Master Forms
Master Forms
Master forms
Table of Contents
General Recordkeeping
Single Safety Plan Review Sign-In Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiple Safety Plan Review Sign-In Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Safety Training Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Employee Orientation Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9.3
9.4
9.5
9.6
Safety and Health
Unsafe Practices Notification Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.7
Employee Safety Suggestion Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.8
Safety Meeting Attendance Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.9
OSHA’s Recordkeeping Forms
Instructions for OSHA’s Recordkeeping forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.10
OSHA Records in Our Workplace (10 or fewer employees) . . . . . . . . . . . . . . . . . . . . 9.17
OSHA Records in Our Workplace (for partially exempt industries/professions). . . . . . . 9.18
OSHA’s Form 300: Log of Work-Related Injuries and Illnesses . . . . . . . . . . . . . . . . . . 9.19
Cal/OSHA’s Form 300: Log of Work-Related Injuries and Illnesses . . . . . . . . . . . . . . . 9.21
OSHA’s Form 300A: Summary of Work-Related Injuries and Illnesses. . . . . . . . . . . . . 9.23
Cal/OSHA’s Form 300A: Summary of Work-Related Injuries and Illnesses. . . . . . . . . . 9.25
OSHA’s Form 301: Injury and Illness Incident Report . . . . . . . . . . . . . . . . . . . . . . . . . 9.27
Cal/OSHA’s Form 301: Injury and Illness Incident Report . . . . . . . . . . . . . . . . . . . . . . 9.29
Aerosol Transmissible Diseases Screening Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.31
Exposure Control
Annual BBP Training Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Employee Exposure Determination Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exposure Control Plan (ECP) Annual Documentation Form. . . . . . . . . . . . . . . . . . . . . .
Solicitation of Input of Non-Managerial Employees. . . . . . . . . . . . . . . . . . . . . . . . . . .
Evaluation Form for Safety Needle/Syringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workplace Hazard Assessment / PPE Selection and Certification Form. . . . . . . . . . . . .
Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Certification of PPE Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Housekeeping Schedule Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hepatitis B Vaccination Declination Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Letter of Receipt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
© 2010 Stericycle, Inc.
Rev.(1/10)
9.32
9.33
9.34
9.35
9.36
9.37
9.38
9.39
9.40
9.41
9.42
Master Forms
9.1
Master forms
Table of Contents
Exposure Control (continued)
BBP Exposure Incident Report Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Source Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BBP Exposure Incident Report Form
Healthcare Professional’s Written Opinion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sharps Injury Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hazard Communication
Hazardous Chemical Inventory Master List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Workplace Hazard Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Personal Protective Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Certification of PPE Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hazardous Chemical Inventory Log / Table of Contents . . . . . . . . . . . . . . . . . . . . . . . .
Weekly Eye Wash Station Inspection Checklist & Log. . . . . . . . . . . . . . . . . . . . . . . . . .
Request for Manufacturer’s Material Safety Data Sheets (MSDS). . . . . . . . . . . . . . . . .
9.43
9.44
9.45
9.46
9.48
9.49
9.50
9.51
9.52
9.53
9.55
Emergency Preparedness Plan
Emergency Action Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.56
Fire Prevention Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.57
Supplemental Workplace Concerns
Electrical Audit Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lockout/Tagout Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lockout/Tagout Audit Checklist and Certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lockout/Tagout Training Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Voluntary and Required Respiratory Use Hazard Evaluation. . . . . . . . . . . . . . . . . . . . .
Hazard Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Respirator Fit Testing Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Respiratory Training Written/Oral Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resident/Patient Handling Assessment Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accident/Incident Report Form (for injuries other than sharps related) . . . . . . . . . . . .
© 2010 Stericycle, Inc.
Rev.(1/10)
9.58
9.59
9.61
9.62
9.63
9.64
9.65
9.66
9.67
9.68
Master Forms
9.2
Safety Plan Review Sign-In Sheet
For: __________________________________
Our Plan has been reviewed by:
____________________________________________________________________________
Reviewer’s Name (print)
Title
____________________________________________________________________________
Signature of Reviewer
Date
Sign below to indicate that you have read and reviewed the plan listed above and that you have been given the
opportunity to ask questions to management to ensure a complete understanding of the employer’s plan:
Print Name
Title Signature Date
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.3
Multiple Safety Plan Review Sign-In Sheet
For: Safety and Health Plan (Injury and Illness Prevention Program), BBP Exposure Control Plan,
Hazard Communication Program, and Emergency Action Plan
(Use this form if you wish to record reviewing all four Safety Plans at once)
The four plans listed above have been reviewed by:
____________________________________________________________________________
Reviewer’s Name (print)
Title
____________________________________________________________________________
Signature of Reviewer
Date
Sign below to indicate that you have read and reviewed the plans listed above and that you have been given
the opportunity to ask questions to management to ensure a complete understanding of the employer’s plans:
Print Name
Title Signature Date
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
_________________________________________________ ____________________________
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.4
Safety Training Record
Topic
Facility Name
Complete this attendance sheet as a documented record of attendance for any safety trainings that do not have their
own separate, dedicated attendance records. All affected employees must be in attendance, if possible. This record
should be retained for a minimum of three years.
Date of Training
Person or Position Conducting Training
Qualification or Title
Employees in Attendance
Print Name
Signature Job Title
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
Signature of Person Conducting Meeting
© 2010 Stericycle, Inc.
Rev.(1/10)
Title
Date
Master Forms
9.5
Employee Orientation Guidelines
Provided below is a checklist of the most common items to be covered in the initial workplace orientation provided for most
healthcare workers. This checklist is limited to information specifically required by OSHA, CDC guidelines, or other regulatory
agencies, and does not, therefore, include information related to administrative policies, human resources matters,
workplace benefits, etc., that may also be required by an employer for new worker orientation.
Training
Many OSHA Standards have specific requirements for training that must be completed before a worker is ever placed into
service. For a full overview, see OSHA publication 2254 available at https://www.osha.gov/Publications/osha2254.pdf.
Common topics typically requiring training for healthcare workers are:
• Bloodborne Pathogens
• Hazard Communication, including:
�
Hazardous chemicals in your workplace
�
Safety Data Sheets location and use
�
Pictograms
�
Safety Data Sheet format
�
Elements required for manufacturers to use on labels
• Personal Protective Equipment
• Emergency Preparedness/Evacuation Plans
�
Fire extinguisher policy
�
Emergency Action Plan
�
Fire Prevention Plan
�
Portable Fire Extinguisher use
• Use of eyewash or drench shower
• Use of first aid kit and spill kit
• Use of engineering controls such as sharps containers, medical waste containers,
scalpel blade removers, fume hoods, etc.
• Biohazardous Waste
• DOT hazardous material training related to Biohazardous Waste
• Respiratory Protection (if applicable)
• Formaldehyde (if applicable)
• LASER training (if applicable)
• Aerosol Transmissible Diseases (if applicable; California only)
• Any other OSHA or other government agency’s required training as applicable.
© 2013 Stericycle, Inc. Rev.(9/13)
Master Forms
Written Plans/Programs
Be sure to also train affected workers in the various written Safety Plans that may be required for your workplace:
• Bloodborne Pathogens Exposure Control Plan
Be sure to cover training on :
�
Annual review and update requirements
�
Annual evaluation and implementation of safer devices
�
Annual solicitation of non-managerial input
�
Written certification of hazard assessment for selection of PPE
�
Housekeeping schedule
• Hazard Communication Program
• Emergency Preparedness Plan
• Safety and Health Plan (if applicable) (also called Injury and Illness Prevention Program in some states)
• Respiratory Protection Program (if applicable)
• Aerosol Transmissible Diseases Exposure Control Plan/Protocols (if applicable; California only)
Labor Laws
The contents of various required labor law posters should also be covered in new worker orientation:
• OSHA – Occupational Safety and Health Administration
• USERRA – Uniformed Services Employment and Reemployment Act
• Federal Minimum Wage
• Polygraph Protection
• EEOC – Equal Employment Opportunity Commission
• FMLA – Family Medical Leave Act
• NLRB – National Labor Relations Board (as applicable)
• State labor law posters (for your convenience, see websites of various poster vendors such as www.
postercompliance.com for a listing of what may be required in your State).
© 2013 Stericycle, Inc. Rev.(9/13)
Master Forms
Medical Issues
In addition to formal trainings and informing workers about any written Safety Plans/Programs and Labor Laws, be sure to
also comply with OSHA required medical immunization or surveillance/clearance issues for affected workers such as:
• Hepatitis B vaccination offered
• HBV Vaccination records or Declination form on file in employee confidential medical records
• Initial/Annual notice to employees of their right to access their own medical records (may be accomplished with a
posting on Labor Law bulletin board, etc.)
• Tuberculosis testing
• Respirator medical clearance (as applicable)
• Respirator annual fit testing (as applicable)
• Aerosol Transmissible Disease immunizations (if applicable; California only).
Signature of Person Conducting Orientation Title
Employee Signature
Date
© 2013 Stericycle, Inc. Rev.(9/13)
Master Forms
Unsafe Practices Notification Form
This form should be completed and placed in an employee’s personnel file.
_______________________________________________________________________________
Name of Employee
Date of Hire
Job Title or Assignment
Violation (give full explanation)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Date
Time
Place of Violation
Explanation of Employee
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Witness Interviewed
Was employee previously warned verbally for the violation?
Has employee had previous written warning for this violation?
Date of:
Verbal Warning
1st Written Warning
❏ Yes
❏ Yes
❏ No
❏ No
2nd Written Warning
3rd Written Warning
Recommended Action (check appropriate)
Suspension From
❏ Probation
To
❏ Suspensions
Termination date
❏ Termination
I have just read this warning and understand the rule I have violated. I also understand the General Safety Rules
of our facility.
_______________________________________________________________________________
Employee Signature
Date
_______________________________________________________________________________
Verification of Corrective Action Completed Date
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.7
Employee Safety Suggestion Form
Employees who wish to provide a safety suggestion or to report an unsafe workplace condition or practice should
do so using this form. Please give this completed form to your OSHA Coordinator for follow-up.
I am concerned about
I think this is the cause or contributing factor
My suggestion for improving safety is
Has this matter been reported to the employer?
❏ Yes ❏ No
_______________________________________________________________________________
Reviewed by
Date
_______________________________________________________________________________
Corrective Action Taken By Date
_______________________________________________________________________________
Employee Name (optional) Date
The employer will investigate any reports or questions as required by our Safety and Health Plan and will advise
the employee who submitted the safety suggestion or the workers in the area of the employer’s response.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.8
Safety Meeting Attendance Record
Facility Name
Complete this attendance sheet prior to beginning monthly or quarterly safety meetings. Keep completed sheet for
recordkeeping. This record should be retained for a minimum of three years. Attach separate sheet if additional names
are needed.
