards that could cause injury or illness to our employees. We will meet the requirements of state safety standards where there are specific rules about a hazard or potential hazard in our workplace. Whenever possible we will design our facilities and equipment to eliminate employee exposure to hazards. Where these engineering controls are not possible, we will write work rules that effectively prevent employee exposure to the hazard. When the above methods of control are not possible or are not fully effective we will require employees to use personal protective equipment (PPE) such as safety glasses, hearing protection, foot protection etc. 2. Safety Rules and Work Procedures A. General Safety Rules The XYZ Company Written Safety and Health Program apply to all employees. The rules may be very simple or extremely complex, depending on the nature of the work processes and the number and kinds of employees involved. Some items that are addressed by general safety rules are: 1) Personal protective equipment requirements; 2) Clothing appropriate for the work; 3) Behavior expected of all employees; 4) How to leave the workplace safely, with particular reference to emergency procedures; and 5) Danger areas that are: off-limits for employees.

Section 6 Emergency Planning DECISION POINT 1. Emergency Planning and Procedures An evacuation map for the building is posted (Customize by adding location, if this applies to your company). It shows the location of exits, fire extinguishers, first aid kits, and where to assemble outside (Customize by adding meeting location for your location). A copy of the map is attached to this program. All XYZ Company employees will receive training on how to use a portable fire extinguisher as part of their initial orientation. Buildings will display a map that shows the location of exits, fire extinguishers, first aid kits, and where to assemble outside. At XYZ Company, advance planning and preparation for emergencies is good insurance. Some emergency planning is mandated by regulations, such as for first aid and fire evacuation and for certain situations in specific industries or operations. A list of possible emergencies shall be prepared and procedures established to respond to those emergency situations. Emergency plans shall be reviewed with individuals such as doctors, fire and explosives experts or special consultants where possible, and on an as needed basis. Emergency procedures shall be updated whenever changes are made in materials, equipment or building structures.

Section 7 Safety and Health Training Training at XYZ Company is an essential part of our plan to provide a safe work place. Training Administrator Written Safety and Health Program training administrator, Training Administrator has the authority and responsibility for implementing the provisions of this program. DECISION POINT Enter a name or position title (recommended) The Training Administrator for XYZ Company is. The Training Administrator is responsible to verify that each employee has received an initial safety orientation by their supervisor, has received any training needed to do the job safely and that the employee file documents the training. This administrator will make sure that an outline and materials list is available for each training course we provide: 1. New-Hire Employee Orientation A. All XYZ Company employees will attend the new-hire employee orientation prior to commencing employment. New-hires shall receive occupational health and safety training in the following subject areas: 1) XYZ Company Safety Philosophy and Policy 2) Disciplinary procedures for non-compliance 3) Employee Danger Reporting System 4) Accident Reporting System 5) Personal Protective Equipment (when applicable) 6) Fall Protection -100% tie-off (when applicable)

Section 8 Company Required Safety Programs Due to the nature of work and operations performed by XYZ Company, it is necessary that the following regulatory programs are included in our Injury and Illness Prevention Program: For convenience, programs listed in the table below are alpha sorted. DECISION POINT Review and select those programs that apply or included others not listed Company Required Safety and Health Plans & Programs Accident Prevention Program Asbestos Management Plan Bloodborne Pathogens Program Chemical Hygiene Plan Confined Space Entry Program Control of Hazardous Energy Program Cranes and Derricks Safety Program Electrical Safety Program Emergency Action Plan Excavation and Trenching Program Fall Protection Program Fire Prevention Work Plan Flammable Storage / Compressed Gas Forklift Safety Program Hazard Communication Program Hearing Conservation Program Hot Work Permit Program Ladders and Stairways Work Plan Laser Safety Program Lead Safety Program Personal Protective Equipment Plan Powered Industrial Truck Program Radiation Protection Program Respiratory Protection Program Scaffolding Safety Program Welding Safety Program Table 1

