Deluxe Safety Manual Customization Form

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Please fill out each area as completely as possible.  This information will be used to customize your Accident Prevention & Safety Manual.  If an area does not apply to your business simply leave it blank or mark it as Not Applicable (NA).  Do not hit enter on your keyboard or click on the submit button below until you have completed entering all of your information.  If you accidentally do this just click on the "BACK" button on your browser toolbar.

Once you have completed and submitted the form you will be directed to a page where you can place your order.  Should you have any questions or require additional information, please don't hesitate to contact us at (417) 385-8034 or at sales@safetymanualpro.com  .

 

Name of individual completing this form: Telephone: Email:          Company Specific Information Enter the name of your company or organization just as you want it spelled throughout your manual: Address:   Tele: Fax:   Provide a brief description of your business and what you manufacture, produce or the types of services you offer. Provide the name of your Safety Manager/Responsible Safety Officer.  This is the person responsible for the implementation and overall management of your safety program. How often do you hold safety meetings (weekly, monthly, quarterly)?  It is highly recommended, and in some states required, that construction contractors and subcontractors hold weekly tailgate/toolbox meetings. Emergency eyewash facilities meeting the requirements of ANSI Z358.1-1981 must be provided in all areas where the eyes of any employee may be exposed to corrosive materials. All such emergency facilities must be located where they are easily accessible to those in need.  If you have emergency eyewashes or showers please provide us with their location(s). If you have a logo you would like incorporated into your safety manual simply email it to sales@safetymanualpro.com  . The following chapters/sections are included in all safety manuals as the basic foundation of your safety program. Illness & Injury Prevention Program (IIPP) OSHA Reporting Disciplinary Policy Engineering Controls Code of Safe Work Practices Equipment Preventative Maintenance Safety Committees Purchasing Controls Hazard Identification & Risk Mgt. Safety Rewards Accident Investigation Safety Performance Assessment Incident & Accident Reporting Training Courses Accident Statistics Employee Evaluation Program Inspections Drug & Alcohol Free Workplace Hazard Reporting Workplace Violence Prevention Risk Control Personal Protective Equipment Standard Work Procedures Emergency Action Plan  Safety Training Hazard Communication:  Labeling & MSDS OSHA Recordkeeping Employee Access to Exposure & Medical Records To add any of the safety programs below to your safety manual simply place a check in the appropriate box next to the program name.  If additional information is requested please provide the information as thoroughly as possible. When choosing the chapters you want included in your safety manual please keep in mind that more does not necessarily mean better.  Choose only chapters that address hazards and safety management/compliance issues specific to your business.  Including chapters that do not apply to your business activities could potentially raise questions with an OSHA Compliance Officer during inspection, thereby, unnecessarily increasing your overall compliance liability.  If you are not sure which chapters to include simply contact one of our consultants at (417) 385-8034 for assistance.***   Place a ü next to each safety program you want included in your safety manual.    GENERAL SAFETY PROGRAMS Return-to-Work Behavior-Based Safety Working Alone Emergency Action First Aid  *Additional information required.  See below. Bloodborne Pathogens  *Additional information required.  See below. Fire Prevention Electrical Safety Assured Grounding Conductor Lockout Tagout Ergonomics Job Safety Analysis (JSA) Heat Stress Cold Stress Fatigue Management Employee Safety Evaluation Program      HIGH HAZARD/SPECIALIZED SAFETY PROGRAMS Personal Protective Equipment (PPE) Respiratory Protection  *Only select if your employees are  or have the potential to be exposed to respiratory hazards above OSHA permissible exposure levels (PEL).  *Additional information required.  See below. Noise Control/Hearing Conservation  *Only select if your employees are exposed to noise levels above OSHA permissible exposure levels (PEL).  *Additional information required.  See below. Fall Protection     Chemicals/Hazardous Substances Asbestos Exposure*  Benzene Exposure* Cadmium Exposure* Lead Exposure* Hydrogen Sulfide (H2S) Exposure* Naturally Occurring Radioactive Material (NORM) Exposure Silica Exposure* Abrasive Blasting Hazardous Waste Operations (HAZWOPER) - RCRA *Additional information required.  