Date of Meeting
Subject(s) Discussed
Person or Position Conducting Meeting
Employees In Attendance
Print Name
Signature Job Title
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
_______________________________________________________ ____________________________
Signature of Person Conducting Meeting
© 2010 Stericycle, Inc.
Rev.(1/10)
Title
Date
Master Forms
9.9
Instructions for OSHA’s Recordkeeping forms
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An example to guide you in filling out the log properly.
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OSHA
Summary of Work-Related Injuries and Illnesses
Removable Summary pages for easy posting at the end of the year. Note that you
post the Summary only, not the log.
OSHA’s 301: Injury and Illness Incident Report
A copy of the OSHA 301 to provide details about the incident. You may make as many
copies as you need or use an equivalent form.
_____
_____
_____
_____
_______
_____
_____
_____
_____
_____
Log of Work-Related Injuries and Illnesses
Several pages of the log (but you may make as many copies of the log as you need.)
Notice that the log is separate from the summary.
Worksheet to Help You Fill Out the Summary
A worksheet for figuring the average number of employees who worked for your
establishment and the total number of hours worked.
_____
_____
_____
_____
_____
____
_____
_____
_____
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____
_____
_____
_____
_____
____
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_____
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An Overview: Recording Work-Related Injuries and Illnesses
General instructions for filling out the forms in this package and definitions
of terms you should use when you classify your cases as injuries or illnesses.
Depa
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Forms for Recording Work-Related Injuries and Illnesses
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Recording Work-Related Injuries and Illnesses
The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to prepare and maintain records of work-related injuries and illnesses. Use these
definitions when you classify cases on the Log. OSHA’s recordkeeping regulation (see 29 CFR Part 1904) provides more information about the definitions below.
The Log of Work-Related Injuries and Illnesses (Form 300) is used to classify work-related injuries and illnesses and to note
the extent and severity of each case. When an incident occurs, use the log to record specific details about what happened
and how it happened. The Summary — a separate form (Form 300A) — shows the totals for the year in each category.
At the end of the year, post the Summary in a visible location so that your employees are aware of the injuries and illnesses
occurring in their workplace.
Employers must keep a Log for each establishment or site. If you have more than one establishment, you must keep a
separate Log and Summary for each physical location that is expected to be in operation for one year or longer.
Note that your employees have the right to review your injury and illness records.
Cases listed on the Log of Work-Related Injuries and Illnesses are not necessarily eligible for workers’ compensation or
other insurance benefits. Listing a case on the Log does not mean that the employer or worker was at fault or that an
OSHA Standard was violated.
When is any injury or illness considered work-related? An injury or illness is considered work-related if an event or exposure
in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the workplace, unless an exception
specifically applies. The work environment includes the establishment and other locations where one or more employees are
working or are present as a condition of their employment.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.10
Which work-related injuries and illnesses should you record?
Record those work-related injuries and illnesses that result in:
•
•
•
•
•
death,
loss of consciousness,
days away from work,
restricted work activity or job transfer, or
medical treatment beyond first aid.
You must also record work-related injuries and illnesses that are significant
(as defined below) or meet any of the additional criteria listed below.
You must record any significant work-related injury or illness that is
diagnosed by a physician or other licensed healthcare professional. You must
record any work-related case involving cancer, chronic irreversible disease,
a fractured or cracked bone, or a punctured eardrum.
What are the additional criteria?
You must record the following conditions when they are work-related:
• any needlestick injury or cut from a sharp object that is
contaminated with another person’s blood or other potentially
infectious material;
• any case requiring an employee to be medically removed under
the requirements of an OSHA health Standard;
• tuberculosis infection as evidenced by a positive skin test or
diagnosis by a physician or other licensed healthcare professional
after exposure to a known case of active tuberculosis.
• an employee’s hearing test (audiogram) reveals 1) that the
employee has experienced a Standard Threshold Shift (STS) in
hearing in one or both ears (averaged at 2000, 3000, and 4000 Hz)
and 2) the employee’s total hearing level is 25 decibels (dB)
or more above audiometric zero (also averaged at 2000, 3000,
and 4000 Hz) in the same ear(s) as the STS.
What do you need to do?
1. Within 7 calendar days after you receive
information about a case, decide if the
case is recordable under the OSHA
recordkeeping requirements.
2. Determine whether the incident is a new
case or a recurrence of an existing one.
3. Establish whether the case was work-related.
4. If the case is recordable, decide which form
you will fill out as the injury and illness
incident report.
You may use OSHA’s 301: Injury and Illness
Incident Report or an equivalent form. Some state
workers compensation, insurance, or other reports
may be acceptable substitutes, as long as they
provide the same information as the OSHA 301.
How to work with the Log
1. Identify the employee involved, unless it is
a privacy concern case.
2. Identify when and where the case occurred.
3. Describe the case, as specifically as you can.
4. Classify the seriousness of the case by
recording the most serious outcome associated
with the case, with column G (Death)
being the most serious and column J (Other
recordable cases) being the least serious.
5. Identify whether the case is an injury or
illness. If the case is an injury, check the
injury category. If the case is an illness,
check the appropriate illness category.
What is medical treatment?
Medical treatment includes managing and caring for a patient for the purpose of combating disease or disorder. The
following are not considered medical treatments and are NOT recordable:
• visits to a doctor or healthcare professional solely for observation or counseling;
• diagnostic procedures, including administering prescription medications that are used solely for diagnostic purposes;
• and any procedure that can be labeled first aid. (See below for more information about first aid.)
What is first aid?
If the incident required only the following types of treatment, consider it first aid. Do NOT record the case if it involves only:
•
•
•
•
•
using non-prescription medications at non-prescription strength;
administering tetanus immunizations;
cleaning, flushing, or soaking wounds on the skin surface;
using wound coverings, such as bandages, BandAids™, gauze pads, etc., or using SteriStrips™ or butterfly bandages.
using hot or cold therapy;
9.11 Master Forms
© 2010 Stericycle, Inc.
Rev.(1/10)
• using any totally non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc.;
• using temporary immobilization devices while transporting an accident victim (splints, slings, neck collars, or
back boards);
• drilling a fingernail or toenail to relieve pressure, or draining fluids from blisters;
• using eye patches;
• using simple irrigation or a cotton swab to remove foreign bodies not embedded in or adhered to the eye;
• using irrigation, tweezers, cotton swab, or other simple means to remove splinters or foreign material from
areas other than the eye;
• using finger guards;
• using massages;
• drinking fluids to relieve heat stress.
How do you decide if the case involved restricted work?
Restricted work activity occurs when, as the result of a work-related injury or illness, an employer or healthcare
professional keeps, or recommends keeping, an employee from doing the routine functions of his or her job or from
working the full workday that the employee would have been scheduled to work before the injury or illness occurred.
How do you count the number of days of restricted work activity or the number of days away from work?
Count the number of calendar days the employee was on restricted work activity or was away from work as a result
of the recordable injury or illness. Do not count the day on which the injury or illness occurred in this number. Begin
counting days from the day after the incident occurs. If a single injury or illness involved both days away from work
and days of restricted work activity, enter the total number of days for each. You may stop counting days of restricted
work activity or days away from work once the total of either or the combination of both reaches 180 days.
Under what circumstances should you NOT enter the employee’s name on the OSHA Form 300?
You must consider the following types of injuries or illnesses to be privacy concern cases:
•
•
•
•
•
an injury or illness to an intimate body part or to the reproductive system,
an injury or illness resulting from a sexual assault,
a mental illness,
a case of HIV infection, hepatitis, or tuberculosis,
a needlestick injury or cut from a sharp object that is contaminated with blood or other potentially
infectious material, and
• other illnesses, if the employee independently and voluntarily requests that his or her name not be
entered on the log.
You must not enter the employee’s name on the OSHA 300 Log for these cases. Instead, enter “privacy case” in
the space normally used for the employee’s name. You must keep a separate, confidential list of the case numbers
and employee names for the establishment’s privacy concern cases so that you can update the cases and provide
information to the government if asked to do so.
If you have a reasonable basis to believe that information describing the privacy concern case may be personally
identifiable even though the employee’s name has been omitted, you may use discretion in describing the injury or
illness on both the OSHA 300 and 301 forms. You must enter enough information to identify the cause of the incident
and the general severity of the injury or illness, but you do not need to include details of an intimate or private nature.
What if the outcome changes after you record the case?
If the outcome or extent of an injury or illness changes after you have recorded the case, simply draw a line through
the original entry or, if you wish, delete or white-out the original entry. Then write the new entry where it belongs.
Remember, you need to record the most serious outcome for each case.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
i
9.12
Classifying injuries
An injury is any wound or damage to the body resulting from an event in the work environment.
Examples: Cut, puncture, laceration, abrasion, fracture, bruise, contusion, chipped tooth, amputation, insect bite,
electrocution, or a thermal, chemical, electrical, or radiation burn. Sprain and strain injuries to muscles, joints,
and connective tissues are classified as injuries when they result from a slip, trip, fall or other similar accidents.
Classifying illnesses
Skin diseases or disorders
Skin diseases or disorders are illnesses involving the worker’s skin that are caused by work exposure to chemicals,
plants, or other substances.
Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants,
oil acne, friction blisters, chrome ulcers, inflammation of the skin.
Respiratory conditions
Respiratory conditions are illnesses associated with breathing hazardous biological agents, chemicals, dusts, gases,
vapors, or fumes at work.
Examples: Silicosis, asbestosis, pneumonitis, pharyngitis, rhinitis or acute congestion, farmer’s lung, beryllium disease,
tuberculosis, occupational asthma, reactive airways dysfunction syndrome (RADS), chronic obstructive pulmonary
disease (COPD), hypersensitivity pneumonitis, toxic inhalation injury, such as metal fume fever, chronic obstructive
bronchitis, and other pneumoconioses.
Poisoning
Poisoning includes disorders evidenced by abnormal concentrations of toxic substances in blood, other tissues,
other bodily fluids, or the breath that are caused by the ingestion or absorption of toxic substances into the body.
Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals, poisoning by carbon monoxide, hydrogen
sulfide, or other gases, poisoning by benzene, benzol, carbon tetrachloride, or other organic solvents, poisoning by
insecticide sprays, such as parathion or lead arsenate, poisoning by other chemicals, such as formaldehyde.
Hearing Loss
Noise-induced hearing loss is defined for recordkeeping purposes as a change in hearing threshold relative to the
baseline audiogram of an average of 10 dB or more in either ear at 2000, 3000 and 4000 hertz, and the employee’s
total hearing level is 25 decibels (dB) or more above audiometric zero (also averaged at 2000, 3000, and 4000 hertz)
in the same ear(s).
All other illnesses
All other occupational illnesses.
Examples: Heatstroke, sunstroke, heat exhaustion, heat stress and other effects of environmental heat, freezing, frostbite,
and other effects of exposure to low temperatures, decompression sickness, effects of ionizing radiation (isotopes, x-rays,
radium), effects of nonionizing radiation (welding flash, ultra-violet rays, lasers), anthrax, bloodborne pathogenic diseases,
such as AIDS, HIV, hepatitis B or hepatitis C, brucellosis, malignant or benign tumors, histoplasmosis, coccidioidomycosis.
