Resolution No. 2013-080RESOLUTION NO. 2013-80
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
VERNON ADOPTING AN UPDATED CITY OF VERNON WORKPLACE
INJURY AND ILLNESS PREVENTION PROGRAM MANUAL
(SAFETY PROGRAM)
WHEREAS, on May 21, 1991, the City Council of the City of
Vernon adopted Resolution No. 5925 approving the City of Vernon Safety
Program, as amended by Resolution Nos. 6722, 7491, 8485 and 8905 on
December 5, 1995, February 15, 2000, July 14, 2004 and
November 16, 2005; and
WHEREAS, by memorandum dated September 17, 2013, the
Director of Human Resources has recommended the City adopt an updated
City of Vernon Workplace Injury and Illness Prevention Program Manual
("Safety Program"); and
WHEREAS, the purpose of the Safety Program is to establish
general methods and procedures for developing and maintaining a
program of accident prevention throughout the operation of the City;
and
WHEREAS, the City Council desires to adopt an updated Safety
Program.
NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF VERNON AS FOLLOWS:
SECTION 1: The City Council of the City of Vernon hereby
finds and determines that the above recitals are true and correct.
SECTION 2: The City Council of the City of Vernon finds
that this action is exempt under the California Environmental Quality
Act (CEQA), in accordance with Section 15061(b)(3), the general rule
that CEQA only applies to projects that may have an effect on the
environment.
091013645
SECTION 3: The City Council of the City of Vernon hereby
approves the City of Vernon Workplace Injury and Illness Prevention
Program Manual ("Safety Program"), a copy of which is attached hereto
as Exhibit A.
SECTION 4: All resolutions or parts of resolutions,
specifically Resolution Nos. 5925, 6722, 7491, 8485 and 8905, not
consistent with or in conflict with this Resolution are hereby
repealed.
SECTION 5: The Interim City Clerk, or Deputy City Clerk, of
the City of Vernon shall certify to the passage, approval and adoption
of this resolution, and the Interim City Clerk, or Deputy City Clerk,
of the City of Vernon shall cause this resolution and the Interim City
Clerk's, or Deputy City Clerk's, certification to be entered in the
File of Resolutions of the Council of this City.
APPROVED AND ADOPTED this 17t" day of September, 2013.
MAN
Name: W. Michael McCormick
Title: Mayor /
Interim City Clerk / Lap4ti—G-i-t7--eler
APPROVED AS TO FORM:
, Deputy City Attorney
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091013645
STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
I,
Dana Reed
ss
Interim City Clerk 1 Depiity G ty of
the City of Vernon, do hereby certify that the foregoing Resolution,
being Resolution No. 2013-80, was duly passed, approved and adopted by
the City Council of the. City of Vernon at a regular meeting of the City
Council duly held on Tuesday, September 17, 2013, and thereafter was
duly signed by the Mayor or Mayor Pro-Tem of the City of Vernon.
Executed this II.`1 day of September, 2013, at Vernon, California.
(SEAL)
InterilR City Clerk /
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091013645
EXHIBIT A
City of 4emon
Workplace Injurf & rtd,ea
7 everHon diagram
Rev 9113
SAFETY PROGRAM
TABLE OF CONTENTS
Chapter I INTRODUCTION
Policy, Procedures, Responsibilities,
Director of Human Resources, Department Head,
Supervisor, Employee
Chapter 2 ADMINISTRATIVE PROCEDURES
Communication, General Procedures,
CAL/OSHA Requirements
Chapter 3 SAFETY COMMITTEE
Committee Organization, Meeting
Procedures, Activities, Sub -Committees, Supervisors
Injury Reports, Recommendations, Suggestions &
Hazardous Situations
Chapter 4 SAFETY INSPECTION
Procedures for Locating and Eliminating
Possible Hazards, Inspection Schedule
Exhibit A - Report of Safety Problem Form
Chapter 5 TRAINING AND INSTRUCTION
General workplace safety and health practices,
Safety Training Checklist, Job Safety Analysis
Job Instruction Training
Chapter 6 WORK -RELATED INJURY AND ILLNESS
Job Injury Procedures, Modified Work, Lost Time,
Follow-up Visits, Physicians, Reporting Requirements,
ExhibitB —DWCI Form1,
Exhibit C -On the Job Injury Log,
Exhibit D - Supervisor's Report of Accident/Exposure,
Exhibit E- Form 5020
Chapter 7 ACCIDENT INVESTIGATION AND ANALYSIS
Checklist for Identifying Key Factors,
Employer Level Investigation
Exhibit F - Accident Investigation Form
Chapter 8 AUTOMOTIVE ACCIDENTS
Automotive Accident Procedures
Exhibit G — Vehicle Accident Investigation Form
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Chapter 9 SAFETY AND HEALTH ENFORCEMENT
Safety and Health Work Practices Enforcement
Chapter 10 OPERATIONS IN THE PUBLIC WAY
Traffic Controls/Barricades, Pedestrian Safety
Chapter 11 SAFETY REGULATIONS
Principal Causes of Accidents, General Safety Rules,
Office Safety, Clothing and Safety Equipment, Tools and
Equipment, Material Handling, Electrical, Housekeeping,
Automotive, Portable Ladders and Work Platforms, Pneumatic
Tools and Lines, Burning and Welding, Chemicals, Excavations,
Street Repairs, Sub -Surface Operations, and Confined Spaces,
Fire Prevention
Chapter 12 HAZARDOUS MATERIALS
Contingency Plans, Training Plans,
Supervisor Guidelines, Hazardous Materials Training
For Employees, Appendix A
Chapter,13 - EMERGENCY PREPAREDNESS
Chapter 14 VIOLENCE FREE WORKPLACE POLICY
Violence Free Workplace policy and procedure
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CHAPTER I
INTRODUCTION
SAFETY POLICY
The purpose of this Workplace Injury & Illness Prevention Program is to establish general
methods and procedures for developing and maintaining a program of accident prevention
throughout the operations of the City of Vernon.