See below. Hazardous Waste Operations (HAZWOPER) - Emergency Response  *Additional information required.  See below. Ionizing Radiation* Pesticides Process Safety Management Overview** Flammable & Combustible Liquids  *Additional information required.  See below. Gases, Vapors, Fumes, Dusts, & Mists Formaldehyde Exposure       *Only select if your employees are or have the potential to be exposed to levels above OSHA permissible exposure levels (PEL)   **Only select if your employees work with or near "HIGHLY" hazardous chemicals.    Construction Activities Contractor Safety Short Service Employee (SSE) Roof Construction Excavation, Trenching & Shoring Concrete & Masonry Construction Concrete Pump Boom Steel Erection  *Additional information required.  See below. Drywall Installation & Finishing    Permit Required Confined Space Entry  *Additional information required.  See below. Underground Construction (Caissons, Cofferdams & Compressed Air)  *Additional information required.  See below. Demolition Safety Blasting & Explosives Use Logging - General     Equipment/Machinery Hand & Power Tools Ladders Scaffolding  *Additional information required.  See below. Forklifts Aerial & Scissor Lifts Bucket Trucks Heavy Equipment Crane & Derrick Operation Overhead Cranes Rigging - Slings Helicopter Operations Grounds Maintenance Equipment Driving Safety Defensive Driving Jobsite Vehicles, Traffic Control, Barricades, & Warning Signs Boiler Safety Farm Equipment Operation & Maintenance Vac Truck Mechanical Power Presses In Plant Rail Safety Single Rim Servicing     Welding & Cutting Welding & Cutting Compressed Gases  *Additional information required.  See below. Hexavalent Chromium     Medical/Dental/Healthcare Hazardous Drugs Medical Waste Management & Disposal Medical X-ray Tuberculosis     Petroleum/Oil/Gas Oil & Gas Wells - Operations Commercial Diving Operations Offshore Water Survival Offshore Crane Operator Offshore Rigging - Slings     Miscellaneous Topics Spray Finishing  *Additional information required.  See below. Fall Protection - General Industry/Manufacturing Telecommunications Safety Commercial Logging Foodservice Safety Swimming Pool Safety Environmental Protection Program Erosion Control   Additional Information Required - many of the programs listed above require additional company-specific information in order to properly customize your safety manual.  If information is not provided that portion of the safety manual will simply be left blank.  Should you have any questions please don't hesitate to contact us at (417) 385-8034 or sales@safetymanualpro.com .              Safety Committee Provide the names and titles of those who will make up your Safety Committee.  It is best to use personnel from multiple areas (i.e. production, management, maintenance, engineering).  If possible, provide more than one or two names. Name 1 Title Name 2 Title Name 3 Title Name 4 Title Name 5 Title Name 6 Title              Emergency Action Procedures Provide the names, titles, and work and home telephone numbers of key personnel that need to be contacted in the event of an emergency.   Name 1 Title Work Phone Home Phone         Name 2 Title Work Phone Home Phone         Name 3 Title Work Phone Home Phone         Provide the telephone numbers for your local emergency agencies.     Police Fire Ambulance   Describe your evacuation and seek shelter alarms.  The two must be distinctly different.  If you don't have alarms we will describe the evacuation as a "single blast from air horn" and the seek shelter as "repeated intermittent blast from air horn".     "Fire/Evacuation" Alarm "Seek Shelter" Alarm          First Aid   List the medical provider name where injured employees will be treated.   Provider Name Address           City State Alabama Alaska American Somoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip   Should your facility or job site not be within 3 to 4 minutes (near proximity) from an infirmary, clinic or hospital, you are required to have employees trained in first aid and CPR. Are you within near proximity to one of these facilities?    Yes    No   If you answered no, please provide below the names of employees who are trained in first aid and CPR:   Name 1  Name 2  Name 3  Name 4  Name 5  Name 6       Bloodborne Pathogens List below the job classifications that could be potentially exposed to blood or other contaminated human body fluids. (i.e. first aid personnel, custodians, supervisors, nurses, physicians, nursing assistants, phlebotomists)   Classification 1  Classification 2  Classification 3  Classification 4  Classification 5  Classification 6  Classification 7  Classification 8         Hazard Communication   Where are your Material Safety Data Sheets (MSDS) located?         