When must you post the Summary?
You must certify and post the Summary only — not the Log — by February 1 of the year following the year covered
by the form, and keep it posted until April 30 of that year.
How long must you keep the Log and Summary on file?
You must keep the Log and Summary for 5 years following the year to which they pertain.
Do you have to send these forms to OSHA at the end of the year?
No. You do not have to send the completed forms to OSHA unless specifically asked to do so.
9.13 Master Forms
© 2010 Stericycle, Inc.
Rev.(1/10)
Calculating Injury and Illness Incidence Rates
What is an incidence rate?
An incidence rate is the number of recordable injuries and illnesses occurring among a given number of full-time workers
Calculating
Injury
Rates
(usually 100 full-time workers)
overand
a givenIllness
period of timeIncidence
(usually one year). To
evaluate your firm’s injury and illness
experience over time or to compare your firm’s experience with that of your industry as a whole, you need to compute your
What is an incidence rate?
on the OSHA Form 300A.
various classifications (e.g., by industry, by
Because
a specific (H)
number
of ofworkers
andactually
a specific period
are
(c) The number
hours all employees
employerof
size,time
etc.). You
can involved,
obtain these these rates can help you
Anincidence
incidence rate israte.
the number
of recordable
worked during the year. Refer to OSHA Form
published data at www.bls.gov/iif or by calling a
injuries and illnesses occurring among a given
identify problems in your workplace
and/or progress you may have made
in preventing work-related injuries and illnesses.
300A and optional worksheet to calculate this
BLS Regional Office.
number of full-time workers (usually 100 fullOptional
U.S. Department of Labor
Occupational Safety and Health Administration
time workers) over a given period of time
(usually one year). To evaluate your firm’s
injury and illness experience over time or to
compare your firm’s experience with that of
your industry as a whole, you need to compute
your incidence rate. Because a specific number
of workers and a specific period of time are
involved, these rates can help you identify
problems in your workplace and/or progress
you may have made in preventing workrelated injuries and illnesses.
number.
You can compute the incidence rate for all
How do you calculate an incidence
rate?
recordable cases
of injuries and illnesses using
following formula:
You can compute an occupationaltheinjury
and illness incidence
Total number of injuries and illnesses 200,000 ÷
rate for all recordable cases or forNumber
casesof hours
thatworked
involved
days
away
by all employees
= Total
recordable case rate
from work for your firm quickly and
easily. The formula requires
(The 200,000 figure in the formula represents
the number of
100 employees
working
that you follow instructions in paragraph
(a)hours
below
for the
total
40 hours per week, 50 weeks per year would
recordable cases or those in paragraph
(b)
for
cases
that
involved
work, and provides the standard base for
incidence rates.)
How do you calculate an incidence
days away from work, and for bothcalculating
rates
the instructions
You can compute
the incidence ratein
for
rate?
recordable cases involving days away from
You can compute an occupational injury and
paragraph
(c).
work, days of restricted work activity or job
illness incidence rate for all recordable cases or
for cases that involved days away from work for
your firm quickly and easily. The formula
requires that you follow instructions in
paragraph (a) below for the total recordable
cases or those in paragraph (b) for cases that
involved days away from work, and for both
rates the instructions in paragraph (c).
(a) To find out the total number of recordable
injuries and illnesses that occurred during the year,
count the number of line entries on your
OSHA Form 300, or refer to the OSHA Form
300A and sum the entries for columns (G), (H),
(I), and (J).
(b) To find out the number of injuries and
illnesses that involved days away from work, count
the number of line entries on your OSHA
Form 300 that received a check mark in
column (H), or refer to the entry for column
X
Worksheet
Number of
hours worked
by all employees
Total number of
injuries and illnesses
X 200,000
Total recordable
case rate
=
transfer (DART) using the following formula:
of entries in column
H + Number
(a) To find out the total number of(Number
recordable
injuries
and of
entries in column I) 200,000 ÷ Number of hours
illnesses that occurred during the worked
year,bycount
the
number
all employees
= DART
incidence of
rate line
can useto
the same
formula
to calculate
entries on your OSHA Form 300, orYou
refer
the
OSHA
Form
300A
incidence rates for other variables such as cases
involving
work (J).
activity (column (I)
and sum the entries for columns (G),
(H),restricted
(I), and
X
Number of
hours worked
by all employees
Number of entries in
Column H + Column I
on Form 300A), cases involving skin disorders
(column (M-2) on Form 300A), etc. Just
substitute the appropriate total for these cases,
from Form 300A, into the formula in place of
the total number of injuries and illnesses.
X 200,000
DART incidence
rate
=
(b) To find out the number of injuries and illnesses that involved
days away from work, count the number of line entries on your
OSHA Form 300 that received a check
mark
in column
(H), or
What can
I compare
my incidence
rate to?
refer to the entry for column (H) on
the
OSHA
Form
300A.
The Bureau of Labor Statistics (BLS) conducts
a survey of occupational injuries and illnesses
each year and publishes incidence rate data by
(c) The number of hours all employees actually worked during the
year. Refer to OSHA Form 300A and optional worksheet to calculate this number.
You can compute the incidence rate for all recordable cases of injuries and illnesses using the
following formula:
Total number of injuries and illnesses x 200,000 ÷ Number of hours worked by all employees = Total recordable case rate.
(The 200,000 figure in the formula represents the number of hours 100 employees working 40 hours per week, 50 weeks
per year would work, and provides the standard base for calculating incidence rates.)
You can compute the incidence rate for recordable cases involving days away from work, days of restricted work activity
or job transfer (DART) using the following formula:
(Number of entries in column H + Number of entries in column I) x 200,000 ÷ Number of hours worked by all employees
= DART incidence rate
You can use the same formula to calculate incidence rates for other variables such as cases involving restricted work activity
(column (I) on Form 300A), cases involving skin disorders (column (M-2) on Form 300A), etc. Just substitute the appropriate
total for these cases, from Form 300A, into the formula in place of the total number of injuries and illnesses.
What can I compare my incidence rate to?
The Bureau of Labor Statistics (BLS) conducts a survey of occupational injuries and illnesses each year and publishes
incidence rate data by various classifications (e.g., by industry, by employer size, etc.). You can obtain these published
data at www.bls.gov/iif or by calling a BLS Regional Office.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.14
How to Fill Out the Log
The Log of Work-Related Injuries and Illnesses is used to classify work-related injuries and illnesses and to note
the extent and severity of each case. When an incident occurs, use the Log to record specific details about what
happened and how it happened.
If your company has more than one establishment or site, you must keep separate records for each physical
location that is expected to remain in operation for one year or longer.
We have given you several copies of the Log in this package. If you need more than we provided, you may
photocopy and use as many as you need.
The Summary — a separate form — shows the work-related injury and illness totals for the year in each category.
At the end of the year, count the number of incidents in each category, and transfer the totals from the Log to the
Summary. Then post the Summary in a visible location so that your employees are aware of injuries and illnesses
occurring in their workplace.
You don’t post the Log. You post only the Summary at the end of the year.
How to Fill Out the Log
U.S. Department of Labor
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,
days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health
care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this
form. If you’re not sure whether a case is recordable, call your local OSHA office for help.
Describe injury or illness, parts of body affected,
and object/substance that directly injured
or made person ill
CHECK ONLY ONE box for each case
based on the most serious outcome for
that case:
Remained at Work
Death
(G)
You don’t post the Log. You post only
the Summary at the end of the year.
9.15 Master Forms
(F)
Be as specific as possible. You
can use two lines if you need
more room.
Days away Job transfer
from work or restriction
(H)
(I)
Other recordable cases
(J)
MA
Enter the number of
days the injured or
ill worker was:
Away
from
work
(K)
On job
transfer or
restriction
(L)
Check the “Injury” column or
choose one type of illness:
(M)
(1)
(2)
(3)
Poisoning
(E)
Hearing loss
(D)
All other
illnesses
(C)
Injury
(B)
Skin disorders
(A)
Form approved OMB no. 1218-0176
XYZ Company
Anywhere
Respiratory
conditions
If your company has more than one
establishment or site, you must keep
separate records for each physical location
that is expected to remain in operation for
one year or longer.
We have given you several copies of the
Log in this package. If you need more than
we provided, you may photocopy and use as
many as you need.
The Summary — a separate form —
shows the work-related injury and illness
totals for the year in each category. At the
end of the year, count the number of
incidents in each category and transfer the
totals from the Log to the Summary. Then
post the Summary in a visible location so that
your employees are aware of injuries and
illnesses occurring in their workplace.
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
(Rev. 01/2004)
R
(4)
(5)
(6)
}
Occupational Safety and Health Administration
The Log of Work-Related Injuries and Illnesses is
used to classify work-related injuries and
illnesses and to note the extent and severity
of each case. When an incident occurs, use
the Log to record specific details about what
happened and how it happened.
Revise the log if the injury or illness
progresses and the outcome is more
serious than you originally recorded for
the case. Cross out, erase, or white-out
the original entry.
Choose ONLY ONE of these
categories. Classify the case
by recording the most
serious outcome of the case,
with column G (Death) being
the most serious and column
J (Other recordable cases)
being the least serious.
Note whether the
case involves an
injury or an illness.
© 2010 Stericycle, Inc.
Rev.(1/10)
Worksheet to Help You Fill Out the Summary
At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your
employees on the summary. If you don’t have these figures, you can use the information on this page to estimate the
numbers you will need to enter on the Summary page at the end of the year.
Optional
Worksheet to Help You Fill Out the Summary
At the end of the year, OSHA requires you to enter the average number of employees and the total hours worked by your employees on the summary. If you don’t have these figures, you can use the
information on this page to estimate the numbers you will need to enter on the Summary page at the end of the year.
How to figure the total hours worked by all employees:
How to figure the average number of employees
who worked for your establishment during the
year:
U.S. Department of Labor
Occupational Safety and Health Administration
© 2010 Stericycle, Inc.
establishment paid in all pay periods during the
year. Include all employees: full-time, part-time,
temporary, seasonal, salaried, and hourly.
The number of employees
paid in all pay periods =
Count the number of pay periods your
establishment had during the year. Be sure to
include any pay periods when you had no
employees.
The number of pay
periods during the year =
Divide the number of employees by the number of
pay periods.
Round the answer to the next highest whole
Rev.(1/10)
Include hours worked by salaried, hourly, part-time and seasonal workers, as
well as hours worked by other workers subject to day to day supervision by
your establishment (e.g., temporary help services workers).
Do not include vacation, sick leave, holidays, or any other non-work time,
even if employees were paid for it. If your establishment keeps records of only
the hours paid or if you have employees who are not paid by the hour, please
estimate the hours that the employees actually worked.