In carrying out these purposes, this program has as its specific objectives the prevention of physical
injury, disability, sickness, loss of work, fatalities and destruction or damage to property of the City.
As an additional objective, it also includes the prevention of accidents involving the citizens or
property within the City of Vernon.
A common and sympathetic interest exists between the City's management and employees in the
maintenance of an adequate and effective accident prevention program. The promotion of this
common interest is furthered and extended through close cooperation.
The procedures that follow anticipate that such cooperation will be established and maintained at all
times between management, its employees and employee associations.
PROCEDURES
The general procedures to be followed are divided into three parts as follows:
Eliminate unsafe structures, installations, working conditions, acts of individuals,
and unsafe automotive and other equipment.
2. Organize and supervise a program of safety information and training among the
employees to teach:
a. The correct use of tools and equipment.
b. Safe work methods.
c. Safety precautions.
d. Application of safety rules for accident prevention.
e. Proper use of safety devices.
Safety orientation of new employees.
3. Maintain records of accidents and safety performance. Investigate and analyze all
accidents, prepare reports for management and submit recommendations for preventative
measures.
ORGANIZATION
The organization of the safety program utilizes all existing channels of authority within the
City of Vernon. In addition to these established channels, a supplementary organization has
been set up with specific responsibility for the safety program as follows:
The Director of Human Resources is the Safety Officer and serves under the direction of the City
Administrator in all functions in connection with this program. The Director of Human Resources
shall serve as an advisor to the Safety Committee.
Safety Coordinator: Safety Coordinators will be department safety
representatives. They will be responsible for reporting unsafe conditions to
their respective Department Heads and the Director of Human Resources.
Safety Committee: The Safety Committee will consist of the Director of
Human Resources, and Safety Coordinators. The Committee will be
responsible for the overall operation of the safety program. The Safety
Committee shall meet once each month at a regularly scheduled date and time.
Tailgate (department) Meetings. These meetings will provide the Safety
Coordinator with the opportunity to impress upon personnel the necessity of
making accident prevention an essential part of the job. Tailgate meetings shall be
held biweekly at a regularly scheduled date and time as mandated. If not
mandated, Tailgate meetings may be held as needed.
RESPONSIBILITY
Director of Human Resources
The Director of Human Resources has the authority and the responsibility for implementing and
maintaining this IPP Program for the City of Vernon. The Director of Human Resources is
responsible for the development, organization, coordination and implementation of safety programs
and safety education. Responsibilities also include work site inspections, hazard reduction and/or
elimination, accident/injury investigation, reporting and management.
The Director of Human Resources will advise the City Administrator as well as Department
Heads, supervisors and employees of unsafe conditions, problems related to accident
prevention and recommendations for loss control. The Director of Human Resources will not
fulfill obligations of administrators or supervisors relative to providing safe work
environments, necessary equipment, training as well as inspections in the interest of accident
prevention. The Director of Human Resources will prepare a monthly loss analysis report to the
City Administrator, City Council and Department Heads.
Department Head
The Department Head is responsible for fulfillment of departmental goals and objectives as well as
health and welfare of each employee in the department. In the adopted safety policy, the highest
priority has been placed on employee safety, which, therefore becomes the responsibility of the
respective administrator. It is normal practice for supervisors to be delegated the authority to carry
out safety policy in his or her department; but the responsibility for meeting objectives and the
protection of employees in performance of their assignments cannot be transferred.
Supervisors
Supervisors are responsible for implementing and maintaining the IPP Program in their work areas
and for answering workers questions about the IPP Program. A copy of this IPP Program is
available from each manager and supervisor. Supervisors will assume the responsibility of
thoroughly instructing their personnel in the safe practices to be observed in their work situations.
They will consistently enforce safety standards and requirements to the utmost of their ability and
authority. Supervisors will act positively to eliminate any potential hazards within the activities
under theirjurisdiction and they will set the example of good safety practice in all spheres of their
endeavors. The principal duties of supervisors in discharging responsibilities for safety are as
follows:
Enforce all safety regulations in effect and make employees aware that violations of
safety rules will not be tolerated.
Make sure all injuries are reported promptly and all accidents are reported even if injury
is not apparent.
3. Conduct a thorough investigation of all accidents and take necessary steps to prevent
recurrence through employee safety education, operating procedures or modification
of equipment.
4. Provide employees with complete safety instructions regarding their duties prior to
the employee actually starting to work.
5. Conduct regular safety checks of the area, including a careful examination of all new
and relocated equipment before it is placed in operation.
6. Properly maintain equipment and issue instructions for the elimination of fire and
safety hazards.
7. Continuously inspect for unsafe practices and conditions and promptly undertake
corrective action.
8. Develop and administer an effective program of good housekeeping and maintain
high standards of personal and operational cleanliness throughout all operations.
9. Provide and maintain safety equipment and protective devices for each job based on
knowledge of applicable standards or on recommendation of the Department Head
and/or Director of Human Resources.