Respiratory Protection               Not applicable         List respiratory hazards potentially exceeding OSHA permissible exposure levels.         List types & models of respirators, cartridges and other related equipment.         List name and address of Licensed Healthcare professional who conducts medical evaluations on employees required to wear respiratory protection.     Type of fit testing conducted. Qualitative (i.e. irritant smoke, bitrex)   Quantitative (i.e. Portacount) Fit testing substance/equipment used (i.e. irritant smoke, bitrex, Portacount)              Hearing Conservation                           Not applicable List the work areas where hearing protection is mandatory.        Scaffolding                           Not applicable Types of scaffolding used:    Supported            Suspended    Names of competent person(s) responsible for assembly and inspection of scaffolding:              Permit Required Confined Space                           Not applicable List the names of the employees who comprise your Confined Space Rescue Team.         If you are using an outside source as your rescue team, please provide the organization's contact information below:         Rescue Service Name Address         City State Alabama Alaska American Somoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Tele.        Compressed Gases                           Not applicable List the types of compressed gases used in your workplace. If you use hydrogen gas please provide the name and title of the qualified person responsible for the management of this gas. Name Title        Steel Erection                          Not applicable             Safety Latch Site-Specific Plan If you elect, due to conditions specific to the worksite, to deactivate or make inoperable safety latches on hooks you are required to develop a site-specific plan.  This site-specific plan should provide alternative methods of protection for your employees meeting at least minimum OSHA requirements. Describe this alternative method below and provide the name and title of the competent person who developed the plan. Describe alternative methods of protection in the box below: Competent Person Title               Setting Steel Joists Site-Specific Plan If you utilize alternative methods for setting steel joists you are required to develop a site-specific plan.  This site-specific plan should provide alternative methods of protection for your employees meeting at least minimum OSHA requirements. Describe this alternative method below and provide the name and title of the competent person who developed the plan. Describe alternative methods of protection in the box below: Competent Person Title               Placing Deck Bundles Site-Specific Plan If you utilize alternative methods for placing deck bundles you are required to develop a site-specific plan.  This site-specific plan should provide alternative methods of protection for your employees meeting at least minimum OSHA requirements. Describe this alternative method below and provide the name and title of the competent person who developed the plan. Describe alternative methods of protection in the box below: Competent Person Title        Flammable & Combustible Liquids                          Not applicable List the following information for each operation in your workplace:  Operation, Liquid Identity & Class, and Tank/Container Type, Capacity, Quantity, & Location.        Spray Finishing Using Flammable & Combustible Liquids                          Not applicable List and describe below all spray operations present in your workplace.  Include process equipment, chemicals used, location and any other relevant information.  If additional space is required simple send a separate email to sales@safetymanualpro.com .   Before existing and potential hazards can be prevented and controlled, they must be identified and assessed.  List and describe below each hazard (flammable, explosive, respiratory, etc.) identified for each individual spray operation present in your workplace.  If additional space is required simple send a separate email to sales@safetymanualpro.com .   All electrical equipment used in and around spray operations must meet minimum OSHA requirements (i.e. explosion-proof).  List and describe below types of electrical equipment present in and around each individual spray operation present in your workplace.  If additional space is required simple send a separate email to customerservice@oshasource.com .        Gases, Vapors, Dusts, Fumes & Mists                        Not applicable List all any gases, vapors, dusts, fumes, & mists which employees are potentially exposed to above OSHA permissible exposure levels (PEL).  List the documented exposure level for each as well.        Process Safety Management (PSM) of "Highly" Hazardous Materials                         Not applicable If you have more than one process involving a "highly" hazardous material in your workplace you will need to provide all of the following information for each individual process. Name of process: Provide date the Process Hazard Assessment (PHA) was completed and the name of the team leader: Date: PHA Team Leader List chemical(s) involved: List hazards involved: How often are daily inspection conducted: List pieces of process safety equipment: Number & description of each process in process cycle: The maximum intended inventory of each process chemical at this Company (i.e. number of pounds, gallons or cubic feet): Briefly describe the technology used in the process, unique attributes of the process and who controls the technology: Describe ventilation system(s) (number of supply and exhaust fans, special ducting, controls, volume flowrate, alarms, etc.): Design codes and standards followed for the construction and installation of the process: You will need to attached the following documents and diagrams to each PSM Plan. SAFE OPERATING PROCEDURES (SOP) BLOCK FLOW DIAGRAM PIPING & INSTRUMENT DIAGRAM SITE-SPECIFIC EMERGENCY ACTION PLAN        Hazardous Waste Contingency, Emergency Response & RCRA Plan                         Not applicable   Federal EPA ID No. State EPA ID No.   Generator Category: check a box below   Conditionally Exempt Small Quantity Generator:  0-100 kilograms per month   Small Quantity Generator:  100-1000 kilograms per month   Large Quantity Generator:  1000 or more kilograms per month Proved the address and telephone number for each agency listed below: Local Police Department: Local Fire Department: Local Hospital(s): Local Emergency Planning Commission (LEPC): State Emergency Response:     Hazardous Waste Transporter Information EPA ID Number: Name: Address: Telephone Number: Contact Person:     Hazardous Waste Destination Facility(s) List name, address, telephone numbers and EPA identification number of all destination facility along with the types of waste being received by each facility Destination Facility 1:  Destination Facility 2:  Destination Facility 3:  Destination Facility 4:      Emergency Equipment & Procedures Describe your emergency alarm system: List fire control equipment and capabilities: List spill control equipment and capabilities: List decontamination equipment and capabilities:     You will need two designate a primary emergency coordinator and two alternatives.  List names, work & home telephone numbers, home address, and any pager or cell phone numbers that would allow an employee to immediately contact a coordinator. Primary Coordinator Alternate Coordinator 1 Alternate Coordinator 2     Provide the name, work & home telephone numbers, home address, and any pager or cell phone numbers that would allow you to immediately contact the owner or operator. Owner/Operator Information: The owner or operator has responsibilities in the event of an emergency caused by a hazardous waste spill or discharge.  Describe those responsibilities:   Emergency Response Team List below the names of those who comprise your Emergency Response Team and what level of hazwoper training each has completed (i.e. 8-hours, 24-hour, 40-hour).  Those who are required to enter an area in which a spill or leak has occurred, rescue employees, and/or stop, control and/or clean up spills and leaks should have at least completed a 40-hour hazwoper training course and completed annual refresher training as required. Name 1: Qualifications 1: Name 2: Qualifications 2: Name 3: Qualifications 3: Name 4: Qualifications 4: Name 5: Qualifications 5: Name 6: Qualifications 6:        Underground Construction                         Not applicable List below the name and qualifications of the competent person responsible for conducting air monitoring. Name : Qualifications :         List below the name and qualifications of the competent person responsible for inspecting drilling and other associated equipment prior to use. Name : Qualifications :         List below the name and qualifications of the competent person responsible for inspecting haulage equipment prior to use. Name : Qualifications :         List below the name and qualifications of the competent person responsible for inspecting hoisting machinery, equipment, anchorages, and hoisting rope at the beginning of each shift and during hoist use, as necessary Name : Qualifications :         List below the name and qualifications of the competent person responsible at the air control valves as a gauge tender who will regulate the pressure in the working areas. Name : Qualifications : If you have a company logo you would like incorporated into your safety manual just email it to sales@safetymanualpro.com   Place your company name in the "Subject" field.