If this number isn’t available, you can use this optional worksheet to
estimate it.
Add the total number of employees your
Optional Worksheet
Find the number of full-time employees in your
establishment for the year.
=
x
number. Write the rounded number in the blank
marked Annual average number of employees.
This is the number of full-time hours worked.
+
For example, Acme Construction figured its average employment this way:
For pay period…
1
2
3
4
5
▼
24
25
26
Acme paid this number of employees…
10
0
15
30
40
▼
20
15
+10
830
Multiply by the number of work hours for a full-time
employee in a year.
The number rounded =
Number of employees paid = 830
Number of pay periods = 26
830 = 31.92
26
31.92 rounds to 32
Add the number of any overtime hours as well as the
hours worked by other employees (part-time,
temporary, seasonal)
Round the answer to the next highest whole number.
Write the rounded number in the blank marked Total
hours worked by all employees last year.
32 is the annual average number of employees
Master Forms
9.16
OSHA Records in Our Workplace
(workplace of 10 or fewer employees)
OSHA Recordkeeping Administrator
Contact Information
is responsible for maintaining our OSHA recordkeeping.
Since we employ ten or fewer employees, our facility is exempt from the requirement to maintain
OSHA Injury and Illness Recordkeeping. The Occupational Safety and Health Administration does
not require us to record workplace injuries or illness on the OSHA 300 series of logs.
We are committed to workplace safety and health, and we will maintain files on accident reports
and investigations in addition to employee training records.
For workplaces not located in California with ten or fewer employees, this completes your Safety
and Health Plan/Injury and Illness Prevention Program. Please proceed to the next safety plan.
For workplaces located in California with ten or fewer employees, please proceed to page 3.1-3.89
for information concerning the California Aerosol Transmissible Diseases Standards requirements.
For workplaces with 11 or more employees, please continue on the next page.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.17
OSHA Records in Our Workplace
(for partially exempt industries/professions)
OSHA Recordkeeping Administrator
Contact Information
is responsible for maintaining our OSHA recordkeeping.
Since our type of workplace industry/profession appears on the Partially Exempt list, and our
workplace is not in HI, MN, WA, and PR, we are exempt from the requirement to maintain OSHA
Injury and Illness Recordkeeping. The Occupational Safety and Health Administration does not require
us to record workplace injuries or illness on the OSHA 300 series of logs.
We are committed to workplace safety and health and we will maintain files on accident reports
and investigations, in addition to employee training records.
For non-California workplaces in industries/professions appearing on the Partially Exempt list
(except for the exceptions noted for HI, MN, WA and PR), this completes your Safety and Health
Plan/Injury and Illness Prevention Program. Please proceed to the next safety plan. For California
workplaces, please proceed to page 3.1-3.89 for information concerning the California Aerosol
Transmissible Diseases Standard.
If your workplace employs more than ten employees and your type of industry/profession does not
appear on the Partially Exempt list, then your workplace is not exempted and is required to maintain
the OSHA 300 series of logs. Please continue to the next page for information on the required
recordkeeping, and then, if your workplace is located in California, proceed to page 3.1-3.89 for
information on the California Aerosol Diseases Standard.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.18
OSHA’s Form 300:
Log of Work-Related Injuries and Illnesses
*Please note 1904.29(b)(6)-(9) mandates that certain injuries and illnesses are considered privacy
concern cases. Injuries and illnesses involving intimate body parts or the reproductive system,
resulting from a sexual assault, mental illnesses, HIV infection, Hepatitis or tuberculosis, needlestick
injuries and cuts from sharp objects contaminated with blood or other potentially infectious material
and other illnesses that an employee independently requests be left off the log. In such a case you
must enter “privacy case” in the space for the employee name and keep a separate confidential list
of the case numbers and names. Please see regulations for additional details.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.19
OSHA’s Form 300 (Rev. 01/2004)
Log of Work-Related Injuries and Illnesses
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
(H)
(I)
(J)
(K)
(L)
_____
________________________
____________ __
____/___
_______
__________________
____
___________________
_______________________________
_
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
________________________________
__________________
_
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_______________
____
______________________
____________________________
_
■
❑
■
❑
■
❑
■
❑
____ days ____ days
month/day
month/day
_____
________________________
____________ __
____/___
_______
month/day
_____
________________________
____________ __
____/___
_______
_______________
____
______________________
____________________________
_
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
___________________
_______________________________
_
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
month/day
month/day
_____
________________________
____________ __
____/___
_______
month/day
_____
________________________
____________ __
____/___
_______
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
___________________
_______________________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
month/day
month/day
month/day
month/day
month/day
_____
________________________
____________ __
____/___
_______
_______________
____
______________________________
____________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
_____
________________________
____________ __
____/___
_______
__________________
____
___________________
_______________________________
__
■
❑
■
❑
■
❑
■
❑
____ days ____ days
month/day
month/day
(1)
(2)
(3)
(1)
(2)
(3)
All other
illnesses
(G)
(4)
(5)
(6)
All other
illnesses
Other recordable cases
On job
transfer or
restriction
Hearing loss
Days away Job transfer
from work or restriction
(M)
Away
from
work
Hearing loss
Death
Check the “Injury” column or
choose one type of illness:
Poisoning
Remained at Work
Enter the number of
days the injured or
ill worker was:
Poisoning
CHECK ONLY ONE box for each case
based on the most serious outcome for
that case:
Respiratory
condition
(F)
Describe injury or illness, parts of body affected,
and object/substance that directly injured
or made person ill (e.g., Second degree burns on
right forearm from acetylene torch)
Respiratory
condition
(E)
Where the event occurred
(e.g., Loading dock north end)
Skin disorder
(D)
Date of injury
or onset
of illness
Classify the case
Skin disorder
(C)
Job title
(e.g., Welder)
City ________________________________ State ___________________
Injury
(B)
Employee’s name
Establishment name ___________________________________________
Injury
(A)
Case
no.
Describe the case
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer,
days away from work, or medical treatment beyond first aid. You must also record significant work-related injuries and illnesses that are diagnosed by a physician or licensed health
care professional. You must also record work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12. Feel free to
use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (OSHA Form 301) or equivalent form for each injury or illness recorded on this
form. If you’re not sure whether a case is recordable, call your local OSHA office for help.
Identify the person
Year 20__ __
(4)
(5)
Page totals
Be sure to transfer these totals to the Summary page (Form 300A) before you post it.
Public reporting burden for this collection of information is estimated to average 14 minutes per response, including time to review
the instructions, search and gather the data needed, and complete and review the collection of information. Persons are not required
to respond to the collection of information unless it displays a currently valid OMB control number. If you have any comments
about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical
Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, DC 20210. Do not send the completed forms to this office.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
Page ____ of ____
9.20
(6)
Cal/OSHA’s Form 300:
Log of Work-Related Injuries and Illnesses
*Please Note that OSHA mandates that certain injuries and illnesses are considered privacy concern
cases. Injuries and illnesses involving intimate body parts or the reproductive system, resulting from
a sexual assault, mental illnesses, HIV infection, Hepatitis or tuberculosis, needlestick injuries and
cuts from sharp objects contaminated with blood or other potentially infectious material and other
illnesses that an employee independently requests be left off the log. In such a case you must enter
“privacy case” in the space for the employee name and keep a separate confidential list of the case
numbers and names. Please see regulations for additional details.
i
California OSHA 300 Series forms may be downloaded at:
http://www.dir.ca.gov/dosh/PubOrder.asp
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.21
Attention: This form contains information relating to employee health and must be
used in a manner that protects the confidentiality of employees to the extent
possible while the information is being used for occupational safety and health
programs. See CCR Title 8 14300.29(b)(6)-(10)
Cal/OSHA Form 300 (Rev. 7/2007)
Log of Work-Related Injuries and Illnesses
You must record information about every work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first
aid. You must also record significant work- related injuries and illnesses that are diagnosed by a physician or licensed health care professional. You must also record work-related injuries and illnesses that meet any of the specific
recording criteria listed in CCR Title 8 Section 14300.8 through 14300.12. Feel free to use two lines for a single case if you need to. You must complete an Injury and Illness Incident Report (Cal/ OSHA Form 301) or equivalent form for
each injury or illness recorded on this form. If you’re not sure whether a case is recordable, call your local Cal/ OSHA office for help.
Identify the person
(E)
(F)
Enter the number of
days the injured or ill
worker was:
Check the "injury" column or
choose one type of illness
(M)
(2)
(3)
(4)
(5)
(6)
days
days
1
days
days
2
days
days
3
days
days
4
days
days
5
days
days
6
days
days
7
days
days
8
days
days
9
days
days
10
days
days
11
days
days
12
days
days
13
d
days
days
d
14
days
days
15
days
days
0
0
0
0
0
0
Employee's Name
NOTE: If additional pages are required, copy Page Totals to the top (row 15) of the next page.
Page Totals
0
(H)
0
(I)
0
(J)
0
(K)
0
days
0
days
Be sure to transfer these totals to the Summary page
(Form 300A) before you post it.
Page
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.22
1 of 1
(1)
Skin
Disorder
Repiratory
Condition
Case #
(G)
(2)
(3)
(4)
Hearing
loss
All other
illnesses
(1)
Where the event occurred
(e.g. Loading dock north end)
Describe injury or illness, parts of body affected,
and object/substance that directly injured or made
person ill. (e.g. Second degree burns on right forearm
from acetylene torch)
Poisoning
(L)
Job Title
(e.g. welder)
Date of injury or
onset of illness
(month/day)
Skin
Disorder
Repiratory
condition
On the job
transfer or
restriction
Injury
Remained at work
Job transfer
Other
Days away
recordable Away from
or
Death from work restriction
work
cases
All other
illnesses
(D)
Classify the case
Using these four categories, check ONLY
the most serious result for each case:
Hearing
loss
(C)
City/State
Establishment name
Poisoning
(B)
Year:
Injury
(A)
Describe the case
1 0
(5)
(6)
OSHA’s Form 300A:
Summary of Work-Related Injuries and Illnesses
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.23
OSHA’s Form 300A (Rev. 01/2004)
Year 20__ __
Summary of Work-Related Injuries and Illnesses
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
All establishments covered by Part 1904 must complete this Summary page, even if no work-related injuries or illnesses occurred during the year. Remember to review the Log
to verify that the entries are complete and accurate before completing this summary.
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you’ve added the entries from every page of the Log. If you
had no cases, write “0.”
Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access to the OSHA Form 301 or
its equivalent. See 29 CFR Part 1904.35, in OSHA’s recordkeeping rule, for further details on the access provisions for these forms.