10. Conduct tailgate meetings for safety education at biweekly intervals, allow
discussion period for employees to express their concerns, ask questions, etc.
11. Give full support to all safety procedures, activities and programs.
Employee
Each employee, as part of the comprehensive safety and loss prevention program, is expected to
place safe work practices and identification of unsafe conditions in their highest priority while
performing their daily tasks. Each employee's safety commitment must include, but is not limited
to the following:
Using safety equipment which has been provided in performing his/her daily work
assignments.
2. Wearing the prescribed uniform and safety shoes as required. Wearing any and all safety
apparatus as required by the job.
Not operating equipment or using tool for which training or orientation has not been
received.
4. Warning supervisors and co-workers of unsafe conditions or practices they are engaged in
which could lead to or cause an accident.
5. Reporting defective equipment, including vehicles, immediately to a supervisor and filing
repair orders per departmental policy.
6. Reporting dangerous or unsafe conditions that exist in the work place as well as throughout
the city. This would include defective sidewalks, broken curbs, hanging limbs, loose
handrails, open manholes, sunken basins and sewers, missing signs, etc.
7. Reporting of all injuries and accidents regardless of severity.
8. Taking care not to abuse tools and equipment, so that these items will be in usable condition
for as long as possible as well as to ensure that they are in the best possible condition while
being used.
COMPLIANCE
All workers, including managers and supervisors, are responsible for complying with safe and
healthful work practices. Our system of ensuring that all workers comply with these practices
includes the following checklist:
✓ Informing workers of the provisions of the City of Vernon IIP Program
✓ Evaluating the safety performance of all workers.
✓ Recognizing employees who perform safe and healthful work practices.
✓ Providing training to workers whose safety performance is deficient.
✓ Disciplining workers for failure to comply with safe and healthful work practices.
CHAPTER 2
ADMINISTRATIVE PROCEDURES
COMMUNICATION
All managers and supervisors are responsible for communicating with all workers about
occupational safety and health in a form readily understandable by all workers. Our
communication system checklist encourages all workers to inform their managers and supervises
about workplace hazards without fear of reprisal.
Our communication system includes the following checklist of items:
✓ New worker orientation including a discussion of safety and health policies and procedures.
✓ Review of our IIP Program.
✓ Training programs.
✓ Regularly scheduled safety meetings.
✓ Posted or distributed safety information.
✓ A system for workers to anonymously inform management about workplace hazards.
✓ Our department communicates with and instructs employees orally about general safe work
practices and hazards unique to each employee's job assignment.
GENERAL PROCEDURES
Under the direction of the Human Resources Director, administrative procedures shall be
established for the following:
The Safety Committee shall meet once each month. Meeting date and time may be
changed by a consensus of the committee but no less than one meeting each month is
required.
2. Department Heads will allocate time for their Safety Coordinators to conduct Tailgate
meetings within their departments. These meetings will be conducted as required by
law.
3. A written record of the minutes of the Safety Committee and department or unit safety
meetings shall be made. A copy of such minutes will be made and forwarded to Human
Resources Department.
4. Prompt written response of action(s) taken on reports from Human Resources
Director and/or recommendations submitted by the Safety Committee.
5. Effective accident investigation.
6. Action against individual violators of safety rules and practices.
7. Safety training programs for employees and supervisory personnel.
8. Complaints from employees concerning a possible injury or potential illness.
9. Inspections, audits and a periodic review of all premises, equipment and materials.
Recommendations may be categorized as follows:
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a. Immediate Action- those items which pose imminent danger or which require
only modest expenditures of time and material, and can be accomplished by the
person having direct responsibility.
b. As Soon As Possible - those items which require the assistance of another
department, routine maintenance items, hazards which may lead to possible
serious injury and those requiring a modest expenditure of time and money.
c. As Schedule Permits - those items which are temporarily acceptable but will
require correction.
d. Pre -planning Necessary - recommendations requiring new programs,
equipment or process
Documentation
Action on any of the above shall be documented in all instances.
CaIOSHA POSTING, REPORTING AND RECORD KEEPING REOUIREMENTS
1. Posting Requirements
CalOSHA poster must be posted in a prominent place. This poster states the intent and
coverage of CalOSHA and the responsibilities of employers and employees to maintain
a safe and healthful working environment.
2. Reporting
All fatal accidents, serious injuries, and catastrophes involving five or more employees
that require hospitalization for more than 24 hours, must be reported immediately to the
Department of Industrial Relations and in no case more than 24 hours of occurrence.
3. Record Keeping
Records shall be made and maintained in accordance with CalOSHA requirements. The
official records will be kept by the Human Resources Director.
4. Inspections
The CalOSHA inspector usually will arrive unannounced. Refer the inspector to the
Director of Human Resources.
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CHAPTER 3
SAFETY COMMITTEE
COMMITTEE ORGANIZATION
Representation on the Safety Committee shall be as follows:
All City departments will be represented by a Safety Coordinator.
2. Committee members shall serve for two years or until replaced by the Department Head.
3. The Director of Human Resources may be the Chairperson.
4. One of the committee persons may be designated as vice -chairperson who will chair the
meetings in the absence of the chairperson.
5. Chairperson may appoint a secretary to record the minutes of the meetings.
6. Chairperson may appoint sub -committees and members as required with approval of the
City Administrator.
The Safety Committee shall meet monthly at a regularly scheduled date and time. Meetings
should not extend beyond one and one-half hours and should normally be of one -hour duration or
less depending on the business to be conducted.
