IECRM Safety Evaluation Form

Review each section, and enter the number that best describes your level of safety. No partial credit is given. Please choose one whole number for each category.

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* First Name:

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* Last Name:

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* Title:

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* Company:

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* Phone:

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* What is your company size?

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* Management Commitment

Management Commitment Criteria

Score: 9
• Management supports safety
• Management actively participates in safety program
• Management provide support for safety activities
• Management sets objectives and goals
• Requires feedback on safety program
• Safety is a part of company-wide performance appraisals

Score: 6
• Management supports safety
• Management actively participates in safety program
• Management provide support for safety activities
• Management sets objectives and goals

Score: 3
• Management supports safety
• Management actively participates in safety program
• Management provide support for safety activities

Score: 0
• Safety is not discussed

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* Management Policy Statement on Safety

Management Policy Statement on Safety

Score: 9
• Safety policy exists
• Safety policy is posted in writing or is part of employee handbook
• Safety policy is known by all employees
• Safety policy is contained in separate safety manual

Score: 6
• Safety policy exists
• Safety policy is posted in writing or is part of employee handbook

Score: 3
• Safety policy exists

Score: 0
• No safety policy

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* Responsibility For Safety Defined

Responsibility For Safety Defined Criteria

Score: 9
• Owner and/or Safety Coordinator has full responsibility for safety program
• Supervisors perform safety activities
• Responsibility for safety is in writing for all levels of the firm and is stated in a safety manual
• All employees have responsibilities in safety program

Score: 6
• Owner and/or Safety Coordinator has full responsibility for safety program
• Supervisors perform safety activities
• Responsibility for safety is in writing for all levels of the firm and is stated in a safety manual

Score: 3
• Owner has full responsibility for safety

Score: 0
• No one is responsible for safety

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* Safety Statistics

Safety Statistics Criteria

Score: 9
• Know what EMR* is
• Know your company’s EMR rate
• EMR is below 1.0
• Management knows and reviews the cost of accidents and the impact of the EMR/LR**
on the company

Score: 6
• Know what EMR* is
• Know your company’s EMR rate
• EMR is below 1.0
• The cost of accidents are reported

Score: 3
• Know what EMR* is
• Know your company’s EMR rate
• EMR has shown recent decrease

Score: 0
• What is EMR*?

*EMR = Experience Modification Rate
**LR = Loss Ratio

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* Safety Budget

Safety Budget Criteria

Score: 9
• The safety budget provides funds for safety activities
• An annual safety budget is established and based on planned programs
• Estimates are made on savings contributed by safety program

Score: 6
• The safety budget provides funds for safety activities
• An annual safety budget is established and based on planned programs

Score: 3
• The safety budget provides funds for safety activities

Score: 0
• No funds for safety program

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* Safety Program Goal-Setting

Safety Program Goal-Setting

Score: 9
• Company has a written safety program and goals
• Written goals & objectives are set to be achieved through the safety program
• Goal results are discussed and published/distributed annually
• Feedback from those responsible for achieving results is required to measure performance
• A strategy is developed to accomplish safety goals

Score: 6
• Company has a written safety program and goals
• Written goals & objectives are set to be achieved through the safety program
• Goal results are discussed and published/distributed annually
• Feedback from those responsible for achieving results is required to measure performance

Score: 3
• Company has a written safety program and goals

Score: 0
• Company has no safety program

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* Management Supervisory Meetings

Management Supervisory Meetings Criteria

Score: 9
• Information is given to supervisors on safety
• Management gives an overview of safety activity to supervisor/ leadperson
• Supervisor gives status report on jobsite activities
• Regular safety meetings are held with supervisor/leadperson
• Accidents are reviewed at supervisor meetings
• Near-misses are discussed and investigated

Score: 6
• Information is given to supervisors on safety
• Management gives an overview of safety activity to supervisor/ lead person
• Supervisor gives status report on jobsite activities
• Regular safety meetings are held with supervisor/lead person

Score: 3
• Company has a written safety program and goals

Score: 0
• No information is given to supervisors on safety

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* Pre-Jobsite Inspection

Pre-Jobsite Inspection Criteria

Score: 9
• Pre-jobsite inspection and planning are required to identify needed safety equipment
• A checklist is used
• Pre-site training is required
• Job supervisors are trained in planning for pre-jobsite safety inspections

Score: 6
• Pre-jobsite inspection and planning are required to identify needed safety equipment
• A checklist is used
• Pre-site training is required

Score: 3
• No pre-jobsite inspection but some thought is given to safety prior to starting work

Score: 0
• No pre-jobsite inspection

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* Employee Participation

Employee Participation Criteria

Score: 9
• Information is given to supervisors on how to involve employees
• Training is provided for supervisors
• Employee suggestions/comments program
• Procedures are set for employees to participate in activities ranging from training to accident investigators

