Annual Workplace Safety Management Report Completion and submission instructions: Completing the report

Year: Please indicate the year of the report and whether it is for the calendar or fiscal year. Preference is fiscal year, however, agencies that have been creating safety goals and objectives based on a calendar year need not change their process to accommodate MnSAFE reporting. Agency: Please indicate the Agency that is reporting. Agencies need only submit one report for the entire agency. Agencies can attach multiple goal summaries/tables if desired for the various aspects of their organization. Report Date: Please indicate the date the report was completed Achievements: Please list any recent safety management achievements. If recent achievements are available in different formats or reports, please feel free to attach achievements to the report. Goals and Objectives: Please provide an update on your past years goals. For goals/objectives not achieved, please described what prevented you from achieving the goal/objective. Please attach a copy of your current goals as you have them formatted. We have provided a Goals and Objectives template for your convenience if you dont have them formally drawn up. Metrics: Please include a summary of the third quarter FY13 MnSAFE metric for your agency. The third quarter FY13 MnSAFE metrics is expected to be posted to the MnSAFE website by the 2nd week of June. A notice will be sent when available. Agency Head Name and Signature: The report must be reviewed and signed by the Commissioner/Director of the Agency.

Submitting the report

Due Date: Your MnSAFE Annual Workplace Safety Management Report is due June 28, 2013. Format: Your MnSAFE Annual Workplace Safety Management Report can be submitted in any format that is convenient. Electronic formats (MSWord, PDF) are preferred but not required. Where to Submit: Your MnSAFE Annual Workplace Safety Management Report should be submitted to: Todd Christenson, Program Manager Safety & Loss Control Risk Management Division, Dept. of Administration 310 Centennial Office Building 658 Cedar Street St. Paul, MN 55155 FY 2014 MnSAFE Report

Fax: 651-297-5471 Email: todd.christenson@state.mn.us Questions: Please contact Todd Christenson at (651)-201-3005 or todd.christenson@state.mn.us with any questions regarding MnSAFE or your MnSAFE Annual Workplace Safety Management Report. Annual Workplace Safety Management Report _________________ (Calendar or Fiscal Year) _________________ (Agency) _________________ (Report Date) Commitment The ___(Agency)___ is committed to creating safe and healthy workplaces as outlined in Governor Daytons MN SAFE workplace safety initiative. Under my leadership and direction, we are: Working to reduce the incidence of workplace injuries by 25% through FY14. Establishing targeted annual safety and loss control goals to reduce the frequency and severity of injuries. Reviewing available injury data quarterly to assess progress towards goals. Continuously communicating our safety commitment to our employees and stakeholders. Integrating our safety and loss control responsibilities into daily operations. Providing resources necessary to carry out agency safety and loss control responsibilities. Achievements Our commitment is evident by the following recent safety management achievements (please summarize achievements from the past calendar or fiscal year): 1. 2. Goals and Objectives The ___(Agency)___ continues to establish targeted annual safety and loss control goals intended to reduce the frequency and severity of injuries. We have attached last years goals and objectives and provided a status update. For those goals/objectives not achieved, we have described what prevented us from achieving the goal/objective. We have also attached a copy of our new safety and loss control goals including specific objectives, responsible entities, and timelines. Metrics FY 2014 MnSAFE Report

Base Workers Compensation Claim Incident Rate (FY11)

25% Reduction Target Rate

FY13 Year Target Rate

Latest Reported Rate (_________ Qtr FY13)

________________________ Agency Head Signature ________________________ Agency Head Name and Title

FY 2014 MnSAFE Report

Workplace Safety Goals and Objectives (Template)

Agency___________________ Year ________________ Goal Fiscal Calendar Responsible Party 1. 2. 3. 1. 2. 3. 1. 2. 3. Target Date 1. 2. 3. 1. 2. 3. 1. 2. 3. Status 1. 2. 3. 1. 2. 3. 1. 2. 3.

Objectives 1. 2. 3. 1. 2. 3. 1. 2. 3.

Developed by____________________________________ Date__________________________

Reviewed by_____________________________________ Date__________________________

Approved by_____________________________________ Date__________________________ (Agency Head Name and Title)

FY 2014 MnSAFE Report