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Except for check boxes, all questions are required and must be answered. If not currently applicable, write what/who would be applicable after implementing the safety program. If still not applicable, write "none" or "unknown."

Your Name

Your Email

The name of the person who will approve the manual and contact information

Full name of the company:

Short version of the company name:

Company Street Address to list in the safety manual:

Company Phone Number to list in the safety manual:

Number of employees (at least an approximate if exact number unknown).

Describe your business, the occupations and the facilities:

This listings below are the chapter headings in the BASIC MANUAL. Below this list are listings for optional chapters. Check the boxes for every optional chapter you think your business will need for the employee safety manual.
Agreement Between All Parties
Statement Of Safety Goals
Program Outline And Responsibilities
Accident Investigation
Bloodborne Pathogens
Clothing And Jewelry
Discipline And Termination
Electrical Safety - GFCI
Emergency Response - Fire Prevention
Ergonomics Protection Program (EPP)
Guardrails, Handrails And Covers
Hazard Communication - MSDS
Housekeeping
Ladder Safety
Machinery And Tools
Personal Protective Equipment (PPE)
Reporting An Injury Or Near Miss
Reporting Unsafe Conditions
Safety Meetings
Substance Abuse
Workplace Violence
Appendix A - Safety At Home And Play
Employee Safety Acknowledgement
Employee Substance Abuse Acknowledgement

Check the optional chapters your business will need in the safety manual:
 Abrasive Blasting Blasting And Explosives Chem Hazard: Benzene Chem Hazard: Hydrogen Sulfide (H2S) Chem Hazard: Lead Concrete And Masonry Construction Confined Space Practices Demolition Fall Protection Forklifts And Materials Handling Framing - Residential Construction Hazwoper - Emergency Response Heavy Equipment Lockout - Tagout (LOTO) Mobile Lifting Devices And Cranes Mobile Manlifts And Work Platforms Motor Vehicle Operation Noise Exposure - Hearing Conservation Rigging Equipment Roof Construction Safety Committee Scaffold Use Spray Finishing And Dip Tanks Steel Erection Traffic Control Tree Trimming & Removal (Logging) Trenching And Shoring Welding, Cutting And Hot Work

List any chapters your business will need that are not listed above:

If your employees come into contact with or work with any of the following chemicals in the course of the regular activities of the workplace, OSHA has specific regulations that you and your employees need to know. Check all that apply:
 1,2-dibromo-3-chloropropane 1,3-Butadiene 2-Acetylaminofluorene, CAS No. 53963 3,3'-Dichlorobenzidine (and its salts) CAS No. 91941 4-Aminodiphenyl, CAS No. 92671 4-Dimethylaminoazo-benzene, CAS No. 60117 4-Nitrobiphenyl (CAS No.) 92933 Acetylene Acrylonitrile alpha-Naphthylamine, CAS No. 134327 anhydrous ammonia asbestos Benzene Benzidine, CAS No. 92875 beta-Naphthylamine, CAS No. 91598 beta-Propiolactone, CAS No. 57578 bis-Chloromethyl ether, CAS No. 542881 Cadmium Chromium (VI) Cotton dust Ethylene oxide Ethyleneimine, CAS No. 151564 Formaldehyde Hydrogen Inorganic arsenic Ionizing radiation LP gas methyl chloromethyl ether, CAS No. 107302 Methylene Chloride Methylenedianiline Nitrous Oxide N-Nitrosodimethylamine, CAS No. 62759 Oxygen Vinyl chloride

Do any of the occupations require driving for the company or during working hours?

List any occupations that may expose employees to excessive noise levels (8 hour time-weighted average of 85 dB):

If you have, or desire to have, a Bloodborne Pathogen Exposure Control Plan:
1) Who is responsible for implementing, maintaining, reviewing and updating the exposure control plan.

2) Who will be responsible for making sure all medical actions required are performed, and that appropriate employee medical records are maintained.

3) List job classifications in which ALL employees have occupational exposure to bloodborne pathogens.

4) List job classifications in which SOME employees have occupational exposure to bloodborne pathogens.

Who is the decision maker about evacuation if a bomb threat is received?

Does your business employ qualified electricians?

Has your business established and assured grounding conductor program? or will you prefer to connect all equipment to GFCI? (recommend GFCI)

What is the job title of the person who is responsible for maintaining the fire protection and detection equipment?

Describe your fire evacuation plan:

Make and model of forklifts:

Where will the MSDS notebook be kept?

The name or job title of your hazard communications coordinator:

List all occupations involved with hazardous waste:

Where is the first aid kit located?

Where is the eye wash station located?

Where is the board which displays the employee safety posters and employment posters located?

Name, location, hours and contact info of nearest urgent care center:

Any other medical services information to list in the safety manual?

Name or job title of the person-in-charge of medical records:

Describe any equipment (type, make and model), stationary machines and/or trailered equipment where anyone performing maintenance could be injured or killed if another were to energize the equipment - equipment needing Lock Out / Tag Out procedures:

List any stationary machines, mobile lift devices, manlifts and cranes by type, make and model:

Name or job title of the person-in-charge of the respirator program

Name of person to report injuries to:

Name of the employee safety representative (this is usually the chairman of the safety committee):

Name or job title of the drug policy administrator:

Name or job title of the workplace violence administrator:

Day of the week, time and location of safety meetings:

Additional Comments or Questions