Score: 6
• Information is given to supervisors on how to involve employees
• Training is provided for supervisors
• Employee suggestions/ comments program
• Procedures are set for employees to participate in activities ranging from training to accident investigation

Score: 3
• Information is given to supervisors on how to involve employees
• Training is provided for supervisors
• Employee suggestions/comments program

Score: 0
• No employee participation

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* New Employee Orientation

New Employee Orientation Criteria

Score: 9
• A safety orientation is given to new employees
• The orientation program includes safety information
• A record is kept showing information covered
• Orientation includes Lockout/Tagout, PPE, falls, automobile accidents, and material handling
• Management’s concern for safety is stressed
• Employee signs orientation training form

Score: 6
• A safety orientation is given to new employees
• The orientation program includes safety information
• A record is kept showing information covered
• Orientation includes Lockout/Tagout, PPE, falls, automobile accidents, and material handling

Score: 3
• A safety orientation is given to new employees

Score: 0
• There is no safety orientation given to new employees

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* Safety Rules

Safety Rules Criteria

Score: 9
• There are written company rules
• All employees are made aware of all safety rules
• Rules are enforced all of the time
• Rules are updated on an as needed basis
• Supervisors enforce all of the rules
and report violations

Score: 6
• There are written company rules
• All employees are made aware of all safety rules
• Rules are enforced all of the time

Score: 3
• There are safety rules such as those found in the IEC Safety Manual Guidelines
• Some employees are made aware of safety rules
• Rules are enforced some of the time

Score: 0
• No safety rules

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* On-Going Employee Safety Training (Safety Data Sheets)

On-Going Employee Safety Training (Safety Data Sheets) Criteria

Score: 9
• Formal GHS training program
• Safety Training is provided and documented in use of SDS, First Aid/CPR, hazard recognition, and Lockout/Tagout
• Safety training is provided and documented in areas such as hazard, standard, specific, heavy equipment, personal safety, OSHA, and Lockout/Tagout
• Training comprehension/understanding by employees is verified and documented

Score: 6
• Some basic formal training
• Safety Training is provided and documented in use of SDS, First Aid/CPR, hazard recognition, and Lockout/Tagout

Score: 3
• Some basic formal training
• Safety Training is provided in use of SDS and First Aid/CPR

Score: 0
• What are SDS?

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* Safety Toolbox Meetings

Safety Toolbox Meetings Criteria

Score: 9
• Supervisor or Safety Coordinators hold toolbox talks meetings
• Meetings are held monthly for all employees; topics and attendance records are documented and maintained
• Employees participate openly
• Management attends occasionally

Score: 6
• Supervisor or Safety Coordinators hold toolbox talks meetings
• Meetings are held monthly for all employees; topics and attendance records are documented and maintained

Score: 3
• Supervisor or Safety Coordinators hold toolbox talks meetings

Score: 0
• No toolbox talks held

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* Inspections

Inspections Criteria

Score: 9
• Jobsite inspections are made by supervisor/employee or management weekly
• Monthly jobsite inspections made by supervisor or management
• Site inspections done by independent source and/or Safety Director
• Critical safety items are identified and checked
• Discoveries are classified according to seriousness
• Target dates are set for corrective follow-up action

Score: 6
• Jobsite inspections are made by supervisor/employee or management weekly
• Monthly jobsite inspections made by supervisor or management
• Site inspections done by independent source and/or Safety Director
• Critical safety items are identified and checked

Score: 3
• Jobsite inspections are made occasionally by supervisor and/or employee

Score: 0
• No inspections

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* Supervisory Training

Supervisory Training Criteria

Score: 9
• All supervisors are sent to outside training courses
• Supervisor training in hazard communication, First Aid/ CPR, emergency reporting, jobsite inspections, accident investigations, job safety analysis and planning, conducting meetings, and supervisor skills is offered
• Supervisors attend OSHA 10-Hour Course
• Company has in-house facilities for training or has good outside source for training
• Supervisors have access to a safety professional

Score: 6
• All supervisors are sent to outside training courses
• Supervisor training in hazard communication, First Aid/CPR, emergency reporting, jobsite inspections, accident investigations, job safety analysis and planning, conducting meetings, and supervisor skills is offered
• Supervisors attend OSHA
10-Hour Course

Score: 3
• Some supervisors are sent to
outside training course

Score: 0
• No supervisor training

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* Accident Investigation

Accident Investigation Criteria

Score: 9
• Supervisor trained to conduct investigations
• Formal investigation by supervisor and written report made
• Safety personnel involved in all investigations
• Management reviews all investigation reports
• Information on “serious” incidents is shared with employees
• Basic causes of accidents are determined and follow-up system is in place to assure corrective action is taken

Score: 6
• Supervisor trained to conduct investigations
• Formal investigation by supervisor and written report made
• Safety personnel involved in all investigations
• Management reviews all investigation reports

Score: 3
• Investigations made by supervisor

Score: 0
• No accident investigation

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* Use of Personal Protective Equipment (PPE)

Use of Personal Protective Equipment (PPE) Criteria

Score: 9
• Analysis made to determine needs and PPE is provided, paid for, and required to use
• All employees trained in use and maintenance of PPE
• Employees informed of PPE requirements on each job and are made aware of disciplinary consequences of not using PPE
• Annual review of program made; re-training required

Score: 6
• Analysis made to determine needs and PPE is provided, paid for, and required to use
• Training is provided for use and maintenance of PPE

Score: 3
• PPE use is encouraged but not provided by employer

Score: 0
• Not familiar with PPE

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* Performance Audit

Performance Audit Criteria

Score: 9
• Subjective evaluation made of safety activities to judge if they are effective
• Safety performance level is evaluated at least annually
• Exceeds standards measuring performance
• Rating is given to each area audited
• Results are discussed with all employees

Score: 6
• Subjective evaluation made of safety activities to judge if they are effective
• Safety performance level is evaluated at least annually
• Meets standards measuring performance

Score: 3
• Review safety activities regularly

Score: 0
• No review

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* Substance Abuse Policy

Substance Abuse Policy Criteria

Score: 9
• Company has written policy
• Policy contains strict rules regarding drug/alcohol use
• All employees trained in hazards of drug/alcohol use on the job
• Company pre-employment and post-accident testing
• Conducts random tests
• Has employee assistance program

Score: 6
• Company has written policy
• Policy contains strict rules regarding drug/alcohol use
• All employees trained in hazards of drug/alcohol use on the job
• Company pre-employment and post-accident testing

Score: 3
• Company has policy
• Policy contains rules regarding drug/alcohol use

Score: 0
• No policy

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* Recordkeeping

Recordkeeping Criteria

Score: 9
• OSHA 300 log maintained according to OSHA requirements (if required)
• Records are kept on accident investigations, inspections, and First Aid treatment
• Records are kept on safety training orientations, hazards, and employee absences
• Post previous year’s OSHA Form 300A Summary of Work-Related Injuries and Illnesses log during month of February

Score: 6
• OSHA 300 log maintained according to OSHA requirements (if required)
• Records are kept on accident investigations, inspections, and First Aid treatment

Score: 3
• Not required to keep information for OSHA 300 log

Score: 0
• No records kept of injuries and accidents

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* Test Equipment

Test Equipment Criteria

Score: 9
• Employees required & trained in the use of test equipment (documented)
• Written test equipment policy
• Semi-annual equipment calibration per individual employees

Score: 6
• Employee required to have a tester
• Annual equipment check per individual employee

Score: 3
• Minimal test equipment used
• Employee equipment checked occasionally

Score: 0
• No test equipment

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* Fall Protection

Fall Protection Criteria

Score: 9
• Recognition of fall hazards
• Fall protection equipment provided
• Documented training in use of fall protection methods and inspection
• Documented annual re-training

Score: 6
• Fall protection equipment provided
• Training and inspection

Score: 3
• Some fall protection inspection and training

Score: 0
• No knowledge of fall protection

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* Material Handling

Material Handling Criteria

Score: 9
• Training provided to encourage proper handling of materials and tools
• Tools are recommended to minimize ergonomic injuries
• Tools are provided for workers
• Supervisors are trained in ergonomic injuries and best practices

Score: 6
• Training provided to encourage proper handling of materials and tools
• Tools are recommended to minimize ergonomic injuries

Score: 3
Training provided to encourage proper handling of materials and tools

Score: 0
• No knowledge of ergonomics

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* Automobile Accidents

Automobile Accidents Criteria

Score: 9
• Defensive driving required for companies with a fleet of one or more vehicles
• Employees who drive company vehicles are required to have good driving records
• Seat belts are required
• Company has a policy not to use mobile devices while driving

Score: 6
• Defensive driving required for companies with a fleet of one or more vehicles
• Employees who drive company vehicles are required to have good driving records
• Seat belts are required

Score: 3
• Defensive driving required for companies with a fleet of one or more vehicles

Score: 0
• Company does not provide automobile training

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* Energized Work

Energized Work Criteria

Score: 9
• Written policy with guidelines and procedures. Management has authority to approve work
• Use qualified personnel and proper equipment
• Regular testing and maintenance of equipment; training/re-training
• Use of PPE required

Score: 6
• Use qualified personnel and proper equipment
• Written policy with procedures enforced

Score: 3
• Use qualified personnel and proper equipment
• Unwritten policy exists

Score: 0
• Company does not have a working live policy

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* Confined Space

Confined Space Criteria

Score: 9
• Written policy is mandatory for all confined space work
• Pre-job training and retraining
• Utilize permit and non-permit systems for confined space work

Score: 6
• Written confined space policy
• Confined space training

Score: 3
• Identify confined space

Score: 0
• No training or inspections

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