Establishment information
Your establishment name
__________________________________________
Street
_____________________________________________________
City
____________________________ State ______ ZIP _________
Number of Cases
Total number of
deaths
__________________
Total number of
cases with days
away from work
Total number of
cases with job
transfer or restriction
Total number of
other recordable
cases
__________________
__________________
__________________
(G)
(H)
(I)
Industry description (e.g., Manufacture of motor truck trailers)
_______________________________________________________
Standard Industrial Classification (SIC), if known (e.g., 3715)
____ ____ ____ ____
OR
(J)
North American Industrial Classification (NAICS), if known (e.g., 336212)
Number of Days
____ ____ ____ ____ ____ ____
Total number of days away
from work
Total number of days of job
transfer or restriction
___________
___________
(K)
(L)
Employment information (If you don’t have these figures, see the
Worksheet on the back of this page to estimate.)
Injury and Illness Types
Annual average number of employees
______________
Total hours worked by all employees last year
______________
Sign here
Knowingly falsifying this document may result in a fine.
Total number of . . .
(M)
(1)
Injuries
______
(2)
Skin disorders
______
(3)
Respiratory conditions
______
(4)
Poisonings
______
(5)
Hearing loss
______
(6)
All other illnesses
______
I certify that I have examined this document and that to the best of my
knowledge the entries are true, accurate, and complete.
___________________________________________________________
Company executive
Title
(
)
/ /
___________________________________________________________
Post this Summary page from February 1 to April 30 of the year following the year covered by the form.
Public reporting burden for this collection of information is estimated to average 58 minutes per response, including time to review the instructions, search and gather the data needed, and
complete and review the collection of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. If you have any
comments about these estimates or any other aspects of this data collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.24
Phone
Date
Cal/OSHA’s Form 300A:
Summary of Work-Related Injuries and Illnesses
i
California OSHA 300 Series forms may be downloaded at:
http://www.dir.ca.gov/dosh/PubOrder.asp
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.25
Cal/OSHA Form 300A (Rev. 7/2007)
Summary of Work-Related Injuries and Illnesses
Year:
All establishments covered by CCR Title 8 Section 14300 must complete this Annual Summary, even if no
work-related injuries or illnesses occurred during the year. Remember to review the Log to verify that the
entries are complete and accurate before completing this summary.
Using the Log, count the individual entries you made for each category. Then write the totals below, making sure
you’ve added the entries from every page of the Log. If you had no cases, write “0.”Employees, former employees,
and their representatives have the right to review the Cal/ OSHA Form 300 in its entirety. They also have limited
access to the Cal/ OSHA Form 301 or its equivalent. See CCR Title 8 Section 14300.35, in Cal/ OSHA’s
recordkeeping rule, for further details on the access provisions for these forms.
Facility Information
Number of Cases
Industry description:
Total number of deaths
(G)
Total number of
cases with days
away from work
(H)
Total number of cases
with job transfer or
restriction
Total number of
other recordable
cases
(I)
(J)
Establishment name:
Street
City
State
ZIP
Standard Industrial Classification (SIC)
Iff known (e.g.,
SIC
3715)
(
S
C3
1 )
Employment Information
Number of Days
Total number of days away
from work
(If you don't have these figures, use the optional Worksheet to estimate)
Total number of days of
job transfer or restriction
Annual average number of employees
Total hours worked by all employees last year
(K)
(L)
Sign here
Injury and Illness Types
Knowingly falsifying this document may result in a fine.
Total number of…
(M)
I certify that I have examined this document and that to the best of my knowledge the
entries are true, accurate, and complete.
(1) Injuries
(4) Poisonings
Company executive
(2) Skin Disorders
(5) Hearing loss
(
Phone
(3) Respiratory Conditions
(6) All other illnesses
Post this Annual Summary from February 1 to April 30 of the year following the year covered by the form.
© 2010 Stericycle, Inc.
Rev.(1/10)
Title
Master Forms
9.26
)
Date
OSHA’s Form 301:
Injury and Illness Incident Report
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.27
OSHA’s Form 301
Injury and Illness Incident Report
Attention: This form contains information relating to
employee health and must be used in a manner that
protects the confidentiality of employees to the extent
possible while the information is being used for
occupational safety and health purposes.
U.S. Department of Labor
Occupational Safety and Health Administration
Form approved OMB no. 1218-0176
Information about the employee
This Injury and Illness Incident Report is one of the
first forms you must fill out when a recordable workrelated injury or illness has occurred. Together with
the Log of Work-Related Injuries and Illnesses and the
accompanying Summary, these forms help the
employer and OSHA develop a picture of the extent
and severity of work-related incidents.
Within 7 calendar days after you receive
information that a recordable work-related injury or
illness has occurred, you must fill out this form or an
equivalent. Some state workers’ compensation,
insurance, or other reports may be acceptable
substitutes. To be considered an equivalent form,
any substitute must contain all the information
asked for on this form.
According to Public Law 91-596 and 29 CFR
1904, OSHA’s recordkeeping rule, you must keep
this form on file for 5 years following the year to
which it pertains.
If you need additional copies of this form, you
may photocopy and use as many as you need.
1) Full name _____________________________________________________________
2) Street ________________________________________________________________
City ______________________________________ State _________ ZIP ___________
3) Date of birth ______ / _____ / ______
_____________________ (Transfer the case number from the Log after you record the case.)
11) Date of injury or illness
______ / _____ / ______
12) Time employee began work ____________________ AM / PM
13) Time of event
____________________ AM / PM
Check if time cannot be determined
tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while
carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.”
Male
Female
Information about the physician or other health care
professional
6)
10) Case number from the Log
14) What was the employee doing just before the incident occurred? Describe the activity, as well as the
4) Date hired ______ / _____ / ______
5)
Information about the case
15) What happened? Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, worker
fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker
developed soreness in wrist over time.”
Name of physician or other health care professional __________________________
________________________________________________________________________
7) If treatment was given away from the worksite, where was it given?
Facility _________________________________________________________________
16) What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be
more specific than “hurt,” “pain,” or sore.” Examples: “strained back”; “chemical burn, hand”; “carpal
tunnel syndrome.”
_______________________________________________________________
Street
City ______________________________________ State _________ ZIP ___________
8)
Completed by _______________________________________________________
Title _________________________________________________________________
Phone (________)_________--_____________
Date
_____/ _____
_
/ _____
17) What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”;
Was employee treated in an emergency room?
9)
“radial arm saw.” If this question does not apply to the incident, leave it blank.
Yes
No
Was employee hospitalized overnight as an in-patient?
Yes
No
18) If the employee died, when did death occur? Date of death ______ / _____ / ______
Public reporting burden for this collection of information is estimated to average 22 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Persons are not required to respond to the
collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW,
Washington, DC 20210. Do not send the completed forms to this office.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.28
Cal/OSHA’s Form 301:
Injury and Illness Incident Report
i
California OSHA 300 Series forms may be downloaded at:
http://www.dir.ca.gov/dosh/PubOrder.asp
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.29
Attention: This form contains information relating to employee
health and must be used in a manner that protects the
confidentiality of employees to the extent possible while the
information is being used for occupational safety and health
purposes. See CCR Title 8 14300.29(b)(6)-(10)
Cal/OSHA Form 301
Injury and Illness Incident Report
Information about the employee
This Injury and Illness Incident Report is one of the
first forms you must fill out when a recordable workrelated injury or illness has occurred.Together with
the Log of Work-Related injuries and Illnesses and
the accompanying Summary , these forms help the
employer and Cal/OSHA develop a picture of the
extent and severity of work-related incidents.
Within 7 calendar days after you receive information
that a recordable work-related injury or illness has
occurred, you must fill out this form or an equivalent.
Some state workers' compensation, insurance, or
other reports may be acceptable substitutes.To be
considered an equivalent form, any substitute must
contain all the instructions and information asked for
on this form.
According to CCR Title 8 Section 14300.33 Cal/OSHA's
recordkeeping rule, you must keep this form on file for 5
years following the year to which it pertains.
If you need additional copies of this form, you
may photocopy and use as many as you need.
1)
Full Name
10)
Case number from the Log
2)
Street
11)
Date of injury or illness
12)
Time employee began work
AM/PM
AM/PM
City
State
Zip
Date of birth
13)
Time of event
4)
Date hired
14)
What was the employee doing just before the incident occurred? Describe the activity, as
well as the tools, equipment or material the employee was using. Be specific. Examples:
"climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily
computer key-entry."
15)
What happened? Tell us how the injury occurred. Examples: "When ladder slipped on wet floor,
worker fell 20 feet"; "Worker was spayed with chlorine when gasket broke during replacement";
"Worker developed soreness in wrist over time."
16)
What was the injury or illness? Tell us the part of the body that was affected and how it was
affected; be more specific than "hurt", "pain", or "sore." Examples: "strained back"; "chemical
burn, hand"; "carpal tunnel syndrome."
17)
What object or substance directly harmed the employee? Examples: "concrete floor";
"chlorine"; "radial arm saw." If this question does not apply to the incident, leave it blank.
18)
If the employee died, when did death occur? Date of death
5)
Male
Check if time cannot be determined
Female
Information about the physician or other healthcare professional
6)
Name of physician or other healthcare professional
7)
If treatment was given away from the worksite, where was it given?
Facility
8)
Completed by
State
Zip
Was employee treated in an emergency room?
Yes
No
Title
9)
Date
Was employee hospitalized overnight as an in-patient?
Yes
No
Rev.(1/10)
(Transfer the case number from the Log after you record the case.)
3)
City
© 2010 Stericycle, Inc.
Division of Occupational Safety & Health
Information about the case
Street
Phone
Department of Industrial Relations
Master Forms
9.30
/
/
California Only Training in Aerosol Transmissible Diseases
Screening Protocol Sign-In Sheet
For: Aerosol Transmissible Diseases Screening Protocol
Our ATD Screening Protocol has been reviewed by:
Reviewer’s Name (print) Title
Signature of Reviewer
Date
Sign below to indicate that you have read and and received training in your facility’s ATD Screening
Protocol and that you have been given the opportunity to ask questions to management to ensure a
complete understanding of the screening protocol:
Print Name
Title Signature Date
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
___________________________________________ __________________________
Maintain a copy of this form for a period of three years.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.31
Annual BBP Training Record
Facility Name
Complete this attendance sheet prior to beginning the required Annual Bloodborne Pathogens Training
Review. All employees with the potential for exposure to bloodborne pathogens must be in attendance,
if possible. Keep completed sheet for recordkeeping. This record should be retained for a minimum of
three years. This training covers the 14 elements of the Bloodborne Pathogens Standard. If additional
rows are needed, attach separate sheet.
______________________________________________________________________­
Date of Meeting
Person or Position Conducting Training
Qualification
Employees in Attendance
Print Name
Signature Job Title
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Signature of Person Conducting Meeting
© 2010 Stericycle, Inc.
Rev.(1/10)
Title
Date
Master Forms
9.32
Employee Exposure Determination
The following is a list of all our job classifications in which employees have occupational exposure to
bloodborne pathogens.
