Dashboard For Safety Related Items

Safety Dashboard Questionnaire
Category Component Excellent Good Opportunity 2014 2015 2016 2017 2018
Not Applicable 10 5 0 Points Comments Points Comments Points Comments Points Comments Points Comments
Members of management are

actively involved in the safety Members of management No evidence of management
management process through attend some safety meetings
Management Commitment Involvement being involved in the safety
participation in each meeting to and establish safety in process.
modeling and coaching safe correspodence to employees.
behavior.
Management has drafted and Management has signed the No evidence of management
Management Commitment Policy Statement stands behind the organization's safety policy statement. being involved with the safety
safety policy statement. policy statement.
Clear objectives are set on an

annual basis and communicated Objectives are written but no Management has not
Management Commitment Established objectives to the entire organization. metric developed to measure established safety objectives.
Metrics are established to efforts.
identify successes.
Funds are adequately allocated

for safety efforts. Individual Funds are allocated for safety
Management Commitment Safety Budget departments budget for safe on a request basis. There is no safety budget.
operations.
All levels of employment are

equally accountable for safe
operations. Safety Safety accountability written No evidence of accountability
Management Commitment Accountability for safety until mistakes are
accountability is written into job into job descriptions. made.
descriptions. Accountability
parameters are established.
Management hosts and Members of management No evidence of managers or

participates in risk management attend safety training given to
Management Commitment Supervisory / Management Training supervisors involvement in
and safety training on a employees on a scheduled safety training.
scheduled basis. basis.
Managers and supervisors have The safety coordinator provides No evidence of established
Management Commitment Employee Training a role in providing or arranging all safety training. safety training needs.
for job specific safety training.
Management and supervisors

are effective with timely
investigation of reported The safety coordinator conducts Investigations are not
incidents or accidents. Their all investigations and
Management Commitment Investigations recommends corrective action conducted. Only first reports of
report is documented with
recommendations for corrective to management. injury are completed.
action and established
completion dates.
Safety is an active agenda item Safety is occassionally on the No deliberate agenda for safety
Management Commitment Risk Management on Meeting Agendas in each management meeting. agenda in management in management meetings.
meetings.
Management is involed with all Management participates in

Management Commitment Facility Inspections safety inspections at least once Management is not involved
facility safety inspections. with facility safety inspections.
per year.
Management gives the Safety

Management always reviews Management isn't involved with
and signs off on approved Coordinator the responsibility approval of safety policies and
Management Commitment Approval of Safety Policies and Procedures
safety policies and procedures. to approve safety policies and procedures.
procedures.
Individual departments have

established metrics to identify Individual departments review The safety coordinator is
and address their safety
performance. Department their injury trends and are responsible for the
Management Commitment Safety Performance Responsibility responsible for addressing organization's safety
supervisors are held them. performance.
accountable to their safety
commitments.
Managers and supervisors are

actively involved in claims Human Resources and /or the
management through timely Safety Coordinator handles all The company lacks claims
Management Commitment Claims Management management.
investigations to serving on the claims management activities.
RTW Team
Managers and supervisors are

aware of claims costs and
trends specific to their Human Resources and/or the
department. They are charged Safety Coordinator generates
with implementing controls to No formal analysis of costs or
reports that are specific to each trends
Management Commitment Claims Costs and Claims Trends reduce or mitigate costs and department. The reports are of failures in safety is
trends related to safety failures. conducted.
reviewed with the respective
A charge back system or other manager or supervisor.
effective accountability process
is in place for each
department's performance.
Managers provide written The Safety Coordinator is There is no formal response to

responses to safety committee
Management Commitment Safety Recommendations responsible for all Safety safety committee
recommendations and follows Committee recommendations. recommendations.
through on completion items.
Supervisors complete the First

Report of Injury (FROI) and Injuries are reported to
Roles and Responsibilties submit to HR within 24 hour of supervisors, but HR or Safety
Management Roles Injury Reporting notice. Supervisors and Coordinator completes the FROI Injury reporting lags.
managers are accountable for timely.
accurate completion of FROI.
Supervisors thoroughly
complete an Incident
Investigation Report and submit HR or Safety Coordinator is
Roles and Responsibilties No incident investigations are
Incident Investigation to HR within 24 hours of notice. responsible for all incident
Management Roles completed.
Supervisors and managers are investigations.
held accountable for
incomplete investigations.
Provides recognition and

feedback for employee who Provides recognition and
Roles and Responsibilties deliberately work safely. coaching broadly to the No visible effort in cultivating
Management Roles Cultivates a Positive Culture Provides timely coaching to organization via email, in staff positive culture.
employees who are observed meetings, or other means.
working unsafely.
Ensures all employees receive

adequate safety orientation. Provides an employee
The orientation is completed handbook or other written New employees do not receive
Roles and Responsibilties New Employee Safety Orientation thoroughly by knowledgeable document for new employee to an adequate new employee
Human Resources Roles personnel. The orientation is review and sign in receipt of the orientation.
documented accurately with information.
topics and dates.
Works with supervisors and

Roles and Responsibilties management to address Assists employees with special
Accomodation documented requests for accomodation requests without No accomodations are made.
Human Resources Roles special safety needs of involving supervisor.
employees.
Roles and Responsibilties Safety standards are Safety standards are expected No safety standards are in
Human Resources Roles Job Profiles incorporated to job profiles. but not formally written. place.
Safety is incorporated into Safety is incorporated into

Roles and Responsibilties Safety is not incorporated into
Performance Evaluations performance evaluations for all performance evaluations only
Human Resources Roles performance evaluations.
levels of the organization. for line staff.
Reports all First Report of Timely submission of FROI lags