Committee meeting procedures are as follows:
Start of meeting - Chairperson (date and time).
2. Roll call - record members present and absent.
3. Introduction of visitors, if any.
4. Review minutes of previous meetings and approve or amend.
5. Unfinished business (reports from committees).
6. Review of accidents and recommendations to prevent recurrence.
7. New business (recommendations, suggestions, hazardous situations).
8. Other business, if any.
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9. Announcement of next meeting, date, time and place.
10. Adjourn meeting (time).
SCOPE OF COMMITTEE ACTIVITIES
The Safety Committee recommends matters of policy such as training needs and methods, safety
equipment, rules and practices, etc. They may review accident reports and statistics; and project
future plans for the advancement of the safety program through the basic elements: engineering,
education and enforcement.
Safety Inspection Comm ittee- responsible for the coordination of City-wide annual and
specialized inspections. This committee may function at the department level.
SUPERVISORS INJURY REPORTS
The Department Head will review every injury/accident of an employee within his/her department
and recommend action to prevent recurrence, whenever possible. A copy of the recommendations
will be forwarded to the Director of Human Resources and City Administrator for further action.
RECOMMENDATIONS. SUGGESTIONS AND HAZARDOUS SITUATIONS
Committee members are encouraged to bring all safety matters to the attention of the affected
Department Head for correction prior to being brought up at a Committee meeting.
Every recommendation, suggestion or reported hazardous situation shall be assigned for action and
reported to the Committee person where the situation exists. However, there may be situations
when the Chairperson may have to contact management on a particular problem or where the
services of the Director of Human Resources may be required. In no case shall new business be
brought up and recorded without an assignment of responsibility.
The Safety Committee person who has been assigned a project will do the necessary research
and/or contact the Department Head for appropriate action.
CHAPTER 4
SAFETY INSPECTION
PURPOSE
The purpose of this part of the program is to eliminate unsafe structures, installations, working
conditions and equipment.
PROCEDURES FOR LOCATING HAZARDS
1. Periodic inspections will be conducted to recognize and correct unsafe working
conditions, acts and environmental hazards on or about facilities of the City, as follows:
a. Supervisors must maintain a continuous visual inspection of locations,
equipment, tools, personal protective devices and working conditions under
their supervision.
b. Safety Coordinators will conduct periodic inspections of departments they
represent.
c. Employees will report all possible hazards and/or safety problems to the
supervisor.
d. The Human Resources Director may inspect facilities and working
conditions and submit his/her findings and recommendations to management.
PROCEDURES TO ELIMINATE OR CORRECT HAZARDS
Unsafe or unhealthy work conditions, practices or procedures shall be corrected in a timely manner
based on the severity of the hazards. Hazards shall be corrected according to the following
procedures:
The supervisor responsible makes corrections whenever it is within his/her authority to
do so.
2. If corrections are beyond the authority of the supervisor responsible, he/she prepares a
request for correction and submits it through established channels for approval.
3. In the event the recommended corrections are of an urgent nature, verbal approval is
obtained from the proper authority, followed by the written request for approval.
4. If correction cannot immediately be made and danger to human life and property is
imminent, the equipment will be taken out of service and "tagged" to prohibit its use or
the operation will be stopped until such time as the hazard is either removed or
corrected.
4
When an imminent hazard exists which cannot be immediately abated without endangering
employee(s) and/or property, we will remove all exposed workers from the area except those
necessary to correct the existing condition. Workers who are required to correct the
hazardous condition shall be provided with the necessary protection.
5. If the possible hazard and/or problem does not pose an imminent danger to human life or
property, the employee shall:
a. Notify the supervisor of the problem
b. Complete the "Report of Safety Problem" form (Exhibit A).
INSPECTION SCHEDULE
Periodic inspections are performed according to the following schedule:
When we initially established our IIP Program.
When new substances, processes, procedures or equipment which present potential new
hazards are introduced into our workplace.
When new, previously unidentified hazards are recognized.
4. When occupational injuries and illnesses occur; and
5. Whenever workplace conditions warrant an inspection.
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EXHIBIT A
REPORT OF SAFETY PROBLEM
Date of Inspection: Person Conducting Inspection:
Unsafe Condition or Work Practice:
Corrective Action Taken:
Date of Inspection: Person Conducting Inspection:
Unsafe Condition or Work Practice:
Corrective Action Taken:
Date of Inspection: Person Conducting Inspection:
Unsafe Condition or Work Practice:
Corrective Action Taken:
When Corrected Supervisor signature: Date
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CHAPTER 5
TRAINING AND INSTRUCTION
All workers, including managers and supervisors, shall have training and instruction on general and
job -specific safety and health practices. Training and instruction is provided:
1. When the IIP Program is first established;
2. To all new workers, except for construction workers who are provided training through a
construction industry occupational safety and health training program approved by
Cal/OSHA;
3. To all workers given new job assignments for which training has not previously provided;
4. Whenever new substances, processes, procedures or equipment are introduced to the
workplace and represent a new hazard;
5. Whenever the employer is made aware of a new or previously unrecognized hazard;
6. To supervisors to familiarize them with the safety and health hazards to which workers
under their immediate direction and control may be exposed; and
7. To all workers with respect to hazards specific to each employee's job assignment.
General workplace safety and health practices include, but are not limited to, the following:
I . Implementation and maintenance of the IIP Program.
2. Emergency action and fire prevention plan.
3. Provisions for medical services and first aid including emergency procedures.
4. Prevention of musculoskeletal disorders, including proper lifting techniques.
5. Proper housekeeping, such as keeping stairways and aisles clear, work areas neat and
orderly, and promptly cleaning up spills.
6. Prohibiting horseplay, scuffling, or other acts that tend to adversely influence safety.
7. Proper storage to prevent stacking goods in an unstable manner and storing goods against
doors, exits, fire extinguishing equipment and electrical panels.
8. Proper reporting of hazards and accidents to supervisors.
9. Hazard communication, including worker awareness of potential chemical hazards, and
proper labeling of containers.
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10. Proper storage and handling of toxic and hazardous substances including prohibiting eating
or -storing food and beverages in areas where they can become contaminated.
SAFETY TRAINING CHECKLIST
Each department has the responsibility of providing on-the-job training to each employee on
the topics that will permit the employee to do his job safely and efficiently. This training shall
include:
✓ Orientation to departmental and City-wide safety and work rules.
✓ Procedures for reporting on-the-job injuries
✓ Workers' Compensation process
✓ City requirements for use of vehicles
✓ Reporting of Unsafe Conditions
In addition, specialized training must be offered in the use of tools and equipment in order to
maximize the capabilities of the equipment as well as to prolong its usable life and to prevent
accidents.
Every employee is expected to request instruction in those tasks or pieces of equipment with
which they are not familiar.
JOB SAFETY ANALYSIS (JSA)
A Job Safety Analysis is a structured outline used to train and review procedures in a manner that
highlights the key points and hazards in each task. It is recommended that the Job Safety
Analysis be prepared for each special function where many people are trained regularly to do the
job and where the potential for serious injury exists.
JOB SAFETY ANALYSIS (JSA)
JOB INSTRUCTION TRAINING (JIT)
A. Definitions:
Job Safety Analysis A procedure that identifies hazards or potential accidents
in each step of a job, and develops solutions that will eliminate or guard against
hazards.
Job Instruction Training A technique for on-the-job instructors when teaching
a person how to perform a particular task.
B. Job Safety Analysis Procedure
Select the job to be analyzed
Priority for selection
a. Frequency of injuries
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b. Potential for severe injury
c. Newly established jobs
d. Jobs where changes have been made
2. Break down the job
a. List steps in sequence
b. Not too detailed
c. Not too general
d. Technique of making JSA
(1). Select the right person to observe
(2). Brief the employee on the purpose
(3). Observe the employee performing the job
(4). Record each step in the breakdown
(5). Check the breakdown with the operator
3. Identify hazards and potential accidents
a. Environmental hazards (mist, fumes, dust, etc.)
b. Potential accidents (slip, trip, strain, etc.)
4. Develop solutions to eliminate hazards
a. Change existing conditions
b. Find a new way to do the job
c. Different tools, materials, equipment or location
5. The JSA should be developed by the operator and the supervisor
C. Job Instruction Training Procedure
1. Planning the training
a. Inventory present skills
b. Analyze the need for training
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2. How to instruct - the four -step method (JIT)
a. Prepare the worker
(1). Put the employee at ease
(2). Define the job
(3). Place in the correct position
b. Present the operation
(1). One step at a time
(2). Tell and show each step
(3). Stress each key point
c. Try out performance
(1). Have employee perform the task
(2). Have employee explain each key point
(3). Make sure he/she understands
d. Follow-up
(1). Put employee on his/her own
(2). Designate to whom the employee goes for help
(3). Check frequently
(4). Encourage questions
1s
CHAPTER 6
WORK -RELATED INJURY AND ILLNESS
PROCEDURES — TIME OF INJURY
Report the injury to your supervisor immediately. If the injury is serious and no supervisor is
present, get medical attention first.
2. Secure approval from your supervisor, the Department Head, or Human Resources
Department.
A Work Status Report form must be completed by physician and returned to the Human
Resources Department.
MODIFIED WORK
If restrictions are placed upon the injured employee, the treating physician shall notify
Human Resources Department of said restrictions either by phone or in writing.
2. If the Department Head and/or Supervisor determines that no modified work assignment is
available, the employee shall remain off work until one becomes available or released to full
duty
3. Employees are responsible for notifying their supervisors prior to any absence from home
beyond two days.
4. Modified work assignments are the responsibility of the department head and supervisor.
LOST TIME
The treating physician must authorize all time off from work. The certification of time off
may be subject to concurrence by a City physician.
2. It is the employee's responsibility to return doctors notes for all time off. Any time off not
supported by documentation shall be charged against the employee's benefit time (i.e.,
vacation, comp, time, etc) or considered unpaid leave at the discretion of the Department
Head.
FOLLOW-UP VISITS
Employees are required to attend all scheduled follow-up visits.
2: If an appointment cannot be kept, it is the employee's responsibility to cancel and/or
reschedule a minimum of 24 hours in advance. ,
Failure to comply with the above may result in a monetary expense to the employee if it
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is charged to the City by the treating physician.
PHYSICIANS
Employees should be treated at the City's designated industrial medical clinic unless an
Industrial Injury Physician P re - Designation Form is on file in the employee's personnel
file.
2. In the event of serious injury the employee should call 911 and have paramedic treat and
transport.
REPORTING REOUMEMENTS
If an employee is injured on the job beyond first aid give him/her the DWC Form I (Rev.
1 194) Employee's Claim For Workers' Compensation Benefits within 24 hours of date
you are informed. This may be handed to the employee or mailed regular mail but must be
done within 24 hours of date you learn he/she has been injured (See Exhibit B).
