Forms & Tools

Safety coordinator collaboration website: This site can be used by agency safety coordinators to keep track of safety events, collaborate on or exchange documents and files, or discuss safety topics via online messages. For help with the collaboration site or to be granted access email ra-oasafety@pa.gov.

Agency Workplace Safety and Health Manual: The manual includes templates to customize to ensure they meet the needs of the agency. The forms and tools below, while included in the manual, are among those most commonly used.

Accident Investigation

Accident Investigation Form: A sample form to conduct initial or follow-up accident investigations including completion instructions and suggested best practices. This can assist agencies in documenting accidents to determine contributing factors and ways to prevent similar accidents from recurring in the future.
Accident Investigation Supervisor Memo: The memo can be used to inform supervisors of their responsibility to conduct accident investigations and the corresponding forms to be completed.
Incident Statement: This form should be used to obtain information from a witness to a work-related injury or accident.

Compliance Tools

Policy & Program Evaluation Form: All mandatory program elements and protocols require an annual review to evaluate compliance and opportunities for improvement. This form may be used to document the review.
Program Review Form: An OA form may be used by agencies as a self-audit checklist or evaluation tool when reviewing program elements for compliance.
Protocol Assessment Checklist: A checklist, generally forwarded to program staff for completion, assists in determining whether there is a need for any additional protocols.
Element O - Data Analysis Tool and Element O - Injury Analysis Tool: The self-insured employer must be able to demonstrate a statistical analysis of losses incurred during the current fiscal year and the two previous to identify the overall effectiveness of the A&IP Program efforts. The analysis of the statistical data must identify the type of injuries, where the injuries are occurring, and any other identifiable trends.

Hazard Identification and Program Improvement

Office Safety Inspection Checklist: This checklist can be used to assess and document potential safety hazards that may be present in administrative work locations. The form should be completed by employees who have been trained to perform safety inspections. The form can be customized. This version shows an example of other questions that may be considered for office settings.
Inspection Checklist for Industrial Settings: This checklist can be used to assess and document potential safety hazards that may be present in industrial work locations, such as warehouses or maintenance areas. The form should be completed by employees who have been trained to perform safety inspections.
Industrial Hygiene Evaluation Report: This report can be used to gather information in order to evaluate workplace industrial hygiene related issues or complaints.
Safety Suggestion Form: Provide employees with a standard method to communicate safety suggestions or concerns. The Safety Suggestion Program Memo can be used in conjunction with the form to inform employees of the agency’s Safety and Health Suggestion Program.
Goals & Objectives: The form provides two samples that may be used to list and track the progress of developed goals, objectives, and action items.
Office Ergonomic Concern and Ergonomic Assessment: These forms can be used to identify and evaluate potential ergonomic hazards in the workplace.

Communication Templates

Elements Requiring Communication & Frequency: The chart provides a quick reference regarding the minimum requirements for most annual or periodic communications.
Annual Safety Communication: A sample letter that combines several required annual communications in to one notification.
First Responder Volunteer Memo: This memo can be used to garner interest and seek volunteers to participate in voluntary first aid, CPR, and AED training.
First Responder Availability Memo: This memo can be used to communicate the procedure to initiate an internal response and the contact information of volunteers trained in first aid, CPR, and/or AEDs.
First Responder Volunteers for Medical Emergencies: This form can be used to list, post, or communicate the individuals that are trained (first aid, CPR, AED) and volunteered to assist in the event of a medical emergency.
Industrial Hygiene Related Services Memo: This memo can be used to communicate the industrial hygiene procedures and available services to managers, supervisors, and/or employees.
Safety Committee Letter to Unions: This letter informs unions regarding the formation of agency safety committees. The letter asks the unions to provide the names of employees who are willing to serve on the committee(s).
Safety Policy Statement: A template safety and health policy statement that may be used by any agency.