Injuries to the insurer within 24 Attempts to submit FROIs
Roles and Responsibilties within 24 hours, but often other by evidence of accident dates
Human Resources Roles Timely Reporting hours. Has designated a back tasks promote later reporting. and date received by insurance
up if out of the office. carrier.
Roles and Responsibilties Serves as the point of contact Supervisor, Safety Coordinator, No designated point of contact
Claims Communications for the insurer to begin and/or HR serves as initial point in place.
Human Resources Roles processing the claim. of contact.
Provides or arranges training for

supervisors on accurate Completes incomplete
Roles and Responsibilties completion of the FROI. Holds information on the FROI for the Supervisors are not involved in
Claims Training
Human Resources Roles supervisors accountable for supervisors. the FROI process.
incomplete reports.
Provides or arranges training for

supervisors on accurate
Roles and Responsibilties completion of the Incident Completes the Incident No incident investigations are
Incident Investigation
Human Resources Roles Investigation Report. Holds Investigation Report. completed.
supervisors accountable for
incomplete reports.
Reviews reports provided by the

insurance carrier and
communicates internally on Reviews reports from the Receives reports, but doesn't
Roles and Responsibilties status of claims and injury
Analysis insurance carrier, but no action know what to do with them or
Human Resources Roles trends. Works with is taken. doesn't receive reports.
management and Safety
Coordinator on identified
needs.
Serves as coordinator for the
RTW process. Coordinates RTW
meetings and documents
Roles and Responsibilties results. Assists with finding Coordinates light duty with
Human Resources Roles Return to Work (RTW) Team supervisor and employee. RTW teams are not used.
light duty tasks. Documents
RTW job offers. Tracks
progressive healing process.
Actively participates in new Is not required to participate in

employee orientations. Asks Signs off on new employee
Employee Roles Safety Orientation new employee safety
questions andunderstanding is orientation. orientation.
evidenced.
Actively participates in job

Signs off on Job Safety Training. Is not required to participate in
Employee Roles Job Safety Training specific safety training. Job Safety Training.
Demonstrates understanding.
Reports injuries or incidents as Injury and incident reporting is Reports are only given if
Employee Roles Reporting Incidents and Injuries soon as possible and within the usually timely. medical treatment or property
same workday. damage occur.
Always wears the required PPE. Uses PPE when Safety

Employee Roles Personal Protection Equipment (PPE) Keeps PPE clean and well Coordinator or Supervisor is Does not wear PPE.
maintained. present.
Maintains good housekeeping

in work areas. Uses warning or Cleans work area when told to Housekeeping is generally not
Employee Roles General Housekeeping caution signs if work area will do so. maintained.
be disturbed.
Reports hazards to supervisor.

Takes initiative to address Reports hazard after incident or
Employee Roles Hazard Reporting hazard if within the employees Reports only serious hazards. injury.
control.
Plans work with safety

forecasting. Arranges work
process safely. Controls or Follows safety rules and No forethought put into safe
Employee Roles Safe Work Practices guidelines as they are written. work processes.
mitigates hazards before
starting task.
Helps coworkers work safely.

Openly communicates hazards Will work as a team and talk
safety as other employees do. Each employee is responsible
Employee Roles Teamwork and controls of tasks. Informs Does not address safety on for his/her own safety.
others as information is
available. his/her own.
Safety management is a full Safety management is a half Safety management is an

Safety Coordinator Appointed time position. time position. additional duty.
Can stop work if conditions or Works with supervisor on
Safety Coordinator Authority practices are unsafe. resolving safety issues. No visible authority.
Delegates projects, follows up Chairs committee and takes on Effective safety committee
Safety Coordinator Leads Safety Committee on completion. the committee work load. leadership is not visible.
Drafts, formalizes, and works to Proposes safety programs to

implement safety programs. management and waits for Safety programs are incomplete
Safety Coordinator Safety Programs Evaluates program effectiveness approval. Implements via email and not implemented.
annually. memo.
Reports quarterly to Executive Emails communications to No lines of communication with

Safety Coordinator Management Involvement Management on State of Safety. management as needed. coordinator and management.
Analyzes accident reports and

loss reports from insurance Reviews information and
carrier. Works to implement
Safety Coordinator Analysis effective corrective action. Has provides direction. Follow No formal analysis in place.
established metrics to identify through and metrics lack.
success.
Does not participate in the

Participates in the Emergency There is no Emergency Action
Safety Coordinator Emergency Action Team existing Emergency Action
Action Team. Team.
Team.
Organizes safety training Safety training is held at least Safety training is done as
programs at least quarterly.
Safety Coordinator Safety Training Establishes metric for results of annually. The training is needed and documentation is
safety training. documented. sporadic.
Provides or arranges ergonomic

assessments for new
employees, existing employees,
and injured employees. Follows Ergonomic assessments are
up with management to ensure conducted when requested. Ergonomics process is reactive
Safety Coordinator Ergonomics Training is conducted for new following reported problems.
recommendations have been employees.
implemented. Provides
ergonomic training to all
employees annually.
Poignant in self growth and

development in regard to safety Continues growing through
leadership. Attends at least one company experience. Does not
Safety Coordinator Continues Education have time or budget to attend No continuing education.
safety seminar or conference
per year. safety conferences or seminars.
Conducts an audit of the

organization's safety Conducts self audits on an
management program at least unscheduled basis. Compiles
annually. Formally
recommends improvement report of findings and
Safety Coordinator Self Audits communicates to management. No self audits.
needs to management and Awaits for management
promotes the identified needs direction.
be incorporated into annual
objectives.
Thoroughly understands
organizational risks. Has ability Spends 95% of time in an office
to visit field work and analyze setting. Understands risk by Does not understand or manage
Safety Coordinator Risk Management work practices. Incorporates description but has not the organization's risks.
risk mitigation measures into all thoroughly analyzed the risks.
job categories.
Conducted frequently and Conducted annually and No evidence of facility

Hazard Identification Facility Safety Inspections corrective action is corrective action is inspections being conducted.
documented. documented.
Conducted frequently and Conducted annually and No evidence of grounds