2. Complete the On The Job Injury log indicating employee's name, injury date, date you
were informed of the injury, date you provided the DWC Form I, date the DWC Form 1
was returned to you and the employee's signature that he/she did receive the DWC Form 1.
If employee is unavailable to sign for the form, the supervisor may sign indicating that
employee is unavailable (See Exhibit C).
3. Complete the Supervisor's Report of Accident (See Exhibit D).
4. Employer's Report of Occupational Injury or Illness (Form 5020). Complete this form
only if the injury is other than first aid. If in doubt, complete Form 5020 and send to
Human Resources Department. Workers Compensation staff will make the
determination (See sample at the end of this section, Exhibit E). This form must be
completed by the injured employee's supervisor.
REPORTING REQUIREMENTS FOR FIRST AID INJURIES
Injuries where there is no lost time beyond the date of injury or the injury requires no medical
treatment beyond first aid.
I. Complete the Supervisors Report of Accident/Exposure. Exhibit D
2. Complete the Employer's Report of Occupational Injury or Illness Form 5020. Exhibit E
3. Send both forms to Human Resources Department.
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I� iGIR7YiIIrPPdlad�S�7;7®I
Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reelamo de Compensation de Trabajadores (DWC 1) y Notification de Posible Elegibilidad S9 '
If you are injured or become ill, either physically or mentally, because of
your job, including injuries resulting from a workplace crime, you may be
entitled to workers' compensation benefits. Attached is the form for filing
a workers' compensation claim with your employer. You should read all
of the information below. Keep this sheet and all other papers for your
records. You may be eligible for some or all of the benefits listed
depending on the nature of your claim. If required you will be notified by
the claims administrator, who is responsible for handling your claim,
about your eligibility for benefits.
To file a claim, complete the "Employee" section of the form, keep one
copy and give the rest to your employer. Your employer will then
complete the "Employer" section, give you a dated copy, keep one copy
and send one to the claims administrator. Benefits can't start until the
claims administrator knows of the injury, so complete the form as soon as
possible.
Medical Care: Your claims administrator will pay all reasonable and
necessary medical care for your work injury or illness. Medical benefits
may include treatment by a doctor, hospital services, physical therapy, lab
tests, x-rays, and medicines. Your claims administrator will pay the costs
directly so you should never see a bill. There is a limit on some medical
services.
The Primary Treating Physician (PTP) is the doctor with the overall
responsibility for treatment of your injury or illness. Generally your
employer selects the PTP you will see for the first 30 days, however. in
specified conditions, you may be treated by your predesignated doctor or
medical group. If a doctor says you still need treatment after 30 days, you
may be able to switch to the doctor of your choice. Different rules apply if
yom employer is using a Health Care Organization (HCO) or a Medical
Provider Network (MPN). A MPN is a selected network of health care
providers to provide treatment to workers injured on the job. You should
receive information from your employer if you are covered by an HCO or
a MPN. Contact your employer for more information. If your employer
has not put up a poster describing your rights to workers' compensation,
you may choose your own doctor immediately.
Within one working day after you file a claim form, your employer shall
authorize the provision of all treatment, consistent with the applicable
treating guidelines, for the alleged injury and shall continue to be liable
for up to $10,000 in treatment until the claim is accepted or rejected.
Disclosure of Medical Records: After you make a claim for workers'
compensation benefits, your medical records will not have the same level
of privacy that you usually expect. If you don't agree to voluntarily
release medical records, a workers' compensation judge may decide what
records will be released. .If you request privacy, the judge may "seal"
(keep private) certain medical records.
Payment for Temporary Disability (Lost Wages): If you can't work
while you are recovering from ajob injury or illness, for most injuries you
will receive temporary disability payments for a limited period of time.
These payments may change or stop when your doctor says you are able
to return to work. These benefits are tax-free. Temporary disability
payments are two-thirds of your average weekly pay, within minimums
and maximums set by state law. Payments are not made for the first three
days you are off the job unless you are hospitalized overnight or cannot
work for more than 14 days.
Return to Work: To help you to returnto work as soon as possible, you
Should actively communicate with your treating doctor, claims
administrator, and employer about the kinds of work you can do while
recovering. They may coordinate efforts to return you to modified duty or
other work that is medically appropriate. This modified or other duty may
Si Ud. se lesiona o se enferma, ya sea fisicamente, o mentaamente, debido a
su trabajo, incluyendo lesiones que resullen de on crimen en el lugar de
trabajo, es posible que Ud. tenga derecho a beneficios de compensaci6n de
trabajadores. Se adjunta of formulario Para presentar on reclamo de
compensaci6n de trabajadores con su empleador. Ud. debe leer toda In
informaci6n a continuackin. Guarde cafe hoja y todos Ins demas
documentos Para sus archivos. Es posible que usted retina Ins requisitos
pare todos his beneficios, o parte de 6stos, que se enumeran, dependiendo
de la indole de su reclamo. Si se requiere, of administrador de reclamos.
quien es responsable por el manejo de su reclamo, le notificara sobre su
elegibilidad para beneficios.
Para presentar un reclamo. Ilene In secci6n del formulario designada Para el
"Empleado," guarde una copia, y dele el resto a su empleador. Entonces.
su empleador completara la secci6n designada para el "Empleador," le dare
a Ud. una _copia fechada, guardara una copia, y enviara una al
administrador de reclamos. Los beneficios no pueden comenzar hasta, que
el administrador de reclamos se entere de la lesi6n, asi que complete el
formulario to antes posible.
