Personalize your OSHA Manual

 

OSHA Manual – online form page 1
Front Cover
Name:
Name 2:

Title Page
Name:
Address:
Address 2:
City:
State:
Zip:
Telephone: - -
Email address:

Please select your business's industry type:
 
Effective Date of Manual:
Date:      
Management Official (usually the owner or general manager):
Full Name:
Title:
Person Responsible for Injury and Illness Prevention Program (IIPP):
Full Name:
Title:
Direct questions regarding this program to:
Full Name:
Person responsible for OSHA requirements (instructions, communications and coordination of OSHA requirements):
Full Name:
Location of Manual (please be specific):
Location:
Person responsible for General IIPP (plan administrator):
Full Name:
Person responsible for General Office Safety Plan:
Full Name:
Person responsible for Ergonomics Plan:
Full Name:
Person responsible for Fire and Fire Emergency Plan:
Full Name:
Person responsible for Emergency Action Plan:
Full Name:
Person responsible for Hazard Communication Plan:
Full Name:
Person responsible for Exposure Control Plan:
Full Name:
Person responsible for Medical Waste Plan:
Full Name:
Person to receive Reports (regarding injuries, illnesses, exposures, unsafe or unhealthy conditions):
Full Name:
Person last to Evacuate (ensuring facility is empty):
Full Name:
Person employees report to at the Assembly Area:
Full Name:
Number of Exits and their Locations:
Description:
Assembly Area—The assembly area is a designated area away from the facility where all employees go to in the event of an emergency, this allows those in charge to check the well being of each member of the staff and to ascertain if any one is missing. (Be specific):
Location:
Fire Hazards (list each hazard, it's location, and specific fire prevention practice. For example: Gas burner (laboratory) or coffee-maker (kitchen) , turn off when not in use and keep combustibles away):
Description:
Fire Control Measures (list work area and then check appropriate box):
Work Area Portable Extinguisher Fixed System (Sprinkler)
Does your Facility have: Yes No
Smoke Detectors
Carbon Monoxide Detectors
Fire Alarm (if yes, complete alarm info below)
Burglar Alarm (if yes, complete alarm info below)
Alarm Company:
Telephone: - -
Account #:
Fire Department – Call 911 or:
Telephone: - -
Medical Assistance – Call 911 or:
Telephone: - -
Police – Call 911 or:
Telephone: - -
First Aid Provider:
Name:
Location of First Aid Kit (be specific):
Location:
Location of Medical Emergency Kit (if not applicable enter N/A):
Location:
Location of Eyewash (be specific):
Location:

 

OSHA Manual – online form page 2
List of Hazardous Chemicals—You will have to inventory your office for hazardous substances and list each item here. For every item on the list you must have a MSDS (see MSDS Manuals). You will have to insert a copy of your Hazardous Chemicals list into your OSHA manual once you have received your manual from us.

Location of Hazardous Chemicals—Using your office evacuation diagram as an aid, locate areas that contain hazardous chemicals and then list those locations. You will have to insert a copy of your office evacuation diagram with the hazardous chemicals and regulated waste location when you receive your OSHA manual from us.

Bloodborne Pathogen Questions:

Potential Hazards—create a list of potential exposure hazards; some items have been listed for you, please add others as needed):
Needle Sticks/Sharps Injury Electrical Shock
Radiation Exposure Nitrous Oxide
Blood Soaked Sponges, etc. Chemical Exposure

Bloodborne Pathogens

Employee Job Classifications—read the classifications and then list all Job Titles and their Classifications in the box provided:
Classification A: Job classifications in which ALL employees have exposure to infectious, chemical and radiological agents. (Doctor, Assistant, Lab Technician, Sterilization Clerk, Janitor, etc.)
Classification B: Job classifications in which SOME employees have exposure to infectious chemical and radiological agents. (A front office person who occasionally helps in the back office).
Classification C: Job classifications with no potential exposure. Examples: Office manager, bookkeeper, outside sales person, etc.
List:
These are some tasks and procedures with occupational exposure of "A" job classification that may be performed by "B" job classification employees. Please indicate which are performed in your office:
Treatment Procedures Radiographic procedures
Instrument Processing Treatment room cleaning and disinfecting
Laboratory Procedures Handling or disposing of contaminated waste

Hand Washing Facilities:
Locations:

Office Procedure for Handling Sharps—please indicate which procedures are used in your office:
Needles are to be recapped with a one-handed technique.
Needles are to be recapped with a mechanical device.
Sutures and blades should be separated from the rest of the surgical set-up to ensure that they are visible.
Tongs or a basket are to be used for removal of instruments from the ultrasonic cleaner. Never use your hands.
Brush-scrubbing of debris from contaminated instruments is only permitted after they are pre-cleaned in an ultrasonic cleaner. Utility gloves and face protection are to be used when brush scrubbing.
Sharps devices with Engineered Sharps Injury Protection (E.S.I.P.).
  Types or Brands of E.S.I.P.

Contaminated Linens:
Locations:
Contaminated Linens are:
Discarded into waste container.
Decontaminated in a washer/dryer on site by staff.
Decontaminated by an outside laundry service.
Decontaminated by an unincorporated doctor.

Engineering and Work Practice Controls—when does your facility assess these:
quarterly semi-annually
annually other (specify)

During each assessment we consider:
All engineering and work practice controls at one time.
Selected engineering and work practice controls on a staggered schedule.
Our staggered schedule is

Person responsible for Ordering new ESIP products:
Full Name:

Blood Specimens (answer true or false): Yes No
Specimens of blood or other potentially infectious materials
are handled in this facility.

Locations for Eating and Drinking:
Locations:
Locations for Food and Drink:
Locations:

Locations for Applying Cosmetics, Handling of Contacts, etc:
Locations:

Minimize splash, spray, etc. (list items used; for example: face masks, goggles, high velocity evac, etc.):
List of Items:

Biohazards (answer true or false): Yes No
Drop through for biohazards are used in this facility.

Solid Waste Containers (normal trash):
Locations:

Human surgery tissue is disinfected by:
appropriate agent heat sterilized
other (specify) 

Sharps Waste Containers:
Locations:

Regulated Waste Containers (not sharps or pharmaceuticals):
Locations:

Pharmaceutical Waste Containers:
Locations:

Disposal of Regulated Medical Waste is by:
A pick up service.
A DHS mail-back system for sharps.
Treatment
If Pick Up or Mail-Back System:
Company Name:
Telephone: - -

Local Location of Records (be specific):
Locations:

If treatment was made, how treated:
Description:

Additional Comments—Is there any other information you can provide us that will help to complete your personalized OSHA Manual?:
Comments: