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Program Evaluation Profile (PEP)


CAUTION: The following excerpts are from the OSHA Notice CPL 2, distributed on August 1, 1996, by the Directorate of Compliance Programs. This Program Evaluation Profile (PEP) notice was cancelled on November 15, 1996. This document is provided as an EXAMPLE of an auditing tool to assist in the evaluation of a Safety and Health Program.

Purpose

This notice establishes policies and procedures for the Program Evaluation Profile (PEP), Form OSHA-195, which is to be used in assessing employer safety and health programs in general industry workplaces.

References

  1. OSHA Instruction CPL 2.103, September 26, 1994, Field Inspection Reference Manual (FIRM).
  2. OSHA Instruction CPL 2.111 [CPL 02-00-111], November 27, 1995, Citation Policy for Paperwork and Written Program Requirement Violations.
  3. Safety and Health Program Management Guidelines, Federal Register, January 26, 1989, Vol. 54, No. 16, pp. 3904-3916.

Background

OSHA's assessment of safety and health conditions in the workplace depends on a clear understanding of the programs and management systems that an employer is using for safety and health compliance. The Agency places a high priority on safety and health programs and wishes to encourage their implementation.

  1. Evaluation of Workplace Safety and Health Programs. In the past, compliance officers have evaluated employers' safety and health programs, but those evaluations have not always required thorough documentation in case files. More detailed evaluation and documentation is now required to meet the Agency's need to assess such programs accurately and to respond to workplace compliance conditions accordingly.
  2. Safety and Health Program Management Guidelines. In January 1989, OSHA published its voluntary Safety and Health Program Management Guidelines (Federal Register, Vol. 54, No. 16, pp. 3904-3916; hereinafter referred to as the 1989 Guidelines), which have been widely used in assessing employer safety and health programs.
  3. The PEP. Appendix A of this directive contains the Program Evaluation Profile (PEP), Form OSHA-195, a new program assessment instrument.
    1. The PEP was developed by representatives of OSHA's National Office and field staff in a cooperative effort with the National Council of Field Labor Locals (NCFLL).
    2. The PEP is presented in a format that will enable the compliance officer to present information about the employer's program graphically. While the PEP is compatible with other evaluation tools based on the 1989 Guidelines, it is not the only such tool that will be used. It is not a substitute for any other kinds of program evaluations conducted by OSHA, such as those that are required by OSHA standards. Program evaluations, such as those required by the Process Safety Management Standard, the Lockout/Tagout Standard, the Bloodborne Pathogens Standard, and others, are considered to be an integral part of a good safety and health program if the workplace is covered by those standards, and therefore must be included in the PEP review.
    3. Instructions for use of the PEP are found in "Using the PEP" section of this notice.

Application

  1. The PEP shall be completed for general industry inspections and compliance-related activities that include an evaluation of an employer's workplace safety and health programs.
    1. The PEP is an educational document for workers and employers, as well as a source of information for OSHA's use in the inspection process.
    2. A new PEP need not be completed when a PEP has recently been done for a specific workplace and the compliance officer judges that no substantive changes in the employer's safety and health program have occurred.
    3. In multi-employer workplaces, a PEP shall be completed for the safety and health program of the host employer. This PEP will normally apply to all subordinate employers onsite, and individual PEPs need not be completed for them. The compliance officer may, however, complete a PEP for any other employers onsite for which he/she believes it is appropriate; e.g., where a subcontractor's program is markedly better or worse than that of the host employer.
    4. The PEP shall be used in experimental programs and cooperative compliance programs (e.g., Maine 200) that require evaluation of an employer's safety and health program, except where other program evaluation methods/tools are specifically approved.
  2. The compliance officer's evaluation of the safety and health program contained in the PEP shall be shared with the employer and with employee representatives, if any, no later than the date of issuance of citations (if any).

    1. The preliminary assessment from the PEP shall be discussed with the employer in the closing conference; the employer shall be advised that this assessment may be modified based on further inspection results or additional information supplied by the employer.
    2. The compliance officer's evaluation of the safety and health program may be shared with the employer and with employee representatives in the following ways:
      1. Giving a copy of the completed PEP to the employer and employee representatives.
      2. Giving a blank PEP to the employer and employee representatives, who may complete it themselves based on compliance officer comments and their own knowledge.
      3. Providing only verbal comments and recommendations to the employer and employee representatives.
      4. Providing written comments and recommendations (e.g., in a letter from the Area Director) to the employer and employee representatives.
    3. Because the PEP represents the compliance officer's evaluation of an employer's worksite safety and health program at the time an inspection was conducted, the scoring shall normally be modified only by the inspecting compliance officer, except in the case of clear errors (e.g., computation).

Using the PEP

The PEP will be used as a source of safety and health program evaluation for the employer, employees, and OSHA.

  1. Gathering Information for the PEP begins during the opening conference and continues through the inspection process.
    1. The compliance officer shall explain the purpose of the PEP and obtain information about the employer's safety and health program in order to make an initial assessment about the program.
    2. This initial assessment shall be verified--or modified--based on information obtained in interviews of an appropriately representative number of employees and by observation of actual safety and health conditions during the inspection process.
    3. If the employer does not wish to volunteer the information needed for the PEP, the compliance officer shall note this in the case file but shall not press the issue. The benefits of a PEP evaluation shall, however, be explained.
  2. Recording the Score. The program elements in the PEP correspond generally to the major elements of the 1989 Guidelines.

    1. Elements. The six elements to be scored in the PEP are:
      1. Management Leadership and Employee Participation
      2. Workplace Analysis
      3. Accident and Record Analysis
      4. Hazard Prevention and Control
      5. Emergency Response
      6. Safety and Health Training
    2. Factors. These elements [except for (6), Training] are divided into factors, which will also be scored. The score for an element will be determined by the factor scores. The factors are:
      1. Management Leadership and Employee Participation.
        • Management leadership.
        • Employee participation.
        • Implementation [tools provided by management, including budget, information, personnel, assigned responsibility, adequate expertise and authority, line accountability, and program review procedures].
        • Contractor safety.
      2. Workplace Analysis.
        • Survey and hazard analysis.
        • Inspection.
        • Reporting.
      3. Accident and Record Analysis.
        • Investigation of accidents and near-miss incidents.
        • Data analysis.
      4. Hazard Prevention and Control.
        • Hazard control.
        • Maintenance.
        • Medical program.
      5. Emergency Response.
        • Emergency preparedness.
        • First aid.
      6. Safety and Health Training (as a whole).
    3. Scoring. The compliance officer shall objectively score the establishment on each of the individual factors and elements after obtaining the necessary information to do so. (See 'Using the PEP' 5., below.) These shall be given a score of 1, 2, 3, 4, or 5.
      1. Appendix B of this notice contains the PEP Tables, which provide verbal descriptors of workplace characteristics for each factor for each of the five levels. Compliance officers shall refer to these tables as appropriate to ensure that the score they assign to a factor corresponds to the descriptor that best fits the worksite.

        NOTE: The descriptors are intended as brief illustrations of a workplace at a particular level. In exercising their professional judgment, compliance officers should proceed with the understanding that the descriptor that "best fits" will not necessarily match the workplace exactly or in literal detail.

      2. Determine scores for each of the six elements as follows:
        1. The score for the "Management Leadership and Employee Participation" element shall be whichever is the lowest of the following:
          1. The score for the "Management Leadership" factor.
          2. The score for the "Employee Participation" factor.
          3. The average score for all four factors.

            NOTE: The factors of "Management Leadership" and "Employee Participation" are given greater weight because they are considered the foundation of a safety and health program.
        2. For the sixth element, Training, just determine the level 1-5 that best fits the worksite and note it in the appropriate box on the PEP.
        3. For each of the other four elements, average the scores for the factors.
        4. In averaging factor scores, round to the nearest whole number (1, 2, 3, 4, or 5). Round up from one-half (.5) or greater; round down from less than one-half (.5).
      3. If the employer declines to provide pertinent information regarding one or more factors or elements, a score of 1 shall be recorded for the factor or element.
      4. If the element or factor does not apply to the worksite being inspected, a notation of "Not Applicable" shall be made in the space provided. This shall be represented by "N/A" or, in IMIS applications, "0." This shall not affect the score.
    4. Overall Score. An "Overall Score" for the worksite will be recorded on the score summary. This will be the average of the six individual scores for elements, rounded to the nearest whole number (1, 2, 3, 4, or 5). Round up from one-half (.5 )or greater; round down from less than one-half (.5).
    5. EXAMPLE: A PEP's element scores are:
    2
    2 13 = 2.16 = 2
    1 6
    3
    2
    +3
    13
    1. Rating and Tracking. The six individual element scores, in sequence (e.g., "2-2-1-2-3-1") will constitute a "rating" for purposes of tracking improvements in an establishment's safety and health program, and shall be recorded.
  1. Program Levels. The Overall Score on the PEP constitutes the "level" at which the establishment's safety and health program is scored. Remember: this level is a relatively informal assessment of the program, and it does not represent a compliance judgment by OSHA--that is, it does not determine whether an employer is in compliance with OSHA standards. The following chart summarizes the levels:
Score Level of Safety and Health Program

5

Outstanding program

4

Superior program

3

Basic program

2

Developmental program

1

No program or ineffective program
  1. Specific Scoring Guidance. The following shall be taken into account in assessing specific factors:
    1. Written Programs. Employer safety and health programs should be in writing in order to be effectively implemented and communicated.
      1. Nevertheless, a program's effectiveness is more important than whether it is in writing. A small worksite may well have an effective program that is not written, but which is well understood and followed by employees.
      2. In assessing the effectiveness of a safety and health program that is not in written form, compliance officers should follow the general principles laid out in OSHA Instruction CPL 2.111 [CPL 02-00-111], "Citation Policy for Paperwork and Written Program Requirement Violations." That is:
        1. An employer's failure to comply with a paperwork requirement is normally penalized only when there is a serious hazard related to this requirement.
        2. An employer's failure to comply with a written program requirement is normally not penalized if the employer is actually taking the actions that are the subject of the requirement.
      3. Thus, compliance officers should follow the general principle that "performance counts more than paperwork." Neither the 1989 Guidelines nor the PEP is a standard; neither can be enforced through the issuance of citations. In using the PEP, the compliance officer is responsible for evaluating the employer's actual management of safety and health in the workplace, not just the employer's documentation of a safety and health program.
    2. Employee Participation.
      1. Employee involvement in an establishment's safety and health program is essential to its effectiveness. Thus, evaluation of safety and health programs must include objective assessment of the ways in which workers' rights under the OSH Act are addressed in form and practice. The PEP Tables include helpful information in this regard.
      2. Employee involvement should also include participation in the OSHA enforcement process; e.g., walkaround inspections, interviews, informal conferences, and formal settlement discussions, as may be appropriate. Many methods of employee involvement may be encountered in individual workplaces.
    3. Comprehensiveness. The importance of a safety and health program's comprehensiveness is implicitly addressed in Workplace Analysis under both "Survey and hazard analysis" and "Data analysis." An effective safety and health program shall address all known and potential sources of workplace injuries and illnesses, whether or not they are covered by a specific OSHA standard. For example, lifting hazards and workplace violence problems should be addressed if they pertain to the specific conditions in the establishment.
    4. Consistency with Violations/Hazards Found. The PEP evaluation and the scores assigned to the individual elements and factors should be consistent with the types and numbers of violations or hazards found during the inspection and with any citations issued in the case. As a general rule, high scores will be inconsistent with numerous or grave violations or a high injury/illness rate. The following are examples for general guidance:
      1. If applicable OSHA standards require training, but the employer does not provide it, the PEP score for "Training" should not normally exceed "2."
      2. If hazard analyses (e.g., for permit-required confined spaces or process safety management) are required but not performed by the employer, the PEP score for "Workplace analysis" should not normally exceed "2."
      3. If the inspection finds numerous serious violations--in particular, high-gravity serious violations--relative to the size and type of workplace, the PEP score for "Hazard prevention and Control" should not normally exceed "2."
  2. Scope of the PEP Review. The duration of the PEP review will vary depending on the circumstances of the workplace and the inspection. In all cases, however, this review shall include:
    1. A review of any appropriate employer documentation relating to the safety and health program.
    2. A walkaround inspection of pertinent areas of the workplace.
    3. Interviews with an appropriate number of employer and employee representatives.

Appendix A
The Program Evaluation Profile (PEP)

Each of the elements and factors of the PEP may be scored from 1 to 5, indicating the level of the safety and health program, as follows:

Overall Score Level of Safety and Health Program

5

Outstanding program

4

Superior program

3

Basic program

2

Developmental program

1

No program or ineffective program

Scoring. Score the establishment on each of the factors and elements after obtaining the necessary information to do so. These shall be given a score of 1, 2, 3, 4, or 5.

  • Refer to the PEP Tables, Appendix B of this notice, as appropriate, to ensure that the score given to a factor corresponds to the descriptor that best fits the worksite. Determine scores for each of the six elements as follows:
  • The score for the Management Leadership and Employee Participation element shall be whichever is the lowest of the following:
  • The score for the "Management Leadership" factor, or
  • The score for the "Employee Participation" factor, or
  • The average score for all four factors.
  • For the sixth element, Training, just determine the level 1-5 that best fits the worksite and note it in the appropriate box on the PEP.
  • For each of the other four elements, average the scores for the factors.
  • If the employer declines to provide pertinent information regarding one or more factors or elements, a score of 1 shall be recorded for the factor or element.
  • If the element or factor does not apply to the worksite being inspected, a notation of "Not Applicable" shall be made in the space provided. This shall be represented by "N/A" or, in IMIS applications, "0." This shall not affect the score.

Overall Score. An "Overall Score" for the worksite will be recorded on the PEP. This will be the average of the six individual scores for elements, rounded to the nearest whole number (1, 2, 3, 4, or 5). Round up from one-half (.5 )or greater; round down from less than one-half (.5).

EXAMPLE: A PEP's element scores are:

2.5
2.7 14.8 = 2.467 = 2 PEP Score
2.3 6
3.0
2.3
+2.0
14.8
PEP Chart

TEXT VERSION

Title: PEP Chart
Type:  Chart
Content:

PEP

Program
Evaluation
Profile

Employer:

Inspection No:

Date:

CSHO:

Management Leadership and Employee Participation

Workplace Analysis

Accident and Record Analysis

Hazard Prevention and Control

Emergency Response

Safety and Health Training

 

a*

b*

c*

d*

e*

f*

g*

h*

i*

j*

k*

l*

m*

n*

o*

 
Outstanding

5

                             

5

Superior

4

                             

4

Basic

3

                             

3

Developmental

2

                             

2

Absent or
Ineffective

1

                              1
Score for Element                                  
Overall Score                                  

OSHA-195 (3/96)

*Text Aligned Vertically in the column.

a* - Management Leadership
b* - Employee Participation
c* - Implementation
d* - Contractor Safety
e* -  Survey and Hazard Analysis
f* -  Inspection
g* - Reporting
h* - Accident Investigation
i* -  Data Analysis
j* -  Hazard Control
k* - Maintenance
l* -  Medical Program
m* - Emergency Preparedness
n* -  First Aid
o* -  Training


Appendix B
The PEP Tables

  • The text in each block provides a description of the program element or factor that corresponds to the level of program that the employer has implemented in the workplace.
  • To avoid duplicative language, each level should be understood as containing all positive factors included in the level below it. Similarly, each element score should be understood as containing all positive factors of the element scores below it. That is, a 3 is at least as good as a 2; a 4 is at least as good as a 3, and so on.
  • The descriptors are intended as brief illustrations of a workplace at a particular level. In exercising their professional judgement, compliance officers should proceed with the understanding that the descriptor that "best fits" will not necessarily match the workplace exactly or in literal detail.

MANAGEMENT LEADERSHIP and EMPLOYEE PARTICIPATION

Management Leadership

Visible management leadership provides the motivating force for an effective safety and health program. [1989 Voluntary Safety and Health Program Management Guidelines, (b)(1) and (c)(1)]
1 Management demonstrates no policy, goals, objectives, or interest in safety and health issues at this worksite.
2 Management sets and communicates safety and health policy and goals, but remains detached from all other safety and health efforts.
3 Management follows all safety and health rules, and gives visible support to the safety and health efforts of others.
4 Management participates in significant aspects of the site's safety and health program, such as site inspections, incident reviews, and program reviews. Incentive programs that discourage reporting of accidents, symptoms, injuries, or hazards are absent. Other incentive programs may be present.
5 Site safety and health issues are regularly included on agendas of management operations meetings. Management clearly demonstrates--by involvement, support, and example--the primary importance of safety and health for everyone on the worksite. Performance is consistent and sustained or has improved over time.


MANAGEMENT LEADERSHIP and EMPLOYEE PARTICIPATION

Employee Participation

Employee participation provides the means through which workers identify hazards, recommend and monitor abatement, and otherwise participate in their own protection. [Guidelines, (b)(1) and (c)(1)]
1 Worker participation in workplace safety and health concerns is not encouraged. Incentive programs are present which have the effect of discouraging reporting of incidents, injuries, potential hazards or symptoms. Employees/employee representatives are not involved in the safety and health program.
2 Workers and their representatives can participate freely in safety and health activities at the worksite without fear of reprisal. Procedures are in place for communication between employer and workers on safety and health matters. Worker rights under the Occupational Safety and Health Act to refuse or stop work that they reasonably believe involves imminent danger are understood by workers and honored by management. Workers are paid while performing safety activities.
3 Workers and their representatives are involved in the safety and health program, involved in inspection of work area, and are permitted to observe monitoring and receive results. Workers' and representatives' right of access to information is understood by workers and recognized by management. A documented procedure is in place for raising complaints of hazards or discrimination and receiving timely employer responses.
4 Workers and their representatives participate in workplace analysis, inspections and investigations, and development of control strategies throughout facility, and have necessary training and education to participate in such activities. Workers and their representatives have access to all pertinent health and safety information, including safety reports and audits. Workers are informed of their right to refuse job assignments that pose serious hazards to themselves pending management response.
5 Workers and their representatives participate fully in development of the safety and health program and conduct of training and education. Workers participate in audits, program reviews conducted by management or third parties, and collection of samples for monitoring purposes, and have necessary training and education to participate in such activities. Employer encourages and authorizes employees to stop activities that present potentially serious safety and health hazards.


MANAGEMENT LEADERSHIP and EMPLOYEE PARTICIPATION

Implementation

Implementation means tools, provided by management, that include:

-- budget
-- information
-- personnel
-- assigned responsibility
-- adequate expertise and authority
-- means to hold responsible persons accountable (line accountability)
-- program review procedures.

[Guidelines, (b)(1) and (c)(1)]
1 Tools to implement a safety and health program are inadequate or missing.
2 Some tools to implement a safety and health program are adequate and effectively used; others are ineffective or inadequate. Management assigns responsibility for implementing a site safety and health program to identified person(s). Management's designated representative has authority to direct abatement of hazards that can be corrected without major capital expenditure.
3 Tools to implement a safety and health program are adequate, but are not all effectively used. Management representative has some expertise in hazard recognition and applicable OSHA requirements. Management keeps or has access to applicable OSHA standards at the facility, and seeks appropriate guidance information for interpretation of OSHA standards. Management representative has authority to order/purchase safety and health equipment.
4 All tools to implement a safety and health program are more than adequate and effectively used. Written safety procedures, policies, and interpretations are updated based on reviews of the safety and health program. Safety and health expenditures, including training costs and personnel, are identified in the facility budget. Hazard abatement is an element in management performance evaluation.
5 All tools necessary to implement a good safety and health program are more than adequate and effectively used. Management safety and health representative has expertise appropriate to facility size and process, and has access to professional advice when needed. Safety and health budgets and funding procedures are reviewed periodically for adequacy.


MANAGEMENT LEADERSHIP and EMPLOYEE PARTICIPATION

Contractor Safety

Contractor safety: An effective safety and health program protects all personnel on the worksite, including the employees of contractors and subcontractors. It is the responsibility of management to address contractor safety. [Guidelines, (b)(1) and (c)(1)]
1 Management makes no provision to include contractors within the scope of the worksite's safety and health program.
2 Management policy requires contractor to conform to OSHA regulations and other legal requirements.
3 Management designates a representative to monitor contractor safety and health practices, and that individual has authority to stop contractor practices that expose host or contractor employees to hazards. Management informs contractor and employees of hazards present at the facility.
4 Management investigates a contractor's safety and health record as one of the bidding criteria.
5 The site's safety and health program ensures protection of everyone employed at the worksite, i.e., regular full-time employees, contractors, temporary and part-time employees.


WORKPLACE ANALYSIS

Survey and Hazard Analysis

Survey and hazard analysis: An effective, proactive safety and health program will seek to identify and analyze all hazards. In large or complex workplaces, components of such analysis are the comprehensive survey and analyses of job hazards and changes in conditions. [Guidelines, (c)(2)(i)]
1 No system or requirement exists for hazard review of planned/changed/new operations. There is no evidence of a comprehensive survey for safety or health hazards or for routine job hazard analysis.
2 Surveys for violations of standards are conducted by knowledgeable person(s), but only in response to accidents or complaints. The employer has identified principal OSHA standards which apply to the worksite.
3 Process, task, and environmental surveys are conducted by knowledgeable person(s) and updated as needed and as required by applicable standards. Current hazard analyses are written (where appropriate) for all high-hazard jobs and processes; analyses are communicated to and understood by affected employees. Hazard analyses are conducted for jobs/ tasks/workstations where injury or illnesses have been recorded.
4 Methodical surveys are conducted periodically and drive appropriate corrective action. Initial surveys are conducted by a qualified professional. Current hazard analyses are documented for all work areas and are communicated and available to all the workforce; knowledgeable persons review all planned/changed/new facilities, processes, materials, or equipment.
5 Regular surveys including documented comprehensive workplace hazard evaluations are conducted by certified safety and health professional or professional engineer, etc. Corrective action is documented and hazard inventories are updated. Hazard analysis is integrated into the design, development, implementation, and changing of all processes and work practices.


WORKPLACE ANALYSIS

Inspection

Inspection: To identify new or previously missed hazards and failures in hazard controls, an effective safety and health program will include regular site inspections. [Guidelines, (c)(2)(ii)]
1 No routine physical inspection of the workplace and equipment is conducted.
2 Supervisors dedicate time to observing work practices and other safety and health conditions in work areas where they have responsibility.
3 Competent personnel conduct inspections with appropriate involvement of employees. Items in need of correction are documented. Inspections include compliance with relevant OSHA standards. Time periods for correction are set.
4 Inspections are conducted by specifically trained employees, and all items are corrected promptly and appropriately. Workplace inspections are planned, with key observations or check points defined and results documented. Persons conducting inspections have specific training in hazard identification applicable to the facility. Corrections are documented through follow-up inspections. Results are available to workers.
5 Inspections are planned and overseen by certified safety or health professionals. Statistically valid random audits of compliance with all elements of the safety and health program are conducted. Observations are analyzed to evaluate progress.


WORKPLACE ANALYSIS

Hazard Reporting

A reliable hazard reporting system enables employees, without fear of reprisal, to notify management of conditions that appear hazardous and to receive timely and appropriate responses. [Guidelines, (c)(2)(iii)]
1 No formal hazard reporting system exists, or employees are reluctant to report hazards.
2 Employees are instructed to report hazards to management. Supervisors are instructed and are aware of a procedure for evaluating and responding to such reports. Employees use the system with no risk of reprisals.
3 A formal system for hazard reporting exists. Employee reports of hazards are documented, corrective action is scheduled, and records maintained.
4 Employees are periodically instructed in hazard identification and reporting procedures. Management conducts surveys of employee observations of hazards to ensure that the system is working. Results are documented.
5 Management responds to reports of hazards in writing within specified time frames. The workforce readily identifies and self-corrects hazards; they are supported by management when they do so.


ACCIDENT and RECORD ANALYSIS

Accident Investigation

Accident investigation: An effective program will provide for investigation of accidents and "near miss" incidents, so that their causes, and the means for their prevention, are identified. [Guidelines, (c)(2)(iv)]
1 No investigation of accidents, injuries, near misses, or other incidents is conducted.
2 Some investigation of incidents takes place, but root cause may not be identified, and correction may be inconsistent. Supervisors prepare injury reports for lost time cases.
3 OSHA-101 is completed for all recordable incidents. Reports are generally prepared with cause identification and corrective measures prescribed.
4 OSHA-recordable incidents are always investigated, and effective prevention is implemented. Reports and recommendations are available to employees. Quality and completeness of investigations are systematically reviewed by trained safety personnel.
5 All loss-producing accidents and "near-misses" are investigated for root causes by teams or individuals that include trained safety personnel and employees.