Job Title
Department/Location
Example: Phlebotomists
Clinical Lab
The following is a list of job classifications in which employees may have potential exposure
to bloodborne pathogens on an occasional or intermittent basis as a result of performing the
specific tasks itemized below.
Job Title
Example: Housekeeper
Department/Location
Environmental Services
Task/Procedure
Handling regulated waste
Part-time, temporary, contract and per diem employees are covered by the Bloodborne
Pathogens Standard.
Those employees who are determined to have occupational exposure to blood or other potentially
infectious materials (OPIM) must comply with the procedures and work practices outlined in
this facility’s ECP.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.33
Exposure Control Plan (ECP) Annual Documentation Form
1. This is to document the fact that I have, on the indicated date, performed the required annual review and update
as necessary for the Bloodborne Pathogens Exposure Control Plan of our facility.
Documenter’s Name
Signature
Date
2. This is to document the fact that our facility has evaluated and implemented safer medical devices on an ongoing
basis during the past year. These evaluations were conducted by means of (check all that apply):
❏ Attendance at commercial exhibits of vendors of such devices at professional meetings
❏ Examination of products presented by device vendors calling on our facility
❏ Monitoring professional journals and literature on a regular basis
❏ Reports from colleagues
❏ Recommendations from employees
❏ Staff evaluation of selected products. Device Evaluation Forms (see sample) are to be
utilized for such evaluations and are to be maintained and made available upon request.
Documenter’s Name
Signature
Date
3. This is to document the fact that solicitation of non-managerial input into the evaluation of safer medical devices, as
well as into any other area of our operations relating to employee safety, has been conducted. A Solicitation of Input
of Non-Managerial Employees form (see sample) is to be utilized for further documentation of such solicitation and is
to be maintained and made available upon request.
Documenter’s Name
© 2010 Stericycle, Inc.
Rev.(1/10)
Signature
Date
Master Forms
9.34
Solicitation of Input of Non-Managerial Employees
Documenter’s Name
Signature
Date
It is the policy of our facility that our non-managerial employees who provide direct patient care and
are potentially exposed to injuries from contaminated sharps shall be involved in providing input for
the identification, evaluation, and selection of safer medical devices and for effective engineering and
work practice controls. The input of our employees is requested and required as a vital part of our
commitment to providing a safe and healthful workplace.
Sign below to document that, on this date, your input into the selection of safer medical devices and
into any other workplace safety related matters or concerns about our facility, our engineering controls,
personal protective equipment, or about our work practices, has been duly solicited. Please also feel free
to bring any other issues concerning such matters to our management’s attention on an ongoing basis.
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
Name
Signature
Job Title
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.35
Evaluation Form for Safety Needle/Syringe Devices
NameTitle
Department/UnitDate
Product Name/ID
Evaluation Issues 1. The device functioned satisfactorily for its intended purpose
❏ Yes
❏ No
❏ Unknown/Not Applicable
2. Device is suitable for most standard syringe functions
❏ Yes
❏ No
❏ Unknown/Not Applicable
3. The product is available in the sizes needed
❏ Yes
❏ No
❏ Unknown/Not Applicable
4. The product is simple to operate
❏ Yes
❏ No
❏ Unknown/Not Applicable
5. The use of this product requires no training
❏ Yes
❏ No
❏ Unknown/Not Applicable
6. The safety feature activated with a one-handed technique
❏ Yes
❏ No
❏ Unknown/Not Applicable
7. The safety feature worked reliably
❏ Yes
❏ No
❏ Unknown/Not Applicable
8. Both hands remain protected during
engagement of safety feature
❏ Yes
❏ No
❏ Unknown/Not Applicable
9. The safety feature does not interfere with normal
use of this product
❏ Yes
❏ No
❏ Unknown/Not Applicable
10.The product is equally satisfactory for different or
diverse patient populations (adults, children, heavy, thin, etc)
❏ Yes
❏ No
❏ Unknown/Not Applicable
11.The safety feature could not be bypassed ❏ Yes
❏ No
❏ Unknown/Not Applicable
12. The safety feature works well with a wide variety of hand sizes
❏ Yes
❏ No
❏ Unknown/Not Applicable
13. The device is no more difficult to process after use
than non-safety devices
❏ Yes
❏ No
❏ Unknown/Not Applicable
❏ Yes
❏ No
Further Input
14. Did you experience any injuries with the test device?
15. About how many times did you use the test device before you were comfortable using it? __________________
16. Did you have any problems with this device?
❏ Yes
❏ No (if yes, please explain)
___________________________________________________________________________________
___________________________________________________________________________________
17. Which device would you rather use? (Please check one)
❏ The product we normally use ❏ This test product ❏ Other ___________________________________
18.Comments:
___________________________________________________________________________________
___________________________________________________________________________________
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.36
Workplace Hazard Assessment
OSHA requires employers to assess the work environment to determine if hazards are present which
necessitate the use of Personal Protective Equipment, PPE. When PPE is needed to protect employees
from hazards, we are required to specify the correct PPE and its usage.
To accomplish this,
NameLocationPhone
is our PPE coordinator and will ensure that the following requirements are met.
❏ A hazard assessment is accomplished to identify hazards.
❏ The appropriate PPE is assigned to the potential hazard.
❏ PPE is provided.
❏ Properly fitted PPE is maintained and available.
❏ Employees are trained on PPE usage: how to use it, when it is required, and what
are its limitations.
❏ PPE selection decisions and criteria will be communicated to employees.
❏ The employer must also certify that the workplace hazard assessment and PPE
selection has been performed.
PPE Selection and Certification Form
Task
Example: stripping porcelain from dental casting
HazardPPE
hydrofluoric acid
utility gloves, eye shield, face shield as needed
This is to certify that I have performed an assessment of our workplace and procedures, and that the
hazards found are listed above along with the PPE to be used.
Name
© 2010 Stericycle, Inc.
Rev.(1/10)
SignatureDate
Master Forms
9.37
Personal Protective Equipment
Based on our hazard assessments, the types of PPE selected and made available to our employees are as follows
(check all that apply):
Respiratory Protection
Gloves
❏ Latex Exam
(powdered or powder-free)
circle one or both if used
❏ Vinyl Exam
❏ Sterile Surgical
❏ Utility gloves
Keep in mind that whenever respirator use is required,
it also triggers implementation of the provisions of the
Respiratory Protection Standard (see Supplementary
Workplace Concerns section of this manual
for further information).
❏ N95 respirators
❏ Nitrile
❏ Other respirators
❏ Neoprene
❏ ___________________
❏ ___________________
❏ ___________________
❏ ___________________
Eye and Face Protection
Hearing Protection
❏ Safety Glasses
with sideshields
❏ Splash goggles
❏ Face Shield
❏ Face Masks
❏ ___________________
❏ ___________________
❏ Ear Plugs
❏ Ear Muffs
❏ ___________________
❏ ___________________
Other
❏ ___________________
Protective Clothing
© 2010 Stericycle, Inc.
❏ Lab Coats
❏ Gowns
❏ Smocks
❏ Bouffants
❏ Booties
Rev.(1/10)
❏ ___________________
❏ ___________________
i
Helpful Internet Links to more information can be found in the
RESOURCE GUIDE section.
Master Forms
9.38
Certification of PPE Training
The affected employees listed below have been trained on the PPE selected for this facility as the result
of our Workplace Hazard Assessment.
Items of PPE for which training has been provided:
_______________________________________ ______________________________________
_______________________________________ ______________________________________
_______________________________________ ______________________________________
_______________________________________ ______________________________________
_______________________________________ ______________________________________
Employees trained on the above items of PPE:
Name
Date(s) of Training
PPE Item for which Training was Provided
(If different from items already listed above)
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
_________________________________________
This is to certify that the employees listed above have been trained on the PPE indicated above and
that they understand when that PPE is necessary, what PPE is necessary, how to properly don (put on),
off (remove), adjust, and wear the PPE, the limitations of the PPE, and the proper care, maintenance,
useful life, and disposal of the PPE.
i
Printed Name
Signature
Date
Helpful Internet Links to more information can be found in the RESOURCE GUIDE section.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.39
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.40
Reusable sharps, hand
instruments, etc.
Broken glassware
Protective coverings,
plastic wrap, aluminum
foil, imperviouslybacked absorbent
paper used to cover
equipment and
environmental surfaces
Bins, pails, cans, similar
receptacles
Contaminated work
surfaces (specify)
Equipment (list items)
Example:
Item, type of surface
Location within
facility
Cleaner, Disinfectant,
or Sterilant to be Used
Frequency
of Cleaning
PPE, Engineering
Controls to be Used
Housekeeping Schedule Form
Employees
Assigned Task
Hepatitis B Vaccination Declination Form
This declination form should be completed and placed in the employee’s medical file.
The employer shall assure that employees who decline to accept hepatitis B vaccination offered by
the employer sign the following statement as required by the Bloodborne Pathogens Standard.
I understand that due to my occupational exposure to blood or OPIM I may be at risk of acquiring
hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis
B vaccine at no charge to myself, however, I declined this vaccine at this time. I understand that by
declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If, in the future,
I continue to have occupational exposure to blood or OPIM and I want to be vaccinated with hepatitis
B vaccine, I can receive the vaccination series at no charge to me.
Employee Name
Employee Signature
Date
Identification Number (if applicable)
Date of Birth
Employer or OSHA Coordinator
EmployerDate
i
Helpful Internet Links to more information can be found in the RESOURCE GUIDE section.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.41
Letter of Receipt
I have received or already have a copy of the Bloodborne Pathogens Standard.
Healthcare Provider
© 2010 Stericycle, Inc.
Rev.(1/10)
Date
Master Forms
9.42
BBP Exposure Incident Report Form
This report must be completely filled out after any employee exposure incident. A copy of this report should be provided
to the licensed healthcare professional providing post-exposure evaluation and treatment to the injured employee. This
report is to be placed in the employee’s medical records and must remain confidential.
Exposed Employee
Name
Identification Number
Date of Incident
Type of Incident
Employee’s duties as they relate to the incident:
Description of exposure routes and circumstances under which incident occurred:
Check appropriate responses below:
❏ Yes ❏ NoExposed employee has been counseled as to applicable laws and regulations concerning disclosure
of the identity and infectious status of the source patient.
❏ Yes ❏ NoExposed employee has legally consented to blood testing.
❏ Yes ❏ NoExposed employee has agreed to have baseline blood collection, but doesn’t give consent at this
time for HIV serologic testing and understands that the sample shall be preserved for 90 days in
case employee decides to complete testing.
