Forms

Home Injury and Illness Prevention Program Forms

If you would prefer to have any of these forms in Word (.doc) format so you can fill it out electronically or alter the content to be specialized for your workplace, please email Kitty with your request.

Hazard Alert Report: to report unsafe conditions anonymously (Appendix F)

Hazard Correction Tracking: record actions taken to correct workplace hazards (Appendix E)

Responsible Persons: document the assignment of program coordinator (Appendix A)

Inspection Schedule: how often to inspect various types of workplaces (Appendix B)

Recordkeeping Requirements: how long to maintain different IIPP-related documents (Appendix C)

Workers' Compensation Reporting Procedures (Appendix G-1)

Workers' Compensation FAQ for Supervisors (Appendix G-2)

Individual Employee Training Record: for use in any one-on-one training situation (Appendix H-3)

Group Employee Training Record: sign-up sheet for group training sessions (Appendix H-2)

Safety Training Evaluation Form: (Word version developed by CHDCCS, download and customize to your department)

IIPP Employee Orientation: create signed record of employee briefing on IIPP (Appendix H-4)

Employee Training Matrix: determine what training type and frequency is needed depending on job hazard exposure (Appendix H-5)

Program Assessment: determine if your program meets all the necessary criteria

Office Safety Inspection: generic form for standard office environments (Appendix D-2)

Shop Safety Inspection: generic form covering hazards found in shops (Appendix D-1)

Training Needs Identification: determine what training all employees need (Appendix H-1)

Accident Investigation

HazCom (Right to Know)

Confined Space

Chemical Hygiene Plan

Seismic Safety

Hearing Conservation

Occupational Ergonomics

Emergency Response Plan Template

Personal Protective Equipment (PPE)