Sample Workplace Safety and Health Programs
These resources are provided by the Maine Department of Labor SafetyWorks! program as a guide to assist employer in compliance with safety and heath regulations. It is the responsiblity of the employer to modify these documents to meet site-specific hazards.
Asbestos Exposure Program - This Asbestos Operations and Maintenance Program has been developed to eliminate and control hazards associated with asbestos containing materials located at your site.
Bloodborne Pathogen Plan - Provides employers who have employees with BBP exposures, a guide for all areas that are required to be part of a BBP exposure plan.
Chemical Hygiene Plan - Non-production laboratories where small scale chemical experiments are conducted must have a chemical hygiene plan, under OSHA's Laboratory Standard (29 CFR 1910.1450). This sample plan is for secondary schools.
Confined Space Alternate Procedure Checklist - Provides employors and employees with a list of hazards that need to assessed prior to entering a Confined Space other that a PRCS.
Confined Space Permit Form (Sample One) - Guides employers and employees on the hazards that need to be assessed prior to entering a confined space.
Confined Space Permit Form (Sample Two) - Provides employers and employees with permits that are requied to enter PRCS. Air quality, rescue needs and addresses other hazards
Confined Space Program - Sample Permit Required Confined Space program. Itentifying spaces, equipment used, employee responsibilities ...
Construction Jobsite Checklist - Checklists for Construction related exposures.
Control of Hazardous Energy Sources (Lockout/Tagout) - Workplaces where employees do maintenance or repair work need a written Lockout/Tagout program to protect against unexpected startup of equipment.
Crane Inspection Form - Provides basic items on cranes that need to be inspected on a daily bases. (Hooks, steps, attachments, safety glass, drums ect..)
Crane Pre-Operational General Checklist - Provides a critical item checklist to the crane operator prior to operating.
Daily Visual Overhead-Crane - Provides a basic checklist of critical crane items for operators to inspect.
Electrical Task Assessment Checklist - Provides a checklist from NFPA 70E to ensure all safety items have been addressed when the need to work on live electrical systems.
Emergency Action Plan - Workplaces must have an emergency action plan to ensure employee safety in case of emergency. Companies with 10 or more employees must have this plan in writing.
Employer's Report of Occupational Injury or Disease - First report of occupational injury or disease form. Source: Workers' Compensation Board
Energized Electrical Work Permit - When live electrical must be performed all vested parties must be notified. All questions must be answered by the qualified electrician on this permit and turned over to the supervisor for approval.
Facility Inspection Checklist (MS Word Version) - Provides guidance to employers for the periodic inspection of thier facilities.
Fire Department and EMS Blood Borne Exposure Plan - Provides fire department and EMS with a guide for all areas that are required to be part of a BBP exposure plan.
Fire Prevention Plans - Plan to assist employers in fire prevention.
Flammable Liquids Storage - An employer guide to proper storage procedures for flammable liquids.
Forklift Operator Checklist - Daily checklist for safe operation of forklifts
General Respiratory Plan - Sample respiratory plan for general industry and construction workplaces (not for fire departments.)
Ground Ladder Checklist - Checklist for safety inspection of ground ladders.
Hazard Communication Plan - REVISED - Any workplace that has hazardous materials must have a written Hazard Communication program. Because most chemical products, even cleaning products, are consider hazardous, most workplaces need a Hazard Communication program. Revised program includes labeling changes under the Global Harmonization System.
Hearing Conservation Program (Construction) - Assists employers in devoloping a hearing conservation program
Hearing Conservation Program (General Industry) - Policy to assist employers who are required to have a hearing conservation in general industry.
Hepatitis B Vaccination Employer Record - Employer record of employee hepatitis B vaccinations or declination.
Hepatitis B Vaccine Declination Form - Sample Hepatits B Vaccine Declination form the employer shall have a signed copy on file, if an employee chooses not have the Hepatitis B Vaccine.
Hydraulic Jack Inspection Checklist - Provides items to be inspected every 6 months to ensure safe and proper functioning of jacks.
Lock Out / Tag Out Program - Program to assist employers in ensuring employees are using procedures to isolate energy sources prior to maintenance and other duties of equipment in the workplace.
Lock out procedure annual review form. - Annual Lockout - Tagout Administrative review of detailed writen procedures of lockouts for equipment.