Medical Attention
The exposed employee was referred to the following physician or other licensed healthcare professional for medical
evaluation, counseling, and follow-up:
Name
Phone
Address
Date of Exam
Date of Follow-up
Exposed employee’s vaccination records were made available to the attending physician or licensed healthcare professional on:
A copy of the Bloodborne Pathogens Standard was delivered to the attending physician or other licensed healthcare
professional on:
A copy of the physician or other licensed healthcare professional’s written opinion was delivered to the
employee on:
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.43
Source Patient
Name
Phone
Address
City
State
Zip Code
Check appropriate responses below:
❏ Yes ❏ NoSource patient has legally consented to have his/her blood tested for HIV and HBV infectivity.
❏ Yes ❏ No The legally required consent cannot be obtained.
Reason
❏ Yes ❏ No Source patient is known to be infected with HBV.
❏ Yes ❏ No Source patient is known to be infected with HIV.
❏ Yes ❏ No Results of source patient’s tests have been provided to the exposed employee.
Recordkeeping
The following items will be maintained IN STRICT CONFIDENTIALITY and not disclosed without the employee’s
written consent to anyone within or outside the workplace.
Records must be kept for duration of employment plus 30 (thirty) years.
1. The employee Exposure Incident Form.
2. A record of the employee’s hepatitis B vaccination status including the dates of all vaccinations and any
medical records relative to the employee’s ability to receive vaccination.
3. A copy of all results of examinations, medical testing, and follow-up procedures.
4. The employer’s copy of all results of the Healthcare professional’s written opinion.
5. Identity of source patient and source patient’s blood test results.
Form completed by:
Name
Title
Exposed Employee Signature
Date
Employer Signature
Date
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.44
BBP Exposure Incident Report Form
Healthcare Professional’s Written Opinion
Exposed Employee
Name
Identification Number
Date of Incident
Type of Incident
To the Evaluating Healthcare Professional: After you have determined whether there are contraindications
to vaccination of this employee with hepatitis B vaccine, please state in the space below only if vaccine was indicated
and if vaccine was received. Following completion of this form, please provide the original to the employee and a copy
to the employer.
1. ____________Vaccine was indicated.
2. ____________Vaccine was provided.
After your evaluation of this employee, please assure that the following information has been furnished to the employee
and provide your initials beside the following statements:
1. ____________ The employee has been informed of the results of this evaluation.
2. ____________ The employee has been told about any medical conditions resulting from exposure
to blood or other potentially infectious materials, which require further evaluation and treatment.
All other findings or diagnoses shall remain confidential and shall not be included in the written report.
_______________________________________________________
Healthcare Professional’s Signature
_______________________________________________________
Healthcare Professional’s Name (printed) ______________
Date
Medical Attention
The exposed employee was referred to the following physician or other licensed healthcare professional for medical evaluation,
counseling, and follow-up:
Name
Phone
Address
Date of Exam
© 2010 Stericycle, Inc.
Rev.(1/10)
Date of Follow-up
Master Forms
9.45
Sharps Injury Log
Please complete a Log for each employee exposure incident involving a sharp. Check the box
corresponding to the most appropriate answer. Please print
| | | | | | |
| | | | |
Injury ID (please leave blank)
Facility ID (please leave blank)
InstitutionDepartment
Address
Page #
Of
City
State
Zip Code
Date filled out
By
Phone
| | | | | | | | | |
Facility Injury ID#
❏ Male ❏ Female
Date of Injury
Time of Injury
Sex (optional)
Description of the exposure incident:
Job Classification
Department/Location
Procedure
❏ Dentist
❏ Patient Room
❏ Draw Venous Blood
❏ DA
❏ Operating Room
❏ Draw Arterial Blood
❏ RDH
❏ CCU/ICU
❏ Injection, through skin
❏ Housekeeper/Laundry
❏ Clinical Laboratory
❏ Start IV/Set-Up Heparin Lock
❏ CNA/HHA
❏ Medical/Outpatient Clinic
❏ Nurse
❏ Emergency
❏ Unknown/
Not Applicable
❏ RDA
❏ Procedure Room
❏ Student, type
______________________
❏ Home
❏ Other
______________________
© 2010 Stericycle, Inc.
Rev.(1/10)
❏ Service/Utility Area
(disp. rm./laundry)
❏ Other
_____________________
❏ Heparin/Saline Flush
❏ Cutting
❏ Suturing
❏ Other
_____________________
Master Forms
9.46
Did the Exposure Incident Occur
❏ During use of sharp
❏ While putting sharp into disposable container
❏ B etween steps of a multi-step procedure
❏ Sharp left in inappropriate place (table, bed, etc.)
❏ After use and before disposal of sharp
❏ Other ______________________
Body Part
❏ Finger ❏ Hand ❏ Arm ❏ Face/Head ❏ Torso ❏ Leg ❏ Other ______________________
Identify Sharp involved (if known)
Type ______________________ Brand ______________________ Model
______________________
e.g. 18g needle/ABC Medical/“no stick” syringe
Did the device being used have engineered sharps injury protection? ❏ Yes ❏ No ❏ Don’t Know
Was the protective mechanism activated? ❏ Yes-Fully ❏ Yes-Partially ❏ No
Did the exposure incident occur: ❏ Before ❏ During ❏ After Activation
Exposed Employee
If sharp had no engineered sharps injury protection, do you have an opinion that such a mechanism
could have prevented the injury? ❏ Yes ❏ No
Explain
Exposed Employee
Do you have an opinion that any other engineering, administrative, or work practice control could
have prevented the injury? ❏ Yes ❏ No
Explain
9.47 Master Forms
© 2010 Stericycle, Inc.
Rev.(1/10)
Hazardous Chemical Inventory Master List
NameLocation
Phone
is responsible for this list of hazardous chemicals and related work practices used at this location and
will update the list as necessary.
Following is the master list of these hazardous chemicals. Our list of chemicals identifies all of the
chemicals used in our work process.
Each list also identifies the corresponding MSDS. Use additional sheets if needed.
Many facilities like to store each MSDS in a notebook and assign a simple numerical sequence
numbering system to them for ease of location between the master list and the position of the MSDS
in the notebook. This is simply a number you assign; it is not an “official” number that you must look for.
© 2010 Stericycle, Inc.
Product NameLocation of Use/Storage
Rev.(1/10)
MSDS Name/Number
Master Forms
9.48
Workplace Hazard Assessment
OSHA requires employers to assess the work environment to determine if hazards are present which
necessitate the use of Personal Protective Equipment, PPE. When PPE is needed to protect employees
from hazards, we are required to specify the correct PPE and its usage.
To accomplish this,
NameLocationPhone
is our PPE coordinator and will ensure that the following requirements are met.
❏ A hazard assessment is accomplished to identify hazards.
❏ The appropriate PPE is assigned to the potential hazard.
❏ PPE is provided.
❏ Properly fitted PPE is maintained and available.
❏ E mployees are trained on PPE usage: how to use it, when it is required, and what
are its limitations.
❏ PPE selection decisions and criteria will be communicated to employees.
❏ The employer must also certify that the workplace hazard assessment and PPE
selection has been performed.
PPE Selection and Certification Form
Task
Hazard
Example: stripping porcelain from dental casting
hydrofluoric acid
PPE
utility gloves, eye shield, face shield as needed
This is to certify that I have performed an assessment of our workplace tasks and procedures, and that
the hazards found are listed above along with the PPE to be used.
Name
© 2010 Stericycle, Inc.
Rev.(1/10)
SignatureDate
Master Forms
9.49
Personal Protective Equipment
Based on our hazard assessments, the types of PPE selected and made available to our employees are as follows
(check all that apply):
Respiratory Protection
Gloves
❏ Latex Exam
(powdered or powder-free)
circle one or both if used
❏ Vinyl Exam
❏ Sterile Surgical
❏ Utility gloves
Keep in mind that whenever respirator use is required,
it also triggers implementation of the provisions of the
Respiratory Protection Standard (see Supplementary
Workplace Concerns section of this manual
for further information).
❏ N95 respirators
❏ Nitrile
❏ Other respirators
❏ Neoprene
❏ ___________________
❏ ___________________
❏ ___________________
❏ ___________________
Eye and Face Protection
Hearing Protection
❏ Safety Glasses
with sideshields
❏ Splash goggles
❏ Face Shield
❏ Face Masks
❏ ___________________
❏ ___________________
❏ Ear Plugs
❏ Ear Muffs
❏ ___________________
❏ ___________________
Other
❏ ___________________
Protective Clothing
© 2010 Stericycle, Inc.
❏ Lab Coats
❏ Gowns
❏ Smocks
❏ Bouffants
❏ Booties
Rev.(1/10)
❏ ___________________
❏ ___________________
i
Helpful Internet Links to more information can be found in the
RESOURCE GUIDE section.
Master Forms
9.50
Certification of PPE Training
The affected employees listed below have been trained on the PPE selected for this facility as the result of our Workplace
Hazard Assessment.
Items of PPE for which training has been provided:
_______________________ _______________________ ___________________________________________
_______________________ _______________________ ___________________________________________
_______________________ _______________________ ____________________________________________
_______________________ _______________________ ____________________________________________
_______________________ _______________________ ____________________________________________
Employees trained on the above items of PPE:
Name
Date(s) of Training
PPE Item for which Training was Provided
(If different from items already listed above)
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
____________________________ ______________________________________________________________________
This is to certify that the employees listed above have been trained on the PPE indicated above and that they understand
when that PPE is necessary, what PPE is necessary, how to properly don (put on), doff (remove), adjust, and wear the PPE,
the limitations of the PPE, and the proper care, maintenance, useful life, and disposal of the PPE.
Printed Name
© 2010 Stericycle, Inc.
Rev.(1/10)
Signature
Date
Master Forms
9.51
Hazardous Chemicals Inventory Log / Table of Contents ‑
This is a worksheet to inventory the hazardous chemicals found in our facility. Please check the appropriate box for each
material found in our facility. Upon completion of your hazardous material inventory, fill out MSDS Request Form(s) for
the materials that do not have a corresponding MSDS or search with Steri•SafeSM MSDS if available.
Hazardous Chemicals
© 2010 Stericycle, Inc.
Rev.(1/10)
Description Of Materials
Have MSDS Need MSDS
Master Forms
9.52
Weekly Eye Wash Station Inspection Checklist & Log
Location
Date
Initials
Evaluation Issues 1. Free from obstruction
2. Accessible within 10 seconds
3. Easily activated
4. Outlets capped
5. Water flowing from both eyepieces
6. Flow of water is of equal height
7. Water is clear
8. Temperature controlled at tepid level
Location
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No
Date
Initials
Evaluation Issues 1. Free from obstruction
2. Accessible within 10 seconds
3. Easily activated
4. Outlets capped
5. Water flowing from both eyepieces
6. Flow of water is of equal height
7. Water is clear
8. Temperature controlled at tepid level
Location
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No
Date
Initials
Evaluation Issues 1. Free from obstruction
2. Accessible within 10 seconds
3. Easily activated
4. Outlets capped
5. Water flowing from both eyepieces
6. Flow of water is of equal height
7. Water is clear
8. Temperature controlled at tepid level
© 2010 Stericycle, Inc.