Hazard Identification Grounds Safety Inspections corrective action is corrective action is inspections being conducted.
documented. documented.
Pre-operational inspections No evidence of fleet

Hazard Identification Fleet Safety Inspections documented with timely Monthly inspections conducted. inspections.
corrective action.
Pre-operational inspections No evidence of heavy

Hazard Identification Heavy Equipment Safety Inspections documented with timely Monthly inspections conducted. equipment safety inspections.
corrective action.
Pre-operational inspections
Monthly inspections conducted. No evidence of ATV or UTV
Hazard Identification ATV or Utility Vehicle Inspections documented with timely
corrective action. inspections.
Hazard Identification Hand and Power Tool Inspections documented with timely Monthly inspections conducted. No evidence of inspections.
corrective action.
Hazard Identification Ladder Safety Inspections documented with timely Monthly inspections conducted. No evidence of inspections.
corrective action.
Work activities are reviewed on Work activites are addressed on

a scheduled interval with timely an unscheduled, as needed No evidence of behavioral
Hazard Identification Behavioral Safety Inspections feedback provided to safety inspections.
basis.
employees.
Company specific driving rules,

seat belt use, distraction
prevention, fleet inspection,
Hazard Identification and driver training in place. No formal fleet program is in
Hazard Specific Controls Fleet Safety Motor vehicle records are effect.
checked initially and annually
for persons regularly required
to drive a company vehicle.
Written program in place to

include new employee training,
list of hazardous chemicals,
employee access to safety data
sheets, defined labeling Written program in place with
Hazard Identification No written program or
Hazard Specific Controls Hazard Communication requirements, personal some missing elements. employee training in place.
protective equipment Employee training in place.
requirements, and additional
training should a new chemical
or process be introduced into
the workplace.
A written chemical hygiene plan
is in place: standard procedures
in place for handling and storing
hazardous chemicals, fume
hoods are adequately
maintained and verified
functioning. Certain procedures
require permission and
Hazard Identification oversight from the employer A necessary chemical hygiene
Hazard Specific Controls Chemical Hygiene plan is not in place.
prior to performing. Medical
monitoring program is in place
for affected employees if
applicable. Employee training is
conducted initially and annually.
The program is reviewed
annually to evaluate its
effectiveness.
Written respiratory protection

program is in place to include
Hazard Identification Respiratory hazards quantified program administrator, medical No written program, medical
Respiratory Protection and controlled by engineering questionnaire, fit testing, or
Hazard Specific Controls questionnaire, fit testing,
practices. training in place.
equipment inspection, and
training.
Equipment specific hazardous

energy control procedures are Locks and tags are available for
documented. Employees employees performing service No lockout tagout program is in
Hazard Identification Lockout Tagout receive training intially and or maintenance on equipment.
Hazard Specific Controls annually. Periodic inspections Training has been conducted for place.
are conducted and authorized employees.
documented.
Spaces are identified and

employees are trained to never
enter OR a written program is in
place. Entry occurs only by
permit. Atmospheres are Spaces are not identified but
monitored before and during employees may have an
Hazard Identification entry. Attendant always present occasional need to enter a No confined space entry
Confined Space Entry
Hazard Specific Controls without other assigned duties. confined space. Entry occurs program or training is in place.
Emergency rescue plans in with proper ventilation and an
place. Employees trained in attendant present.
confined space entry
procedures and rescue
procedures. An annual review
of the program is in place.
Noise is established safe

through engineering controls
OR a written hearing
conservation program is in Effective hearing protection is Noise exposures have not been
Hazard Identification place that includes baseline and required when working with or evaluated. Employees can wear
Hazard Specific Controls Hearing Conservation Program
annual audiograms, new around noisy equipment. ear plugs if they want to.
employee and annual training,
and properly chosen hearing
protection.
Equipment and power tools

with guards will not operate Machines and equipment are
Hazard Identification without the guards in place. guarded. The guards can be There is no verification of
Hazard Specific Controls Equipment / Machine Guarding Employees receive training on removed but only with a adequate machine guarding.
machine guarding lockout tagout process.
requirements.
Only qualified personnel work

on electrical systems. Electrical
systems are adequately
guarded. Cord powered Only qualified personnel work
equipment is inspected. Cords on electrical systems. Electrical
are not covered with tape and
ground pin is never removed. systems are adequately
Hazard Identification guarded. Cord powered No visible electrical safety
Electrical Safety Ground Fault Circuit
Hazard Specific Controls equipment is inspected and efforts in place.
Interuppters (GFCI) or ground
assurance program are in place. addressed appropriately. Safety
awareness program provided
Inspections look for electrical for all employees.
safety and needs for permanent
wiring. Safety awareness
program provided for all
employees.
Fall protection plans are in

Employees are protected by place. Employees are trained in Fall protection systems are not
Hazard Identification engineered fall protection
Fall Protection Systems use, maintenance, and
Hazard Specific Controls systems while working on requirements of personal fall provided.
elevated work surfaces. protection.
A certified hazard assessment Personal Protective Equipment

has been conducted.
Hazard Identification Employees are provided is available for use, but
Hazard Specific Controls Personal Protective Equipment decide when to use PPE is not provided.
appropriate PPE and are trained employees
it.
in its use.
A written EAP is in place and

addresses potential A written plan is in place.
emergencies at the specific Facility plans are posted.
Hazard Identification workplace. Employees receive
Emergency Action Plan (EAP) Employees are shown exits An EAP does not exist.
Hazard Specific Controls training initially and annually. when they begin their
Physical drills are performed employment
and evaluated on a scheduled
basis.
Hazard Identification A written fire prevention plan is The fire prevention plan is
Hazard Specific Controls Fire Prevention Plan in place and followed. known, but not written. No plans for fire prevention.
Workzones are established