Atenckin M6dica: Su administrador de reclamos pagara toda la atenci6n
medica razonable y necesaria, para su lesi6n o enfermedad relacionada con
el trabajo. Es posible que los beneficios medicos incluyan el tratamiento
por pane de on m6dico, los servicios de hospital, In terapia fisica, los
an6lisis de laboratorio y las medicinas. Su administrador de reclamos
pagar6 directamente los costos, de manera que usted mince vera un cobro.
Hay un limite para ciertos servicios m6dicos.
El Medico Primario que le Atiende-Primary Treating Physician PTP es
el medico con la responsabilidad total Para tratar su lesion o enfermedad.
Generalmente, su empleador selecciona at PTP que Ud. vera durante los
primeros 30 dias. Sin embargo, en conditions especificas, es posible que
usted pueda ser tratado por su medico o grupo medico previamente
designado. Si of doctor dice que usted a6m necesita tratamiento despues de
30 dias, es posible que Ud. pueda cambiar al m6dico de su preferencia. Hay
reglas differentes quese aplican cuando su empleador usa una
Organization de Cuidado Medico (HCO) o una Red de Proveedores
Medicos (MPN). Una MPN es una red de proveedores de asistencia medica
seleccionados Para dar tratamiento a los trabajadores lesionados en el
trabajo. Usted debe recibir informaci6n de su empleador si su tratamiento
es cubierto per one HCO o una MPN. Hable con su empleador Para mas
informaci6n. Si su empleador no ha colocado on cartel describiendo sus
derechos pare la compensaci6n de trabajadores, Ud. puede seleccionar a su
propio medico inmediatamente.
Dentro de on dia despues de que Ud. Presente on formulario de reclamo, su
empleador autorizar& todo tratamiento medico de acuerdo con Ins pautas de
tratamiento aplicables a la presunta lesi6n y sera responsable por $10,000
en tratamiento hasta que el reclamo sea aceptado o rechazado.
Divulgacibn de Exnedientes M6dicos: Despues de que Ud. presente on
reclamo para beneficios de compensation de trabajadores, sus expedientes
medicos no tendran el mismo nivel de privacidad que usted normalmente
espera. Si Ud. no esta de acuerdo en divulgar voluntariamente los
expedientes medicos, on juez de compensaci6n de trabajadores
posiblemente decide que expedientes se revelarim. Si Ud. solicita
privacidad, es posible que el juez "•selle" (nantenga privados) ciertos
expedientes medicos.
Pao por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede
trabajar, mientras se est'a recuperando de una lesi6n o enfermedad
relacionada con el trabajo, Ud. recibirh pagos por incapacidad temporal
pam la mayoria de las lesions por on period limitado. Es posible que estos
pagos cambien o paren, cuando su m6dico diga que Ud. esta on condiciones
de regresar a trabajar. Estes beneficios son libres de impuestos. Los pagos
Rev. 6110 18
EXHIBIT B - DWC-1 FORM
Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reclamo de Compensaei6u de Trabajadores (DWC I) y Notification de Posible Elegibilidad
be temporary or may be extended depending on the nature of your injury
or illness.
Payment for Permanent Disability: If a doctor says your injury or
illness results in a permanent disability, you may receive additional
payments. The amount will depend on the type of injury, your age,
occupation, and date of injury.
Sunolemental Job Displacement Benefit (SJDB): If you were injured
after I/I/04 and you have a permanent disability that prevents you fi'oin
returning to work within 60 days after your temporary disability ends, and
your employer does not offer modified or alternative work, you may
qualify for a nontransferable voucher payable to a school for retraining
and/or skill enhancement. If you qualify, the claims administrator will
pay the costs up to the maximum set by state law based on your
percentage of permanent disability.
Death Benefits: 11' the injury or illness causes death, payments may be
made to relatives or household members who were financially dependent
on the deceased worker.
It is illegal for Your employer to punish or fire you for having a job
injury or illness, for filing a claim, or testifying in another person's
workers' compensation case (Labor Code 132a). If proven, you may
receive lost wages, ,job reinstatement, increased benefits, and costs and
expenses up to limits set by the state.
You have the right to disagree with decisions affecting your claim. If you
have a disagreement, contact your claims administrator first to see if you
can resolve it. If you are not receiving benefits, you may be able to get
State Disability Insurance (SDI) benefits. Call State Employment
Development Department at (800) 480-3287.
You can obtain free information from an information and assistance
officer of the State Division of Workers' Compensation (DWC), or you
can hear recorded information and a list of local offices by calling (800)
736-7401. You may also go to the DWC website at www.dwc.ca.gov.
You can consult with an attorney. Most attorneys offer one free
consultation. If you decide to hire an attorney, his or her fee will be taken
out of some of your benefits. For names of workers' compensation
attorneys, call the State Bar, of California at (415) 538-2120 or go to their
web site at www.califoi niasnecialist.ora.
per incapacidad temporal son dos tercios de su page semanal promedio,
con cantidades mfnimas y maximas establecidas por has ]eyes estatales.
Los pages no se hacen durante los primeros tres dias en que Ud. no trabaje,
a means que Ud. sea hospitalizado una noche o no pueda trabajar durante
mas de 14 dias.