Rev.(1/10)
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No
Master Forms
9.53
Location
Date
Initials
Evaluation Issues 1. Free from obstruction
2. Accessible within 10 seconds
3. Easily activated
4. Outlets capped
5. Water flowing from both eyepieces
6. Flow of water is of equal height
7. Water is clear
8. Temperature controlled at tepid level
9.54 Master Forms
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No
© 2010 Stericycle, Inc.
Rev.(1/10)
Request for Manufacturer’s Material Safety Data Sheets (MSDS)
Date
TO
Manufacturer
Address
City
State
Zip Code
PhoneFax
FROM
Name of Facility
Address
City
State
Zip Code
PhoneFax
To Whom it May Concern
Please send us a Material Safety Data Sheet (MSDS) on your product(s) named:
Name of Product(s)
Product Number(s) or Code(s)
Please forward the MSDS to our facility as soon as possible:
AttentionTitle
Signature
Thank you for your cooperation.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.55
Emergency Action Plan
Establish procedures and train employees on when and how to sound an alarm and notify emergency
personnel. In addition, you must designate and train employees to assist in a safe and orderly
evacuation of other employees. You must also review the Emergency Action Plan with each employee
covered when the following occur:
• When the plan is developed or an employee is assigned initially to a job
• When an employee’s responsibilities under the plan change
• When the plan is changed
How will fires and other emergencies be reported?
In an emergency, how will employees be informed?
In an emergency, our evacuation will be ( ) full or ( ) partial?
We will evacuate through the following primary and alternate exit routes:
Primary evacuation route:
Alternate evacuation route:
Which employee(s), if any, will stay behind and perform critical plant operations?
We will evacuate to the following safe location:
Primary safe location:
Alternate safe location:
How will every employee be accounted for?
Which employee(s), if any, may perform rescue or medical duties?
How frequently will drills be performed for the above procedures?
Who is your contact person for communicating with fire, police, media, etc?
What is the name or job title of the individual for employee(s) to contact for detailed plan information?
This Emergency Action Plan’s Policy for Portable Fire Extinguisher use by our employees is found in the
following Fire Prevention Plan.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.56
Fire Prevention Plan
When you assign employees to a job, you must inform them of any fire hazards they may be exposed
to. You must also review with each employee those parts of the fire prevention plan necessary for
self-protection.
What are the major fire hazards in our workplace?
List any fire hazards such as flammable or combustible liquids, gases, etc. If no special hazards are present, write “No special
hazards use present; general office materials only “ or other suitably descriptive information.
What are the proper handling and storage procedures for hazardous materials in our workplace?
If no hazardous materials requiring proper handling and storage procedures are present, write “Does not apply-no hazardous
materials present.”
What potential ignition sources exist, and how are they controlled?
If no potential ignition sources exist, write “No potential ignition sources exist.”
What type of fire protection equipment is available to control each major hazard?
List any fire protection equipment such as portable fire extinguishers, sprinkler system, etc., that are available. If none is available, write “No fire protection equipment available.”
What are the procedures to control accumulations of flammable and combustible waste materials?
If no heat producing equipment is present, write “No heat producing equipment present.”
What are the procedures for regular maintenance of safeguards installed on heat-producing equipment to
prevent the accidental ignition of combustible materials?
What is the name or job title of the individual responsible for maintaining equipment to prevent or control
sources of ignition or fires?
What is the name or job title of employee(s) responsible for the control of fuel source hazards?
If no fuel source hazards are present, write “ No fuel source hazards present.”
The policy of this Fire Prevention Plan concerning portable fire extinguisher use by our
employees follows.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.57
Electrical Audit Check List
Facility Location: _____________________________________
Date: _______________
Person Conducting the Audit: _____________________________________
Audit Item In Compliance (Y/N)
Electrical Service Panels
All disconnecting switches and circuit breakers labeled
Is there at least 36” free space in front of all electrical panels
All circuit breaker panel doors kept closed
Other _____________________________________
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ No
❏ No
❏ No
❏ No
Electrical Outlets/Switches
All electrical enclosures (switches, receptacles, junction boxes)
provided with intact and tight covers
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
Overloaded Circuits
Circuits and cords are not overloaded
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
Flexible Extension Cords
Extension cords have three-prong plugs for grounding
Flexible cords not spliced
All cords and wiring free of fraying
Flexible cords not run through doors, windows, or wall openings
Machines designed for fixed location serviced by permanent wiring
Other _____________________________________
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
Damp/Wet Locations
All outlets near water sources protected by a GFCI
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
Guarding Live Parts
No exposed electrical conductors or parts
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
Machine Disconnects
Power shut off switch in sight of its motor device
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
Grounding
Portable electrical tools grounded or double insulated
Electrical appliances and machinery/equipment grounded
Other _____________________________________
❏ Yes ❏ No
❏ Yes ❏ No
❏ Yes ❏ No
© 2010 Stericycle, Inc.
Rev.(1/10)
Comments
❏ No
❏ No
❏ No
❏ No
❏ No
❏ No
Master Forms
9.58
Lockout/Tagout Procedure
Lockout/Tagout Procedure for _________________________________________________
The following procedure is to be followed by any person(s) performing maintenance or servicing
operations on this particular piece of machinery in accordance with our lockout/tagout procedures.
❏ Electrical: The following electrical lockout/tagout steps are to be conducted:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
❏ Pneumatic: The following pneumatic lockout/tagout steps are to be conducted:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
❏ Mechanical: The following mechanical lockout/tagout steps are to be conducted:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
❏ Hydraulic: The following hydraulic lockout/tagout steps are to be conducted:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Equipment is now locked out.
Please see back side for Procedure for Returning Equipment/Machine
to Service.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.59
Procedure for Returning Equipment/Machine to Service:
_______________________________________________________
_______________________________________________________
After servicing and/or maintenance is complete and the equipment is ready for normal operations,
check the area around the machine or equipment to ensure that no one is exposed. After all tools have
been removed from the machine or equipment, guards have been reinstalled, and all employees are in
the clear, remove all lockout or tagout devices. Operate the energy isolating devices to restore energy.
❏ Overall Hazards:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
9.60 Master Forms
© 2010 Stericycle, Inc.
Rev.(1/10)
Lockout/Tagout Audit Checklist and Certification
Periodic Inspection - Review of Lockout/Tagout Program
General - a periodic review of the lockout/tagout program must be conducted by the LOTO Coordinator. This review
will be conducted on an annual basis. The review/inspection will consist of observing a lockout procedure and discussing
the procedure and responsibilities with the observed employee.
The following form is to be used to document all reviews/inspections:
Date: ________________________
Person Performing Review: ________________________________________
Machine or Equipment: ____________________________________________
Authorized Employee Observed: _____________________________________
1. The reviewer reviewed with the authorized employee the employee’s responsibilities and knowledge of the lockout procedure and found no deficiencies. _________________ (Initial)
2. The reviewer reviewed with the authorized and affected employees each employee’s responsibilities and the limitations of tags and found no deficiencies. ______________ (Initial)
If the reviewer found deficiencies requiring correction and retraining, they are noted below:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Certification of Reviewer: __________________________
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.61
Lockout/Tagout Training Record
Facility Name
Complete this attendance sheet prior to your lockout/tagout training. All authorized and affected employees must be in
attendance, if possible. Keep completed sheet for recordkeeping. This record should be retained for a minimum of three
years. Attach separate sheet if additional names are needed.
Date of Meeting
Subject(s) Discussed
Person or Position Conducting Meeting
Employees in Attendance
Print Name
Signature
Title
Authorized
Affected
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
Signature of Person Conducting Meeting
© 2010 Stericycle, Inc.
Rev.(1/10)
Title
Date
Master Forms
9.62
Voluntary and Required Respirator Use Hazard Evaluation
Task/Operation
Type Of Respirator
Required
Voluntary
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.63
Hazard Evaluation
Department
Work Process
Hazardous Substance
Monitor Results (Over 8 Hrs)
© 2010 Stericycle, Inc.
Rev.(1/10)
Respiratory Equipment
Master Forms
9.64
Respirator Fit Testing Record
Employees fit tested
Name
Instructor © 2010 Stericycle, Inc.
Rev.(1/10)
Title
Type Of Respirator Model
Size
Signature Fit Tested By
Date
Date
Master Forms
9.65
Respiratory Training Written/Oral Test
Ensure that each employee can demonstrate knowledge of at least the following.
1. Explain where and why we use respirators.
2. How can improper fit affect your protection?
3. Explain the limitations of your respirator.
4. Explain how to clean, inspect, and store your respirator.
Demonstration of understanding the necessary information may be done
with either a written or an oral test using the criteria above.
Employees in Attendance
Name
SignatureDate
Instructor
Signature © 2010 Stericycle, Inc.
Rev.(1/10)
Date
Master Forms
9.66
Resident/Patient Handling Assessment Checklist
Which of the following activities do you perform and which have been involved in past injuries?
Transfers to and from:
❏ Bed Notes:
_____________________________________
❏ Other beds _____________________________________
❏ Chairs _____________________________________
❏ Gurneys _____________________________________
❏ Floor _____________________________________
❏ Walker _____________________________________
❏ Toilet/bedside commode _____________________________________
❏ Bathtub _____________________________________
❏ Wheelchairs _____________________________________
❏ Showers _____________________________________
Ambulating, Repositioning, Manipulating
❏ Repositioning/turning/holding Notes:
_____________________________________
❏ Hand cranking beds _____________________________________
❏ Assisting with ambulation _____________________________________
Transporting or Moving Equipment
❏ Beds or gurneys
Notes:
_____________________________________
❏ Wheelchairs _____________________________________
❏ Room furniture _____________________________________
❏ Carts _____________________________________
❏ Monitors or equipment _____________________________________
Performing Activities of Daily Living
❏ Bathing in bed or bathtub, showering Notes:
_____________________________________
❏ Performing personal hygiene _____________________________________
❏ Dressing and undressing _____________________________________
❏ Making beds with residents/patients in them _____________________________________
❏ Toileting _____________________________________
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.67
Accident/Incident Report Form (for injuries other than sharps related)
Date of incident: Time: AM/PM
Please check one, who was injured? ❏ Employee ❏ Patient ❏ Visitor
Name of injured person:
Address: Phone Number(s):
Date of birth: ❏ Male
❏ Female
Type of injury: Location of occurrence:
Details of incident: Injury requires physician/hospital visit?
❏ Yes
❏ No
Name of physician/hospital: Address: City, State, Zip Physician/hospital phone number: Physician notes, if any
Signature of injured party
Date
Witness Signature Date
Please indicate if no medical attention was desired (signature required) Signature of injured party
Date
Signature of employee accepting report
Date
❏ Yes
❏ No
Return this form to Supervisor on duty within 24 hours of incident.
© 2010 Stericycle, Inc.
Rev.(1/10)
Master Forms
9.68