following the Manual of
Uniform Traffice Control Devices
(MUTCD) guidelines. Internal
traffic control plans are
identified and followed. Site Construction zones are set up to
specific training occurs for control public motorists.
Hazard Identification No visible efforts are in place
Traffic Control Plan affected employees. Flaggers Awareness is discussed for
Hazard Specific Controls for traffic control plans.
are trained specifically for their internal traffic control.
duties. Reflective attire is worn Reflective attire is worn.
when onsite. Public service
announcements are provided to
the community. Law
enforcement is requested to
patrol the site.
An ergonomics process has

been established. Employees
are trained in risk factors and
prevention methods. Employees are trained initially
Engineering methods are used Ergonomics is addressed
and annually in ergonomics.
Hazard Identification to maintain anatomically reactively when discomfort or
Hazard Specific Controls Ergonomics correct postures while Symptoms of injury are cumulative injuries are
reported timely and action is
minimizing repetition and force. reported.
taken.
A reporting system is in place
for symptoms of cumulative
injury. High risk tasks are
analyzed for improvement.
Manual material handling is

minimized. Lifting policies are
in place. Mechanical No visible efforts are in place to
Hazard Identification equipment is available and used Back safety training is
Manual Material Handling address manual material
Hazard Specific Controls by qualified personnel. conducted once per year. handling.
Employees are trained in injury
prevention methods at least
annually.
All operators are trained and

authorized. The equipment is
inspected before operation and
the inspection is documented. All operators are trained and Employees who know how to
Hazard Identification Power Industrial Truck (PIT), often Forklift, Safety issues are addressed authorized. A pre-operational operate the PIT are encouraged
through the inspection process inspection is completed but
Hazard Specific Controls but could be other to pitch in. No inspections are
and a paper trail follows documentation lacks. Safe conducted.
identified issues to completion. operations are enforced.
Seat belts are required. Exhaust
issues, if applicable, are
effectively addressed.
Appropriate sloping, shoring, or
shielding used for 5' or deeper.
Competent person inspects the
trench daily and as conditions
change. Employees receive
Hazard Identification training initially, annually, and No evidence of excavation
Trenching and Excavation
Hazard Specific Controls site specific. Heavy equipment safety in place.
and spoil always kept at least 2
feet away from edge. Ladders
provided for access and exit.
Atmosphere is tested prior to
entry.
Full Exposure Control Program

implemented: Exposure group
identified, initial and annual
training, training records kept,
vaccines offerred and Program is written.
Hazard Identification Exposure Control Plan for Prevention of declinations documented, Improvements are necessary in A necessary exposure control
Hazard Specific Controls Bloodborne Pathogens Exposure engineering controls and safe program is not in place.
implementation.
work practices identified and
followed; decontamination
procedures in place.
Effectiveness is reviewed
annually.
Hazard Identification:
Additional Worksite Hazards: [type your current hazard [type your current hazard [type your current hazard
Define the controls in place for each Welding controls here] controls here] controls here]
as applicable.
Define the controls in place for each Compressed Gas controls here] controls here] controls here]
as applicable.
Define the controls in place for each Hand and Power Tool Program controls here] controls here] controls here]
as applicable.
Define the controls in place for each Consumer Aggression controls here] controls here] controls here]
as applicable.
Define the controls in place for each Violent Offenders controls here] controls here] controls here]
as applicable.
Define the controls in place for each Patient Handling controls here] controls here] controls here]
as applicable.
Define the controls in place for each Working with Livestock controls here] controls here] controls here]
as applicable.
Define the controls in place for each Working with Wildlife controls here] controls here] controls here]
as applicable.
Define the controls in place for each Unexploded Ordinance controls here] controls here] controls here]
as applicable.
Define the controls in place for each Handling Fire Arms or other weapons controls here] controls here] controls here]
as applicable.
Define the controls in place for each Handling Explosives controls here] controls here] controls here]
as applicable.
Define the controls in place for each Airplane Operations controls here] controls here] controls here]
as applicable.
Define the controls in place for each Helicoptor Operations controls here] controls here] controls here]
as applicable.
Define the controls in place for each Wildland Fire Fighting controls here] controls here] controls here]
as applicable.
Define the controls in place for each Structural Fire Fighting controls here] controls here] controls here]
as applicable.
Define the controls in place for each Working in or around waterways controls here] controls here] controls here]
as applicable.
Define the controls in place for each Print Press Operation controls here] controls here] controls here]
as applicable.
Hazard Identification [type additionally identified hazards specific [type your current hazard [type your current hazard [type your current hazard
Other Worksite Hazards: to your organization here] controls here] controls here] controls here]
Open positions are advertised in multiple

Hiring & Onboarding Practices venues for a standardized amount of time. Always Sometimes Never
Hiring & Onboarding Practices Job postings include the job requirements. Always Sometimes Never
Job postings include the requirement to

Hiring & Onboarding Practices pass a drug screen before employment. Always Sometimes Never
A formal application process is in place.

Hiring & Onboarding Practices Always Sometimes Never
The application has been approved by legal Always

Hiring & Onboarding Practices counsel. Sometimes Never
Application is reviewed and content is

Hiring & Onboarding Practices verfied by appointed personnel. Always Sometimes Never
References are provided by the candidate

Hiring & Onboarding Practices and checked by the employer. Always Sometimes Never
Written job desciptions are in place for all

positions.
Job descriptions outline the physcial
requirements of the job.
Job descriptions include expectations of
safe work practices.
Potential candidates are screened by
Hiring & Onboarding Practices meeting the minimum qualifications which Always Sometimes Never
have been defined.
Interviews are conducted by both human

Hiring & Onboarding Practices resources and the supervisor to whom the Always Sometimes Never
candidate would report to.
Hiring managers have received training on

appropriate interview techniques and legal
Hiring & Onboarding Practices issues that may involve the interview Always Sometimes Never
process.
During the interview process the candidates

Hiring & Onboarding Practices are requested to elaborate on their work Always Sometimes Never
history and experience.

