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".

• Explain the deficiencies n the "Comments/Improvements" column and list any specific, planned improvements.
• Indicate the persons responsible for these improvements in the next column.
• Enter the target date for these improvements.
• Finally, when the improvements are actually completed enter the completion date in the last column.

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