DEPARTMENT:     

HEAD:     

AGENCY:                          

LOCATION CODE(S):     

ADDRESS:     

CITY:     

ZIP:     

PARISH:     

OTHER LOCATIONS OF THIS AGENCY:     

NUMBER OF EMPLOYEES COVERED BY AUDIT:     

DATE SELF-AUDIT COMPLETED:     

              POSITION        

PERSON

TITLE

PHONE

E-MAIL ADDRESS

Agency Head

Safety Officer

Financial Officer

Driver Coordinator

Physical Plant Director

Water Vessel Coordinator

AUDIT TYPE:

                                              SAFETY PROGRAM

AUDIT ITEM: 1

FOCUS:

Management Accountability

     Is there a written, operational safety plan modified to fit the specific needs at this

          location?

     Does it include a policy statement from the local agency manager and include

          safety responsibilities for managers, supervisors and employees?

     Are the employees notified of and trained in their safety responsibilities?

RATING:

     Excellent               The fully implemented plan is specific to the agency/Includes a policy

                                           statement from agency head/Employees have access to a copy and are

                                           trained in their responsibilities.

     Good                        Uses departments plan/Includes a policy statement from local agency

                                           agency head/Employees have access to a copy and are trained.

     Fair                         Uses ORM manual/Includes a policy statement from local agency

                                        head/Employees have access to a copy but are not trained.

     Unsatisfactory     No plan/No policy statement/No training.

COMMENTS:

AUDIT ITEM: 2

FOCUS:

Plan Content

     Does the agency have a written program to recognize, evaluate and control hazards?

     Does it include procedures to inspect and eliminate fire hazards from state owned or

         operated grounds and facilities and recommends corrective action within thirty days?

     Are Hazard Control Logs posted in the workplace?

RATING:

     Excellent                 Agency has a written program that covers all aspects of recognizing,

                                          evaluating and controlling hazards/Procedures to inspect & eliminate

                                          fire hazards/Recommend correction action/Posts all hazard control logs.

     Good                         Agency has a written program to inspect all types of hazards and has

                                          written procedures to proceed with corrective action/Most hazard control

                                          logs are posted.

     Fair                          No written program/Periodic inspections and correction of

                                         hazards/Hazard control logs are posted in some areas.

     Unsatisfactory      No written program/No action is taken to correct hazards/No hazard

                                         control logs.

COMMENTS:

AUDIT ITEM: 3

FOCUS:

Investigation & Analysis

     Is there a written accident investigation procedure that identifies causes and

          contributing factors to prevent recurrence?

     Has the immediate supervisor conducted the investigation and is it reviewed by the

          safety officer or safety committee?

     Are Job Safety Analyses developed for trends, death or change in job procedures or

          equipment?

     Are employees trained on JSA’s and are they posted in the workplace?

RATING:

     Excellent                Has written accident investigation procedures that identifies causes to 

                                         prevent recurrence/Immediate supervisor conducts investigation with

                                         review by safety officer/JSA’s have been developed as required/ 

                                         Employees are trained on them & are posted in the workplace.

     Good                        Written accident investigation procedures/Supervisor conducts

                                         investigation & reviewed by safety officer or committee/JSA’s

                                         developed as required/employees not trained/ JSA’s posted in the

                                         workplace.

      Fair                        No written procedures/Supervisor conducts investigation & reports to

                                           higher authority/JSA’s not developed as needed/ employees not

                                        trained/some JSA’s are posted.

     Unsatisfactory     No written procedures/No accidents investigated/JSA’s not

                                           developed as needed/Employees not trained/JSA’s not posted.

COMMENTS:

AUDIT ITEM: 4

FOCUS:

Training

     Are records maintained that indicate when safety meetings were held, who was

          present, who conducted the meeting and what specific subject (s) was discussed?

     Does the agency administrator attend one or more safety meetings during the year?

RATING:

     Excellent                Safety meetings held quarterly-monthly/Documentation of topic, date,

                                      and attendee signatures/Administrator attends all meetings.

     Good                        Safety meetings held quarterly-monthly/Documentation of topic, date,

                                         and attendee signatures/Administrator attends only one meeting per year.

     Fair                         Safety meetings held but not on schedule/No documentation of

                                         topic, date, or attendee signatures/Administrator does not attend any