Hiring & Onboarding Practices are requested to explain gaps in Always Sometimes Never
employment.

are asked if they can perform the essential Always
Hiring & Onboarding Practices Sometimes Never
functions of the job with or without
accomodations.
Interview questions about prior workers

Hiring & Onboarding Practices compensation injuries are avoided. Always Sometimes Never
Questions regarding the candidates

Hiring & Onboarding Practices perception of safety are included in the Always Sometimes Never
interview process.
Post job offer background checks are

Hiring & Onboarding Practices conducted on potential hires with their Always Sometimes Never
consent.
Post offer credit checks are conducted on
potential hires with their consent.
Job offers are made contingent upon the

candidate passing applicable post offer drug
Hiring & Onboarding Practices test, physical, background check, motor Always Sometimes Never
vehicle check, etc.
Pre-employment/ post offer drug testing

follows a lawful chain of custody process.
Candidates who fail the post offer drug test
Hiring & Onboarding Practices have opportunity to retest at their own Always Sometimes Never
expense.
Job offers are made contingent upon

Hiring & Onboarding Practices passing a pre-employment / post offer Always Sometimes Never
physical.
Pre-employment physicals are designed to

Hiring & Onboarding Practices simulate the physical requirements of the Always Sometimes Never
job.
Post offer physicals are medical

Hiring & Onboarding Practices certifications as required by a regulatory Always Sometimes Never
agency.
Clean motor vehicle records are required for

Hiring & Onboarding Practices those who have or may have the duty to Always Sometimes Never
drive as part of their job.
E-verify is used to confirm lawful working

status.
Job offers are provided in writing and
accepted by the candidate's signature.
A probationary period is established,
communicated, and adhered to.
Medical benefits are provided to the
employee by the company.
Medical benefits are affordable, measured

by most employees participating.
New employees are eligible for medical

Hiring & Onboarding Practices benefits within the first 90 days of Always Sometimes Never
employment.
Hiring & Onboarding Practices Proper employment documents are signed Always Sometimes Never
Clear Expectations by the employee and turned in timely.
Hiring & Onboarding Practices A point person reviews company policies

Clear Expectations with the new hire. Always Sometimes Never
Hiring & Onboarding Practices Company commitment to safety and

employee accountability toward success is Always Sometimes Never
Clear Expectations verbalized.
Emergency procedures are discussed and

Hiring & Onboarding Practices the new employee is provided a facility tour
Clear Expectations to effectively identify exit routes, fire Always Sometimes Never
extinguishers, and shelters in place.
Hiring & Onboarding Practices Injury reporting procedures are provided in Always Sometimes Never
Clear Expectations written and oral format.
Hiring & Onboarding Practices The Return to Work program and Always Sometimes Never
Clear Expectations expectations are provided.
If employees supply their own tools, the

Hiring & Onboarding Practices safety requirements/conditions of the tools Always
Clear Expectations Sometimes Never
are provided in written and oral format.
Hiring & Onboarding Practices Employees are informed of their Always Sometimes Never
Clear Expectations empowerment to stop an unsafe job.
Employees are paired with a mentor who
Hiring & Onboarding Practices provides on the job training and observes Always Sometimes Never
Clear Expectations the new employee.
Performance expectations are

Hiring & Onboarding Practices
Clear Expectations communicated to the employee during the Always Sometimes Never
orientation process.
Employee performance is measured and

Hiring & Onboarding Practices reviewed with the employee at pre-
Clear Expectations determined intervals, such as 1 month, 3 Always Sometimes Never
months, and 6 months.
Hiring & Onboarding Practices Performance issues are addressed Always Sometimes Never
Clear Expectations immediately through coaching.
A progressive disciplinary action process is
Hiring & Onboarding Practices established and described to address non- Always Sometimes Never
Clear Expectations performers.
Workstations are verified to be

Hiring & Onboarding Practices ergonomically correct for the new
Clear Expectations Always Sometimes Never
employee.
New Employee Training for All
Training Always Sometimes Never
New Employee orientation conducted orally Always

Training and written Sometimes Never
Training
Employee Orientation Accident Reporting Procedures Always Sometimes Never
Training
Employee Orientation Hazard Reporting Procedures Always Sometimes Never
Training
Employee Orientation Emergency Procedures Always Sometimes Never
Training
Employee Orientation Fire Prevention Always Sometimes Never
Training
Employee Orientation First Aid Always Sometimes Never
Training
Employee Orientation Ergonomics Always Sometimes Never
Training
Employee Orientation Back Injury Prevention Always Sometimes Never
Training
Employee Orientation Slip and Fall Prevention Always Sometimes Never
Training
Employee Orientation Introduction of Safety Committee Members Always Sometimes Never
Training
Employee Orientation Safety Accountability Always Sometimes Never
Training
Employee Orientation Return to Work Program Always Sometimes Never
Training
Job Specific Training Personal Protective Equipment Always Sometimes Never
Training
Job Specific Training Worksite Specific Hazards Always Sometimes Never
Training
Job Specific Training Hazardous Chemicals Always Sometimes Never
Training
Job Specific Training Equipment Operations Always Sometimes Never
Training
Job Specific Training Fall Protection Always Sometimes Never
Training
Job Specific Training Safe Use of Ladders Always Sometimes Never
Training
Job Specific Training Electricity Always Sometimes Never
Training
Job Specific Training Fleet Operations Always Sometimes Never
Training
Job Specific Training Workzone Safety Always Sometimes Never
Training
Job Specific Training Excavation / Trenching Always Sometimes Never
Training Felling / Bucking Trees Always Sometimes Never

Job Specific Training
Training Power Tools Always Sometimes Never
Training Lockout Tagout Always Sometimes Never
Training Hearing Conservation Always Sometimes Never
Training Confined Space Entry Always Sometimes Never
Training Respiratory Protection Always Sometimes Never
Training Machine Guarding Always Sometimes Never
Training Lone Work Procedures Always Sometimes Never
Training Training conducted by knowledgable person Always Sometimes Never
Job Specific Training on topic
Training Regular Refresher Training Scheduled Always Sometimes Never
Training Additional training in areas of major loss Always Sometimes Never
Job Specific Training sources
Training Training conducted when new hazards Always Sometimes Never
Job Specific Training identified
Training Job Transfer Training Always Sometimes Never
Training Safety is on the agenda in staff meetings Always Sometimes Never
Awareness
Training Safety materials are posted Always Sometimes Never
Awareness
Training
Awareness Safety advertisements are done Always Sometimes Never
Training
Awareness Safety fairs or Safety days are used Always Sometimes Never
Training
Awareness Safety incentive programs exist Always Sometimes Never
Training
Awareness Safety newsletters are established Always Sometimes Never
Training Safety Goals and Objectives are

Awareness Communicated Always Sometimes Never
Training Safety Committee notifies the company of

Awareness meeting minutes availability Always Sometimes Never
Training Accident analysis is shared with company

Awareness employees Always Sometimes Never
Training Hazard Alerts communicated with company Always

Awareness employees Sometimes Never
Training
Awareness Safety recognition programs are in place Always Sometimes Never
Training Employees and staff are informed of safety

Awareness committee members Always Sometimes Never
A written incident management policy has
Incident Management Always Sometimes Never
been developed and implemented.
A formal Return to Work program has been Always
Incident Management Sometimes Never
developed.
Employees have been trained in incident
reporting procedures.
All Incidents are reported, regardless of
severity / property damage.
An incident investigation program has been Always
Incident Management Sometimes Never
developed.
Injured employees are involved in the
incident review process.
Incident reviews lead to causation factors
and drive corrective action.
Incidents are managed to ensure prompt

Incident Management medical care to injured employees. Always Sometimes Never
Incidents are managed to ensure all injuries

Incident Management are reported within 24 hours. Always Sometimes Never
OSHA recordkeeping reports are completed

Incident Management immediately. Always Sometimes Never
Temporary transitional jobs are designated

Incident Management so RTW can begin immediately. Always Sometimes Never
Employer sends RTW information to the

doctor with the injured employee.
Employer requires employee to return
Incident Management medical status forms following every doctor Always Sometimes Never
visit.
Temporary duty status is reviewed following
Incident Management every visit to the doctor. Always Sometimes Never
All injuries are considered for participation

Incident Management in RTW. Always Sometimes Never
Employees on transitional duty are

Incident Management managed to ensure they are not working Always Sometimes Never
outside their restrictions.
Corrective actions are taken to prevent the
Incident Management reoccurrance of the injury. Always Sometimes Never
Employees are re-trained in any changes

Incident Management made because of an incident. Always Sometimes Never
Management instills a positive, cooperative

Return to Work (RTW) culture for Return to Work within the Always Sometimes Never
Management Components company.
A transitional duty team coordinator (TDTC)

Return to Work (RTW) has been assigned to facilitate transitional Always Sometimes Never
Management Components duty team meetings and manage the
workers' compensation claim process.
All injured employees immediately notify

Return to Work (RTW)
Management Components their supervisor, human resources or the Always Sometimes Never
TDTC when injured.
The First Report of Injury is submitted to the

Return to Work (RTW) workers compensation carrier within 24
Management Components hours following notification from the Always Sometimes Never
employee of an injury.
The medical status form is provided to the

Return to Work (RTW) employee to take to their first and
Management Components subsequent visits with their health care Always Sometimes Never
provider.
When the medical status form is received

and the injured employee is released to
work, a transitional duty team meeting is
scheduled and held between human
Return to Work (RTW) resources (HR) and or the TDTC, the Always Sometimes Never
Management Components supervisor and the injured employee; to
review medical restrictions listed on the
medical status form and to collectively
develop transitional duty.
The employee provides the medical status

form after every medical visit to the TDTC.
Return to Work (RTW) The TDTC then schedules a meeting with the Always Sometimes Never
Management Components transitional duty team to discuss updates to
those restrictions and make adjustments to
the employee's RTW Plan.
If the employee is not released, the

supervisor and or TDTC makes weekly
Return to Work (RTW) contact with employee and ensures the Always Sometimes Never
Management Components contact log is updated.
The return to work plan is documented

Return to Work (RTW) using the transitional duty tracking form (or
Management Components other form of documentation) after every Always Sometimes Never
transitional duty team meeting.
A copy of the transitional duty tracking form

Return to Work (RTW) is provided to the employee to provide at Always Sometimes Never
Management Components the next health care provider's visit.
The return to work progress of injured

Return to Work (RTW) employees is regularly communicated to the Always Sometimes Never
Management Components workers compensation carrier.
HR/TDTC keeps in contact with the claims

examiner throughout the process. HR/TDTC
Return to Work (RTW) stays informed on severity, lost time, and Always Sometimes Never
Management Components duration. TDTC ensures contact is
maintained between the examiner and the
employee.
HR Specialist/TDTC monitors the claim until

Return to Work (RTW) employee reaches maximum medical
Management Components improvement (MMI); HR/TDTC asks claims Always Sometimes Never
examiner to close the claim.
Medical Status Forms, transitional duty

Return to Work (RTW) tracking forms, contact logs, FROI are filed Always Sometimes Never
Management Components for each injured worker.
The physical/mental demands of the

Return to Work (RTW)
Management Components department's positon are listed in the job Always Sometimes Never
profile.
Return to Work (RTW) Return to work training is provided to all Always Sometimes Never
Management Components employees.
Return to Work (RTW) Return to work training is provided to all Always Sometimes Never
Management Components supervisors.
Return to Work (RTW) Regular RTW training and updates are

incorporated into safety committee Always Sometimes Never
Management Components meetings or other staff meetings.
RTW responsibilities are incorporated into

Return to Work (RTW) position descriptions and performance
Management Components Always Sometimes Never
appraisals.
The number of transitional duty team

Return to Work (RTW) meetings are monitored and the outcome of Always Sometimes Never
Management Components the RTW effort is tracked.
A safety committee has been created.
Safety Committee Yes Maybe No
The safety committee has some employees

Safety Committee from each workgroup. Yes Maybe No
The safety committee has members from

Safety Committee both management and employee groups. Yes Maybe No
Employees have been selected based on

Safety Committee their interest in safety, or their ability to Yes Maybe No
help lead change.
A written Committee Charter has been
Safety Committee developed. Yes Maybe No
Employees have been given permission to

Safety Committee fully participate in the safety committee Yes Maybe No
activities.
The committee has been funded.
Recommendations made by the committee

Safety Committee are considered by management and drive Yes Maybe No
change.
The committee meets regularly.
Safety Committee (Monthly) (Quarterly) (Less)
The committee has clear goals and

objectives.
Meeting minutes are kept and posted where Yes
Safety Committee Maybe No
all employees can see them.
The committee spreads safety awareness
throughout the company.
Safety Committee The committee performs incident reviews. Yes Maybe No
The committee makes recommendations

Safety Committee from incident reviews to prevent future Yes Maybe No
incidents from occurring.
The committee performs hazard

assessments.
Committee members have training in hazard Yes
Safety Committee Maybe No
identification.
The committee has a designated
chairperson.
Committee members review safety
Safety Committee programs and make suggestions for Yes Maybe No
revisions.
Safety Committee members hold toolbox

Safety Committee meetings with their workgroups. Yes Maybe No
Safety committee members bring safety
Safety Committee committee information back from meetings Yes Maybe No
to their workgroup.
Safety committee members bring concerns

Safety Committee and issues to the safety committee Yes Maybe No
meetings from their workgroups.
The safety committee tracks its successes

Safety Committee and shares them throughout the Yes Maybe No
organization.
The safety committee hosts safety events to

Safety Committee raise awareness and education. Yes Maybe No
Safety committee members are the eyes and Yes

Safety Committee ears of the company. Maybe No
The safety committee is viewed as a

Safety Committee resource and trusted group by the Yes Maybe No
employees.
The committee members are renewed or
replaced on a scheduled basis.
Safety Committee members are rewarded

for their participation on the committee.
New employee orientation

Recordkeeping Yes No
Task specific training

Date, topic, and sign in sheet for safety

Recordkeeping trainings Yes No
Safety committee minutes

Date of safety inspections

Date of corrective items applicable to safety

Recordkeeping inspection Yes No
Recordkeeping Progressive discipline for safety violations Yes No
Written safety program

Preventative maintenance
Repair logs
Incident investigation forms

First Report of Injury

Recordkeeping OSHA 300 Logs (current and five years prior) Yes No
Employer Experience Reports, also known

as, Loss Runs
Recordkeeping Safety Data Sheets (SDS), formerly MSDS Yes No
Fire extinguisher inspections

Snow removal logs

Return to Work Program

Offers of Light Duty

Claims notes
Emergency drill evaluations

Safety Dashboard Summary
Hazard Identification Hiring & Onboarding Practices Incident Management

Total Possible Total Possible Total Possible
Year Excellent Good Opportunity Not Answered Points Year Always Sometimes Never Not Answered Points Year Always Sometimes Never Not Answered Points
2014 0 0 0 49 49 2014 0 0 0 47 47 2014 0 0 0 18 18

2015 0 0 0 49 49 2015 0 0 0 47 47 2015 0 0 0 18 18
2016 0 0 0 49 49 2016 0 0 0 47 47 2016 0 0 0 18 18
2017 0 0 0 49 49 2017 0 0 0 47 47 2017 0 0 0 18 18
2018 0 0 0 49 49 2018 0 0 0 47 47 2018 0 0 0 18 18
Excellent
2014 2015 2014 2015 2014 2015
Always Always
Good
Sometimes Sometimes
Opportunity
Never Never
Not Answered
Not Answered Not Answered
2016 2017 2018 2016 2017 2018 2016 2017 2018
Management Commitment Recordkeeping Return to Work Management

Year Excellent Good Opportunity Not Answered Points Year Yes No Not Answered Points Year Always Sometimes Never Not Answered Points
2014 0 0 0 15 15 2014 0 0 21 21 2014 0 0 0 20 20

2015 0 0 0 15 15 2015 0 0 21 21 2015 0 0 0 20 20
2016 0 0 0 15 15 2016 0 0 21 21 2016 0 0 0 20 20
2017 0 0 0 15 15 2017 0 0 21 21 2017 0 0 0 20 20
2018 0 0 0 15 15 2018 0 0 21 21 2018 0 0 0 20 20
2014 2015 2014 2015 2014 2015

Excellent Yes Always
Good Sometimes
Opportunity No Never
Not Answered Not Answered Not Answered
2016 2017 2018 2016 2017 2018 2016 2017 2018
Roles and Responsibilities Safety Committee Safety Coordinator

Year Excellent Good Opportunity Not Answered Total Possible Year Yes Maybe No Not Answered Total Possible Year Excellent Good Opportunity Not Answered Total Possible
Points Points Points
2014 0 0 0 21 21 2014 0 0 0 27 27 2014 0 0 0 12 12

2015 0 0 0 21 21 2015 0 0 0 27 27 2015 0 0 0 12 12
2016 0 0 0 21 21 2016 0 0 0 27 27 2016 0 0 0 12 12
2017 0 0 0 21 21 2017 0 0 0 27 27 2017 0 0 0 12 12
2018 0 0 0 21 21 2018 0 0 0 27 27 2018 0 0 0 12 12
2014 2015 2014 2015 2014 2015