ACCIDENT and RECORD ANALYSIS

Data Analysis

Data analysis: An effective program will analyze injury and illness records for indications of sources and locations of hazards, and jobs that experience higher numbers of injuries. By analyzing injury and illness trends over time, patterns with common causes can be identified and prevented. [Guidelines, (c)(2)(v)]
1 Little or no analysis of injury/illness records; records (OSHA 200/101, exposure monitoring) are kept or conducted.
2 Data is collected and analyzed, but not widely used for prevention. OSHA - 101 is completed for all recordable cases. Exposure records and analyses are organized and are available to safety personnel.
3 Injury/illness logs and exposure records are kept correctly, are audited by facility personnel, and are essentially accurate and complete. Rates are calculated so as to identify high risk areas and jobs. Workers compensation claim records are analyzed and the results used in the program. Significant analytical findings are used for prevention.
4 Employer can identify the frequent and most severe problem areas, the high risk areas and job classifications, and any exposures responsible for OSHA recordable cases. Data are fully analyzed and effectively communicated to employees. Illness/injury data are audited and certified by a responsible person.
5 All levels of management and the workforce are aware of results of data analyses and resulting preventive activity. External audits of accuracy of injury and illness data, including review of all available data sources are conducted. Scientific analysis of health information, including non-occupational data bases is included where appropriate in the program.


HAZARD PREVENTION and CONTROL

Hazard Control

Hazard Control: Workforce exposure to all current and potential hazards should be prevented or controlled by using engineering controls wherever feasible and appropriate, work practices and administrative controls, and personal protective equipment (PPE). [Guidelines, (c)(3)(i)]
1 Hazard control is seriously lacking or absent from the facility.
2 Hazard controls are generally in place, but effectiveness and completeness vary. Serious hazards may still exist. Employer has achieved general compliance with applicable OSHA standards regarding hazards with a significant probability of causing serious physical harm. Hazards that have caused past injuries in the facility have been corrected.
3 Appropriate controls (engineering, work practice, and administrative controls, and PPE) are in place for significant hazards. Some serious hazards may exist. Employer is generally in compliance with voluntary standards, industry practices, and manufacturers' and suppliers' safety recommendations. Documented reviews of needs for machine guarding, energy lockout, ergonomics, materials handling, bloodborne pathogens, confined space, hazard communication, and other generally applicable standards have been conducted. The overall program tolerates occasional deviations.
4 Hazard controls are fully in place, and are known and supported by the workforce. Few serious hazards exist. The employer requires strict and complete compliance with all OSHA, consensus, and industry standards and recommendations. All deviations are identified and causes determined.
5 Hazard controls are fully in place and continually improved upon based on workplace experience and general knowledge. Documented reviews of needs are conducted by certified health and safety professionals or professional engineers, etc.


HAZARD PREVENTION and CONTROL

Maintenance

Maintenance: An effective safety and health program will provide for facility and equipment maintenance, so that hazardous breakdowns are prevented. [Guidelines, (c)(3)(ii)]
1 No preventive maintenance program is in place; break-down maintenance is the rule.
2 There is a preventive maintenance schedule, but it does not cover everything and may be allowed to slide or performance is not documented. Safety devices on machinery and equipment are generally checked before each production shift.
3 A preventive maintenance schedule is implemented for areas where it is most needed; it is followed under normal circumstances. Manufacturers' and industry recommendations and consensus standards for maintenance frequency are complied with. Breakdown repairs for safety related items are expedited. Safety device checks are documented. Ventilation system function is observed periodically.
4 The employer has effectively implemented a preventive maintenance schedule that applies to all equipment. Facility experience is used to improve safety-related preventative maintenance scheduling.
5 There is a comprehensive safety and preventive maintenance program that maximizes equipment reliability.


HAZARD PREVENTION and CONTROL

Medical Program

An effective safety and health program will include a suitable medical program where it is appropriate for the size and nature of the workplace and its hazards. [Guidelines, (c)(3)(iv)]
1 Employer is unaware of, or unresponsive to medical needs. Required medical surveillance, monitoring, and reporting are absent or inadequate.
2 Required medical surveillance, monitoring, removal, and reporting responsibilities for applicable standards are assigned and carried out, but results may be incomplete or inadequate.
3 Medical surveillance, removal, monitoring, and reporting comply with applicable standards. Employees report early signs/symptoms of job-related injury or illness and receive appropriate treatment.
4 Health care providers provide follow-up on employee treatment protocols and are involved in hazard identification and control in the workplace. Medical surveillance addresses conditions not covered by specific standards. Employee concerns about medical treatment are documented and responded to.
5 Health care providers are on-site for all production shifts and are involved in hazard identification and training. Health care providers periodically observe the work areas and activities and are fully involved in hazard identification and training.


EMERGENCY RESPONSE

Emergency Preparedness

Emergency preparedness: There should be appropriate planning, training/drills, and equipment for response to emergencies. Note: In some facilities the employer plan is to evacuate and call the fire department. In such cases, only applicable items listed below should be considered. [Guidelines, (c)(3)(iii) and (iv)]
1 Little or no effective effort to prepare for emergencies.
2 Emergency response plans for fire, chemical, and weather emergencies as required by 29 CFR 1910.38, 1910.120, or 1926.35 are present. Training is conducted as required by the applicable standard. Some deficiencies may exist.
3 Emergency response plans have been prepared by persons with specific training. Appropriate alarm systems are present. Employees are trained in emergency procedures. The emergency response extends to spills and incidents in routine production. Adequate supply of spill control and PPE appropriate to hazards on site is available.
4 Evacuation drills are conducted no less than annually. The plan is reviewed by a qualified safety and health professional.
5 Designated emergency response team with adequate training is on-site. All potential emergencies have been identified. Plan is reviewed by the local fire department. Plan and performance are reevaluated at least annually and after each significant incident. Procedures for terminating an emergency response condition are clearly defined.


EMERGENCY RESPONSE

First Aid

First aid/emergency care should be readily available to minimize harm if an injury or illness occurs. [Guidelines, (c)(3)(iii) and (iv)]
1 Neither on-site nor nearby community aid (e.g., emergency room) can be ensured.
2 Either on-site or nearby community aid is available on every shift.
3 Personnel with appropriate first aid skills commensurate with likely hazards in the workplace and as required by OSHA standards (e.g., 1910.151, 1926.23) are available. Management documents and evaluates response time on a continuing basis.
4 Personnel with certified first aid skills are always available on-site; their level of training is appropriate to the hazards of the work being done. Adequacy of first aid is formally reviewed after significant incidents.
5 Personnel trained in advanced first aid and/or emergency medical care are always available on-site. In larger facilities a health care provider is on-site for each production shift.


SAFETY and HEALTH TRAINING

Safety and health training should cover the safety and health responsibilities of all personnel who work at the site or affect its operations. It is most effective when incorporated into other training about performance requirements and job practices. It should include all subjects and areas necessary to address the hazards at the site. [Guidelines, (b)(4) and (c)(4)]
1 Facility depends on experience and peer training to meet needs. Managers/supervisors demonstrate little or no involvement in safety and health training responsibilities.
2 Some orientation training is given to new hires. Some safety training materials (e.g., pamphlets, posters, videotapes) are available or are used periodically at safety meetings, but there is little or no documentation of training or assessment of worker knowledge in this area. Managers generally demonstrate awareness of safety and health responsibilities, but have limited training themselves or involvement in the site's training program.
3 Training includes OSHA rights and access to information. Training required by applicable standards is provided to all site employees. Supervisors and managers attend training in all subjects provided to employees under their direction. Employees can generally demonstrate the skills/knowledge necessary to perform their jobs safely. Records of training are kept and training is evaluated to ensure that it is effective.
4 Knowledgeable persons conduct safety and health training that is scheduled, assessed, and documented, and addresses all necessary technical topics. Employees are trained to recognize hazards, violations of OSHA standards, and facility practices. Employees are trained to report violations to management. All site employees--including supervisors and managers--can generally demonstrate preparedness for participation in the overall safety and health program. There are easily retrievable scheduling and record keeping systems.
5 Knowledgeable persons conduct safety and health training that is scheduled, assessed, and documented. Training covers all necessary topics and situations, and includes all persons working at the site (hourly employees, supervisors, managers, contractors, part-time and temporary employees). Employees participate in creating site-specific training methods and materials. Employees are trained to recognize inadequate responses to reported program violations. Retrievable record keeping system provides for appropriate retraining, makeup training, and modifications to training as the result of evaluations.

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