Section 9 Company Required Safety Training Courses Due to the nature of work and operations performed by XYZ Company, it is necessary that the following safety training courses are included in our Injury and Illness Prevention Program: For convenience, courses listed in the 3 tables below are alpha sorted. DECISION POINT Review and select those courses that apply or included others not listed Company Required Safety Training Courses Sorted A-E Accident Investigation Accident Prevention Signs & Tags Asbestos Safety Bloodborne Pathogens Initial/Refresher Bloodborne Pathogens Train-the-Trainer Chemical Spills Competent Persons Compressed Gas Cylinder Concrete & Masonry Confined Space Entry Construction Safety Management Crane Safety Refresher Cranes & Derricks in Construction Electrical Safety Emergency Exit Routes Emergency Response Team Ergonomics Basic Human Factors Ergonomics Advanced Human Factors Excavation Safety Eye & Face Protection Table 2

Company Required Safety Training Courses Sorted F-L Fall Protection Portable Fire Extinguisher Flammable & Combustible Liquids Forklift Safety Classroom (English) Forklift Safety Classroom (Spanish) Hand & Power Tools Hazard Communication Hazard Vulnerability Hazardous Materials Management Hearing Protection Hexavalent Chromium Hot Work Permit Safety Indoor Air Quality Introduction to OSHA Job Hazard Analysis Laser Safety Lead Exposure Liquid Nitrogen Lockout-Tagout Table 3 Company Required Safety Training Courses Sorted M-W Machine Guarding Material Handling Office Safety Awareness Pandemic Preparedness Personal Protective Equipment Powered Industrial Truck Radiation Safety Respirator Protection Safe Lifting Awareness Back Safety Safety Audit Training Safety Representative Training Safety Supervisor Training Scaffolding Slip, Trip & Fall Prevention Stairway & Ladder Safety TB Respiratory Protection Walking & Working Surfaces Warehouse Safety Workplace Violence Prevention - Healthcare Workplace Violence Prevention - Retail Table 4

Section 10 Company Required Safety Forms & Checklists Due to the nature of work and operations performed by XYZ Company, it is necessary that the following safety forms and checklists are included in our Injury and Illness Prevention Program: For convenience, forms listed below are subject sorted. DECISION POINT Review and select those forms that apply or included others not listed CONFINED SPACE Confined Space Entry Permit Confined Space Class A & B Permit Confined Space Class C Permit List of Authorized Entrants Permit Required Confined Space Inventory Log CONSTRUCTION INDUSTRY - SAFETY MANAGEMENT Construction Industry Inspection Checklist Job Start-Up Checklist Contractors Job Site Checklist Contractor Safety Performance Report Construction Equipment Checklist Forklift Service Checklist Operator Performance Evaluation Checklist Safety Nets Inspection Checklist Body Harness & Lanyard Inspection Report Competent Person Evaluation Fall Protection CRANE OPERATIONS Cranes, Derricks or Material Handling Devices Worksheet Crane Inspection Checklist Crane Pre-Lift Checklist Sling (Chain) Inspection Report Monthly Hoist Rope Inspection Report Monthly Hoist Hook Inspection Report EMERGENCY ACTION AND RESPONSE Crisis Management Response Team - Contact Log Safety Representatives - Contact Log External Resources Contact Log Vulnerability Analysis Chart Bomb Threat Checklist Employee Evacuation - Accounting Log Physically Challenged Employee List Command Post Equipment Inventory Log Press Information Log Post Exercise Evaluation Report

EMPLOYEE SAFETY RECORDS Employee Acknowledgement Form Employee Orientation Checklist Construction Employee PPE Assessment Form Employee PPE Issue Form Employee Safety Training Record Ergonomic Workstation Analysis Form Employee Ergonomic Workstation Questionnaire Employee Safety Suggestion Form EXCAVATION OPERATIONS Pre-Excavation Checklist Trenching Design Checklist Trench Safety Daily Field Report Competent Person Evaluation Excavation FIRE PREVENTION Hot Work Permit Fire Safety Inspection Checklist Fire Drill Post Response Report Emergency HAZMAT Inventory Log Hazardous Waste Disposal Request Form GENERAL INDUSTRY SAFETY MANAGEMENT General Industry Safety Inspection Checklist Office Safety Inspection Checklist Job Safety Analysis Worksheet & Instructions Accident Prevention Program Analysis Forklift Service Checklist Hearing Conservation Program Log Scaffolding Safety Checklist Site Safety Meeting Record Supervisors Monthly Meeting Record Report of Safety Hazard Form Property Security Survey INCIDENT REPORTING FORMS OSHA 300 Log Employee Injury & Illness Report Employee Injury Cost Accounting Matrix Vehicle Accident & Property Damage Report Compiling Direct and Indirect Costs OCCUPATIONAL HEALTH FORMS Medical Evaluation Questionnaire Respirator Use Respirator Fit Testing Record Hepatitis B Vaccine - Accept/Decline Form Bloodborne Pathogens Risk Classification Flowchart BBP Employee Annual Training Record BBP Source Patient Consent Form RADIATION PROGRAM FORMS Radioactive Material Use Log Pregnancy Declaration Form Laboratory Contamination Survey Record Radiation Producing Device - Authorization Form Training Guide for Radiation Workers Training Guide for Ancillary Radiation Works TRAINING RECOGNITION CERTIFICATE Certificate of Completion

Appendix A List of Training Subjects DECISION POINT Select applicable training subjects - Strikethrough/delete those that do not XYZ Company trains our workers about the following selected training subjects: 1. The employer's Code of Safe Practices. 2. Confined spaces. 3. Safe practices for operating any agricultural equipment. 4. Good housekeeping, fire prevention, safe practices for operating any construction equipment. 5. Safe procedures for cleaning, repairing, servicing and adjusting equipment and machinery. 6. Safe access to working areas. 7. Protection from falls. 8. Electrical hazards, including working around high voltage lines. 9. Crane operations. 10. Trenching and excavation work. 11. Proper use of powered tools. 12. Guarding of belts and pulleys, gears and sprockets, and conveyor nip points. 13. Machine, machine parts, and prime movers guarding. 14. Lock-out/tag-out procedures. 15. Materials handling.

16. Chainsaw and other power tool operation. 17. Tree falling/bucking procedures and precautions, including procedures for recognizing and working with hazard trees, snags, lodged trees, and unsafe weather conditions. 18. Yarding operations, including skidding, running lines, unstable logs, rigging and communication. 19. Landing and loading areas, including release of rigging, landing layout, moving vehicles and equipment, and log truck locating, loading and wrapping. 20. Fall protection from elevated locations. 21. Use of elevated platforms, including condors and scissor lifts. 22. Safe use of explosives. 23. Driver safety. 24. Slips, falls, and back injuries. 25. Ergonomic hazards, including proper lifting techniques and working on ladders or in a stooped posture for prolonged periods at one time. 26. Personal protective equipment. 27. Respiratory Equipment. 28. Hazardous chemical exposures. 29. Hazard communication. 30. Physical hazards, such as heat/cold stress, noise, and ionizing and non-ionizing radiation. 31. Laboratory safety. 32. Bloodborne pathogens and other biological hazards. 33. Other job-specific hazards, such as

Appendix B Hazard Assessment Checklist DECISION POINT Determine which checklists apply to your operation and delete all others XYZ Company has determined the following hazard assessment checklists apply to its operations 1. Abrasive Wheel Equipment Grinders 2. Compressed Air Receivers 3. Compressed Gas & Cylinders 4. Compressors & Compressed Air 5. Confined Spaces 6. Control of Harmful Substances by Ventilation 7. Crane Checklist 8. Electrical 9. Elevated Surfaces 10. Emergency Action Plan 11. Environmental Controls 12. Ergonomics 13. Exit Doors 14. Exiting or Egress 15. Fire Protection 16. Flammable & Combustible Materials 17. Floor & Wall Openings 18. Fueling 19. General Work Environment 20. Hand Tools & Equipment 21. Hazardous Chemical Exposures 22. Hazardous Substances Communication 23. Hoist & Auxiliary Equipment 24. Identification of Piping Systems 25. Industrial Trucks Forklifts 26. Infection Control 27. Lockout-Tagout Procedures 28. Machine Guarding 29. Material Handling 30. Noise 31. Personal Protective Equipment & Clothing 32. Portable (Power Operated) Tools & Equipment 33. Portable Ladders 34. Powder Actuated Tools 35. Sanitizing Equipment & Clothing 36. Spraying Operations 37. Stairs and Stairways 38. Tire Inflation 39. Transporting Employees & Materials 40. Ventilation for Indoor Air Quality 41. Walkways 42. Welding, Cutting & Brazing