Excellent Yes Excellent
Good Maybe Good
Opportunity No Opportunity
Not Answered Not Answered Not Answered
2016 2017 2018 2016 2017 2018 2016 2017 2018
Training and Awareness
Total Possible
Year Always Sometimes Never Not Answered Points
2014 0 0 0 48 48
2015 0 0 0 48 48
2016 0 0 0 48 48
2017 0 0 0 48 48
2018 0 0 0 48 48
2014 2015
Always
Sometimes
Never
Not Answered
2016 2017 2018

Safety Dashboard Summary
Hazard Identification Hiring & Onboarding Practices Incident Management

Year Excellent Good Opportunity Not Answered Points Year Always Sometimes Never Not Answered Points Year Always Sometimes Never Not Answered Points
2014 0 0 0 49 49 2014 0 0 0 47 47 2014 0 0 0 18 18

2015 0 0 0 49 49 2015 0 0 0 47 47 2015 0 0 0 18 18
2016 0 0 0 49 49 2016 0 0 0 47 47 2016 0 0 0 18 18
2017 0 0 0 49 49 2017 0 0 0 47 47 2017 0 0 0 18 18
2018 0 0 0 49 49 2018 0 0 0 47 47 2018 0 0 0 18 18
2018 2018 2018
2017 2017 2017

Excellent
Always Sometimes Always Sometimes
2016 Good 2016 2016
Opportunity
Never Not Answered Never Not Answered
2015 2015 2015
Not Answered
2014 2014 2014
0 5 10 15 20 25 30 35 40 45 50 0 5 10 15 20 25 30 35 40 45 50 0 2 4 6 8 10 12 14 16 18
Management Commitment Recordkeeping Return to Work Management

Year Excellent Good Opportunity Not Answered Points Year Yes No Not Answered Points Year Always Sometimes Never Not Answered Points
2014 0 0 0 15 15 2014 0 0 21 21 2014 0 0 0 20 20

2015 0 0 0 15 15 2015 0 0 21 21 2015 0 0 0 20 20
2016 0 0 0 15 15 2016 0 0 21 21 2016 0 0 0 20 20
2017 0 0 0 15 15 2017 0 0 21 21 2017 0 0 0 20 20
2018 0 0 0 15 15 2018 0 0 21 21 2018 0 0 0 20 20
2018 2018 2018
2017 2017 2017
Excellent Always
Yes
2016 Good 2016 2016 Sometimes
No
Opportunity Never
Not Answered
2015 2015 2015 Not Answered
Not Answered
2014 2014 2014
0 2 4 6 8 10 12 14 16 0 5 10 15 20 25 0 2 4 6 8 10 12 14 16 18 20
Roles and Responsibilities Safety Committee Safety Coordinator

Year Excellent Good Opportunity Not Answered Total Possible Year Yes Maybe No Not Answered Total Possible Year Excellent Good Opportunity Not Answered Total Possible
Points Points Points
2014 0 0 0 21 21 2014 0 0 0 27 27 2014 0 0 0 12 12

2015 0 0 0 21 21 2015 0 0 0 27 27 2015 0 0 0 12 12
2016 0 0 0 21 21 2016 0 0 0 27 27 2016 0 0 0 12 12
2017 0 0 0 21 21 2017 0 0 0 27 27 2017 0 0 0 12 12
2018 0 0 0 21 21 2018 0 0 0 27 27 2018 0 0 0 12 12
2018 2018 2018
2017 2017 2017
Excellent Excellent
Yes Maybe
2016 Good 2016 2016 Good
Opportunity Opportunity
No Not Answered
2015 2015 2015 Not Answered
Not Answered
2014 2014 2014
0 5 10 15 20 25 0 5 10 15 20 25 30 0 2 4 6 8 10 12
Training and Awareness
Total Possible
Year Always Sometimes Never Not Answered Points
2014 0 0 0 48 48
2015 0 0 0 48 48
2016 0 0 0 48 48
2017 0 0 0 48 48
2018 0 0 0 48 48
2018
2017
Always
2016 Sometimes
Never
2015
Not Answered
2014
0 5 10 15 20 25 30 35 40 45 50

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Safety Dashboard Questionnaire

Members of management are

Clear objectives are set on an

Funds are adequately allocated

All levels of employment are

Management hosts and Members of management No evidence of managers or

Management and supervisors

Management is involed with all Management participates in

Management gives the Safety

Individual departments have

Managers and supervisors are

Managers and supervisors are

Managers provide written The Safety Coordinator is There is no formal response to

Supervisors complete the First

Provides recognition and

Ensures all employees receive

Works with supervisors and

Safety is incorporated into Safety is incorporated into

Reports all First Report of Timely submission of FROI lags

Provides or arranges training for

Provides or arranges training for

Reviews reports provided by the

Actively participates in new Is not required to participate in

Actively participates in job

Always wears the required PPE. Uses PPE when Safety

Maintains good housekeeping

Reports hazards to supervisor.

Plans work with safety

Helps coworkers work safely.

Safety management is a full Safety management is a half Safety management is an

Drafts, formalizes, and works to Proposes safety programs to

Reports quarterly to Executive Emails communications to No lines of communication with

Analyzes accident reports and

Does not participate in the

Provides or arranges ergonomic

Poignant in self growth and

Conducts an audit of the

Conducted frequently and Conducted annually and No evidence of facility

Conducted frequently and Conducted annually and No evidence of grounds

Pre-operational inspections No evidence of fleet

Pre-operational inspections No evidence of heavy

Work activities are reviewed on Work activites are addressed on

Company specific driving rules,

Written program in place to

Written respiratory protection

Equipment specific hazardous

Spaces are identified and

Noise is established safe

Equipment and power tools

Only qualified personnel work

Fall protection plans are in

A certified hazard assessment Personal Protective Equipment

A written EAP is in place and

Workzones are established

An ergonomics process has

Manual material handling is

All operators are trained and

Full Exposure Control Program

Open positions are advertised in multiple

Job postings include the requirement to

A formal application process is in place.

The application has been approved by legal Always

Application is reviewed and content is