Lockout / Tagout Procedures Inspection Form - At least annually an inspector will review the Hazardous Energy Control Procedure with all authorized employees and actually observe the use of the procedure.
Lockout Procedure for Dump Body Trucks - Example Lockout Procedure for Maintenance on Dump Body Truck
Lockout Procedure for Water Pump - Detailed sample lock out procedure for a waste water pump.
Lockout Tagout form for Equipment - Forms for lockout/tagout procedures,programs and equipment.
Lockout Tagout Training Form - Ensures that training has been received on the Mandatory Lockout - Tagout Program. Provides checklist of items to be trained on.
LOTO Lock Removal Procedure Form - Provides the proper procedure for removing a LOTO device when the device owner is not availible to remove it.
Maine's 301 Injury Illness Incident Report - If there is a pubic sector injury or illness incident that needs to be reported, and the workers compensation first report of injury is not available, this form may be used.
Medical Evaluation Checklist - Checklist for administrators to use.
N-95 Respiratory Protection Program - State of Maine public sector employers who require n-95 respirators to be used are required to have this program in place. This is a guide to be in compliance.
Need for PPE on Tasks Checklist - Assist employers in determining which areas of the body may need PPE depending on the tasks being performed.
OSHA 300 Injury Reporting Forms - Provides OSHA 300, 300A Summary Form and 301 Forms
Overhead Crane Monthly Inspection Form - Items that are required to be checked on overhead mobile cranes provided by United States Crane Certification Bureau.
Pallet Jack Inspection Form - Items to be inspected on a pallet jack prior to operations at the begining of the shift.
Performance Test for Forklift Operators - Form that allows the employer to evaluate forklift operators skills at the work site.
PPE Assessment Form - Basic form list "task", "hazard", "PPE recommendation". A sample page is provided.
PPE Assessment Form Version 2 - Assist employers in training employees on PPE needs for a task. Provides area to document training.
PPE Assessment Version 3 - Detailed box check off of tasks PPE needed.
Qualitative Fit Test Form (saccharine method) - This form is for fit testing tight fitting respirators using the saccharine method.
Qualitative Respirator Fit Test - Evaluates fit of respirators to ensure safe use.
Respirator Fit Testing Checklist - Items that are required for employees who are using tight fitting respirator facepieces.
Respirator Medical Evaluation Form - Appendix C to 1910.134: OSHA Respirator Medical Evaluation Questionnaire (Mandatory)
Respirator Program Evaluation Checklist - Checklist for program administrators to use.
Respirator Selection Checklist - Helps you select a respirator that is appropriate for the hazards present at the worksite.
Respiratory Plan for Fire Departments - This sample plan concerns respirator use in general industry and construction workplaces as regulated in 29 CFR 1910.134 .
Respiratory Protection Programs Checklist - Helps ensure your facility has met all requirements for a respiratory protection program.
Responding to Domestic Violence Abusers in the Workplace - This toolkit was designed to help employers and workers create a comprehensive response to domestic violence in the workplace.
Safe Operation of Forklifts (2) Daily Checklist - Daily checklist items for safe operation of forklifts.
Safety Harness Inspection Checklist - Provides a safety checklist for fall protection body harnesses. Check stitching,D-rings and other critical items of harnesses and lanyards.
Safety Training Sign Off Sheets - Provides needed documentation for employers to track employee training has been conducted.
Sample Lockout Procedure for Front Loader - Lockout Procedure for Maintenance on Front Loader
Silica Program - Model program to assist employers with high levels of Silica exposures with monitoring,record keeping and training
Staging Checklist - Daily stationary staging checklist,
Torch and Welding Hot Work Permit - List items that need to be addressed prior to cutting and welding to prevent fires in the workplace.
Volunteer Firefighter Model Policy - Public Law 296 provides volunteer firefighters protection from discipline or discharge, in certain employment situations, on the grounds that the volunteer firefighter arrives late or does not arrive to work because the volunteer firefighter is responding to certain emergencies to which the fire department is called to respond. The law allows written agreements between employees and employers to supersede the terms of the proposed law. This model policy / agreement has been developed as an option for employers to use.
Wire Rope Inspection Report - Part of crane inspection concerning the condition of wire ropes on cranes and other material lifting devices.
Workstation Checklist - Helps identify risk factors contributing to work-related discomfort or problems at workstations.