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Policy Statement

It is [COMPANY NAME]’s policy statement to provide a safe and healthy working environment for all employees. [COMPANY NAME] is committed to preventing injuries and illnesses caused by occupational exposures. We will provide training, review our procedures, review accidents, and maintain the equipment to ensure safe working conditions. The responsibility of safety is shared by both the management team and the employees. This safety policy applies to all [COMPANY NAME] employees, regardless of position within the company.

The owner/management team will provide top-level support of safety program initiatives. We will consider all employee suggestions for achieving a safer, healthier workplace. Supervisors will provide training in safe work practices, enforce company safety rules and work to eliminate hazardous conditions. Supervisors will lead safety efforts by example.

Employees will work safely, advise and caution each other, bring hazardous conditions to their supervisor’s attention, and report accidents immediately. All [COMPANY NAME] employees will look after their own safety and the safety of their coworkers.

Any employee/supervisor who knowingly and negligently violates this safety program, any state or federally mandated safety regulations, rules, or instructions, which result in, or could result in, serious injury, property damage, company equipment damage, or a regulatory citation, will be subject to disciplinary action up to and including termination.

____________________________________________________ __________________________________________________

OWNER/SENIOR MANAGER SIGNATURE                                                        DATE

Workplace Analysis

[COMPANY NAME] will regularly analyze the worksite to identify and eliminate potential hazards (see Hazard Identification Form) to ensure safe work practices and healthy conditions. After the hazards have been identified, you can complete a hazard analysis to analyze the hazards that employees experience and present possible solutions.

Incident Investigation

Regardless of whether there was any damage or injury, the [DESIGNATED SAFETY PERSON] will perform an incident investigation with the assistance of the supervisor at the location where the incident occurred. Incidents may include property damage, near-misses, workplace injuries, or illnesses. These investigations are to assess the nature and root cause of the incident and then adjust our standard operation practices (SOP) and training accordingly. Incident investigation reports must be submitted to the designated management personnel as soon as possible after the incident (see Accident Investigation Report form). 

First Report of Injury and Emergency

Our workers’ compensation insurance carrier must be notified as soon as possible of any on-the-job injury that requires medical treatment beyond first aid. In the event of a medical emergency, the injured worker should be transported to the nearest medical treatment facility. They should not drive themselves.

OSHA Forms 300, 300A, and 301

As required by OSHA standards, all work-related injuries and illnesses must be recorded on the OSHA 300 log no later than six working days after an injury is reported to management. The OSHA form 300A (a summary form for the previous calendar year) must be posted on the employee bulletin board for all employees to see on February 1 of each year and must remain posted until April 30 of the same year. The original log will be placed in a file and retained for five years.

When a work-related employee injury or illness occurs, an incident report must be filled out using form 301, or an equivalent. A workers’ compensation, insurance, or other report may be an acceptable substitute if it contains all the information required on form 301.

Safety and Health Training

[COMPANY NAME] has established this training program to assist employees in working safely and to minimize the risk of injury. Supervisors are responsible for regularly training their employees and observing the implementation of the safe operating practices, policies, and practices in the workplace. Workplace safety and health orientation begins on the first day of initial employment or before beginning a new task or job. All employees will be retrained periodically on safety programs, changes made to those programs, and other important safety topics.

Medical Management

Our policy is to maintain and support a return-to-work (RTW) program. When a work-related injury occurs, our goal is to return that injured employee to work in a productive and essential capacity as soon as possible. If an employee is injured on the job and needs medical attention, immediately report the injury to their supervisor so we can find applicable first aid or medical treatment.

Our policy is to identify return-to-work duties in the form of either changed duties within the scope of an employee’s current position or other available duties for a worker. An employee’s early return to work, and return to their normal job assignment, must always include a physician’s review of the appropriate job description along with the signed approval from their physician on a Physician’s Release to Return to Work form. It is the injured worker’s supervisor and the safety coordinator’s responsibility to know and understand the company’s policy and procedures concerning the return-to-work policy and ensure the policy is used properly. There will be regular contact with the employee’s supervisor to assure appropriate recovery and job duties for the injured employee.

Job Hazard Analysis



Task or Step



Personal Protective Equipment (PPE)


























Accident Investigation Report

Report #:                                                         Date:



Name of injured employee:


Gender:                       Age:                             Accident date:

Employee job title:

Length of time on the job:

Address where accident occurred:

Nature and type of injury, part of body affected:

Describe the accident and how it happened:


Cause of the accident:


Was PPE required?:

Was PPE provided?:

Was PPE being used?:

If not, please explain:

Was PPE being used as trained by supervisor/designated trainer?:

List any witnesses:

Was safety training provided to the injured?

If not, please explain:

List interim corrective actions taken to prevent recurrence:


List permanent correction actions recommended to prevent recurrence:


Status and follow-up action taken by safety director:



Supervisor signature:                                                                          Date:

Safety director signature:                                                                    Date:


Physician Release to Return to Work Form

Employee name:                                                                                 Date:

Physician name:                                                                                 Phone:

To be completed by the physician.

After reviewing the attached job description and the specific tasks within the job description, please complete either A or B below as appropriate and sign and date below.

  1. The above-named employee has been released by the above-named physician to return to full duty work as of (date) with NO RESTRICTIONS.
  2. The above-named employee has been released by the above-named physician to return to work on (date) with the restrictions listed below through (date).

(Check/circle all applicable options and provide limitations/restrictions.)

  • Lifting (max weight in lbs.):
  • Repetitive lifting:
  • Carrying:
  • Pushing/pulling:
  • Pinching/gripping:
  • Reaching overhead
  • Reaching away from body
  • Walking (hrs/day):
  • Standing (hrs/day):
  • Sitting (hrs/day):
  • Crawling (hrs/day):
  • Kneeling (hrs/day):
  • Squatting (hrs/day):
  • Climbing (hrs/day):
  • Repetitive motion restrictions:
  • Other restrictions:
  • These limitations are (circle one): temporary limitations/restrictions or permanent limitations/restrictions

If the restrictions listed above constitute modified duty and such duty is not available, it is assumed the employee will be sent home rather than return to work. My signature below indicates that I have read and understand the employee’s job description and the listed tasks, and that my findings are based on my medical assessment of this employee’s physical capabilities as compared to the essential job functions.

Physician name (print):

Physician signature:                                                                           Date:

To be completed by the injured employee.

I agree that I will follow through with all the restrictions listed above. I will notify my supervisor of any departure from these restrictions.

Employee name (print):

Employee signature:                                                                           Date: