Compliance Management Corporation

Safety Manual Development Form

Please fill out the form as completely as possible.

Type of Building Occupied (Describe & Number of Stories)


#Employees: #Supervisors:
#Vehicles: #Fork Lifts:
#People First Aid Trained:
#People CPR Trained:

THE FOLLOWING QUESTIONS MUST BE
ANSWERED TO DEVELOP A COMPLETE PROGRAM!

Are Respirators Used:
yes no		 If So, What Kind & Why: 
Is Hearing Protection Used:
yes no		 If So, Why/Why Not If Noisy: 
Confined Space Exposure (Describe):
Construction Exposures:


Scaffolding Used:
yes no		 Over 30’:
yes no		 Permit:
yes no
     
Excavation/
Underground Work
:yes no
Over 5’ Deep:
yes no
Permits:
yes no
     
Building Demolition:
yes no		 Over 30’:
yes no		 Permits:
yes no


INDUSTRY AND ACTIVITY SPECIFIC SAFETY RULES

PLEASE CHECK ALL ITEMS THAT APPLY TO YOUR
OPERATION AND ENCLOSE ANY SPECIAL SAFETY
RULES OR POLICIES FOR INCLUSION IN YOUR PROGRAM.


MANUFACTURING EXPOSURES 
RETAIL TRADES INDUSTRY 
Machine Guarding  Display Cases/Equipment 
Power Tools  Racks and Counters 
Pneumatic Tools  Retail Area 
Grinders  Storage 
Metal Working Machines  Maintenance 
Die Casting Machines  Exits and Entrances 
Press Brake  Customer and Public Exposure 
Punch Press Accident to the Public 
Welding & Cutting  Parking Lot 
Compressed Gases 
Propane 
CONSTRUCTION INDUSTRY 
Hazardous Chemicals Construction Tools 
Spray Painting  Heavy Equipment 
Specialty Machines  Excavation and Trenching 
Concrete/Form Work 
Grading 
MEDICAL INDUSTRY 
 Foundations 
Medical Exposures  Floor/Hole Openings 
HIV,HBV Exposures  Lifting Ropes, Slings, Chains 
Blood Handling  Elevated Surfaces
Medical Equipment  Stud Guns
Barium X-Ray  Electrical 
X-Ray Equipment  Plumbing 
Nursing  Heating/Air Conditioning 
Patient Handling  Finish Carpentry
Assaultive Behavior Exposure  Skill Saws,Radial Arm Saws
Prescription Drugs  Scaffolding 
Housekeeping  Paints/Solvents 
Infectious Disease  Chemicals 
Infectious Waste  Compressor 
Compressed Gases
Propane 
RESTAURANT INDUSTRY 
Kitchen Safety  Ice Machines 
Knife Safety  Steamers/Pressure Cooking 
Cooking Equipment  Dough Mixers
Fryers  Display Cases/Equipment 
Food Machinery  Walk-In Freezer/Refrigerator 
Microwave  Slicers 
Ovens  Glassware 
Blenders  Dish Washing Machine
Fire Protection Equipment 
THE FOLLOWING ACTIVITY SPECIFIC CHAPTERS ARE ALSO AVAILABLE. PLEASE MARK THE BOX FOR THOSE CHAPTERS THAT ARE APPLICABLE TO YOUR OPERATION. 
*Electrical Lockout/Tagout  *Construction "Safety Meetings" 
*Confined Space Entry- Permit and Non-Permit  Construction Supervisor Safety Manual 
*Motor Vehicle Operation  Food Services Safety 
*Excavation & Trenching  Drug Free Workplace 
*Industrial Trucks/Forklift  *Ergonomics 
*Hearing Conservation  *Hazcom - MSDS Terms, Glossary & Procedures 
*Bloodborne Pathogens & Medical Safety/Health  *Violence In The Workplace
*Respiratory Protection  Indoor Air Quality 
*Welding Safety  Gas Cylinders & Compressed Gases 
Tuberculosis Exposure Control  Fall Protection 
Personal Protective Equipment Safety Incentive Program 
Safety Committee 


NOTE: OSHA REGULATIONS STATE THAT THOSE PROGRAMS MARKED
WITH AN ASTERISK (*) REQUIRE A FORMAL PROGRAM WHICH IS TO BE
"IN WRITING" IF THE EXPOSURE IS PRESENT!!




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