APPENDIX 12-1

EXAMPLE OF A SELF-EVALUATION CHECKLIST FOR SMALL BUSINESSES

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

ELEMENT I.  MANAGEMENT LEADERSHIP AND EMPLOYEE INVOLVEMENT

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
Policies and objectives are established and communicated to all employees          
Top management is visibly involved in safety and health          
Employees are involved in identifying and solving safety and health problems          
All safety and health responsibilities are clearly assigned          
Adequate authority and resources are provided to those with responsibility          
Managers, supervisors and employees are held accountable          
Program operations are reviewed at least annually to evaluate success in meeting goals and objectives and to prepare new objectives          

ELEMENT II.  WORKSITE ANALYSIS

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
A baseline comprehensive survey of hazards has been done or updated within the last three years          
Change analysis is done for every change of facility, equipment, process or material          
Job hazard analysis is done on an ongoing basis          
Self-inspections are conducted regularly by adequately trained supervisors in their work areas          
Broad, regular site inspections are conducted periodically by adequate trained personnel          
Employees know how and whom to notify about hazards, without fear of reprisal and receive timely and appropriate responses          
Accidents and near-miss incidents are investigated to identify all contributing causes and to prevent future occurrences          
Reviews are done of injury and illness experience over a period of time long enough for patterns of potentially common causes to appear.          

ELEMENT II.  WORKSITE ANALYSIS (CON’T)

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
Reviews are done of injury and illness experience over a period of time long enough for patterns of potentially common causes to appear          

ELEMENT III.  HAZARD PREVENTION AND CONTROL

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
All identified hazards are prevented or controlled in the best feasible manner          
Safe work procedures based on job hazard analyses have been established          
Supervision reinforces safe work through positive feedback and training          
Enforcement of safe work procedures and safety and health rules is accomplished fairly and efficiently through a disciplinary system that all employees understand          
New or repeat hazards are identified and corrected in a timely manner          
The facility and equipment are regularly maintained to prevent hazardous breakdowns          
Arrangements have been made for occupational health specialists to provide medical services, including assistance in health problem identification          

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

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
First aid and CPR-trained employees are available on every shift          
Preparations have been made for all types of emergencies          
Exits, evacuation routes and emergency telephone numbers are prominently displayed          

ELEMENT IV.  SAFETY AND HEALTH TRAINING

INDICATORS YES/
NO
COMMENTS
IMPROVEMENTS
RESPONSIBLE
PARTY
TARGET
DATE
DATE
COMPLETED
Employees can explain how and why they do the job safely and healthfully          
Employees use all required PPE properly          
Employees can explain why PPE is used, how to use it and maintain it and what the limits of its protection are          
Supervisors can explain safety rules and procedures for hazard control, how they teach this to employees and how they enforce it          
Managers can explain their safety and health responsibilities          

SPECIAL OBJECTIVES (LIST AND EVALUATE INDIVIDUALLY)

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