Regreso at Trabaio: Para ayudarle a regresar a trabajar to antes posible,
Ud. debe comunicarse de manera activa con el m6dico que le atienda, cl
administrador de reclamos y el empleador, con respecto a las clases de
trabajo que Ud. puede hater mientras se recupera. Es posible que ellos
coordinen esfnerzos Para regresarle a on trabajo modificado, o a otro
trabajo, que sea apropiado desde el punto de vista mddico. Este trabajo
modificado u otro trabajo podria ser temporal o podria extenderse
dependiendo de la indole de su lesi6n o enfermedad.
P92o por Incapacidad Permanente: Si el doctor dice que su lesi6n o
enfermedad resulta en una incapacidad permanente, es posible que Ud.
reciba pagos adicionales. La cantidad dependera de la clase de lesi6n, su
edad, su ocupaci6n y la fecha de In lesi6n.
Beneficio Suplementario por Desplazamiento de Trabaio: Si Ud. Se
lesion6 despu6s del I/l/04 y tiene una incapacidad permanente que le
impide regresar at trabajo dentro de 60 dias despu6s de que los pages per
incapacidad temporal terminen, y su empleador no ofrece on trabajo
modificado o alternativo, es posible que Listed retina los requisitos Para
recibir on vale no-transferible pagadero a una escuela Para recibir on nuevo
entrenamiento y/o mejorar su habilidad. Si Ud. reline los requisition, el
administrador de reclamos pagaM Jos gastos hasta on maximo establecido
por ]as ]eyes estatales basado en su porcentrije de incapacidad permanente.
Beneficios nor Muerte: Si la lesi6n o enfermedad causa la muerte, es
posible que los pages se hagan a los parientes o a Ins personas que viven en
el hogar y que dependfan econ6micamente del trabajador difunto.
Es tlegal gue su empleador le castigue o despida, per sufrir una lesi6n o
enfermedad en el trabajo, por presentar un reclamo o per testificar en el
case de compensaci6n detrabajadores de otra persona. (El Codigo Laboral
secci6n 132a.) De set probado, usted puede recibir pagos por p6rdida de
sueldos, reposicidn del trabajo, aumento de beneficios y gastos hasta los
limites establecidos por el estado.
Ud. tiene derecho a no estar de acuerdo con ]as decisiones que atecten su
reclamo. Si Ud. tiene Lin desacuerdo, primero comuniquese con su
administrador de reclamos para ver Si Listed puede resolverho. Si Listed no
esta recibiendo beneficios, es posible que Ud. pueda obtener beneficios del
Seguro Estatal de Incapacidad (SDI). Llame al Departamento Estatal del
Desarrollo del Empleo (EDD) al (800) 480-3287.
Ud. puede obtener infarmaci6n gratis, de on oficial de informacion y
asistencia, de la Divisi6n Estatal de Compensaci6n de Trabajadores
(Division of Workers' Compensation — DJVQ o puede escuchar
information grabada, asf como una lista de oficinas locales Ilamando al
(800) 736-7401. Ud. tambi6n puede consultar con la pagina Web de la
DWC en www.dwc.ca.gov.
Ud. puede consultar con Lin abogado. La mayoria de los abogados
ofrecen una consults gratis. Si Ud. decide contratar a on abogado, los
honorarios seran tornados de algunos de sus beneficios. Para obtener
nombres de abogados de compensaci6n de trabajadores, (lame a la
Asociaci6n Estatal de Abogados de California (Slate Bar) at (415) 538-
2120, 6 consulte con la pagina Web en www.californiaspeciatist.org.
Rev. 6/10 19
State of California
Depannient of Industrial Relations
DIVISION OF WORKERS' COMPENSATION
EXHIBIT B — DWC-1 FCtd4 de California
Departamenlo de Relaciones Industriales
DIVISION DE COMPENSACION AL TRABAJADOR
WORKERS' COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the "Employee" section and give the form to
your employer. Keep a copy and mark it "Employee's Temporary
Receipt" until you receive the signed and dated copy from your em-
ployer. You may call the Division of Workers' Compensation and
hear recorded information at (800) 736-7401. An explanation of work-
ers' compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer de-
scribing workers' compensation benefits and the procedures to obtain
them.
PETITION DEL EMPLEADO PARA DE COMPENSAC16N DEL
TRABAJADOR (DWC 1)
Empleado: Complete to section "Empleado" y entregue la forma a sit
empleador. Quidese con la copia designada "Recibo Temporal del
Empleado" hasta que Ud reciba la copia firmada y fechada de su empleador.
Ud. puede Ilamar a la Division de Compensation at Trabajador at (800) 736-
7401 para oir information gravada. En la hoja cubierla de esia
forma esia to explication de los beneficios de compensaci6n at irabajador.
Ud. tambien deberia haber recibido de su entpleador un follelo describiendo los
benficios de compensaci6n at trabayador lesionado y los procedimientos para
obtenerlos.
Employee —complete this section and see note above Empleado--coniplete esta secci6n y note la notacitin arriba.
I. Name. Nombre.
2. Home Address. Direction Residential.
3. City. Ciudad.
4. Date of Injury. Fecha de la lesi6n (accidence).
Today's Date. Fecha de Hoy.
State. Esiado.
Zip. C6digo
Time of Injury. Hora en que ocurrib. a.m. p.m.
5. Address and description of where injury happened. Direcci6nllugor d6nde occurio el accidence.
6. Describe injury and part of body affected. Describo to lesion y parte del cuerpo afeclada.
7. Social Security Number. Nfimero de Seguro Social del Empleado.
1
8. Signature of employee. Firma del empleado.
Employer —complete this section and see note below. Empleador—complete esta secci6n y note la notation abajo.
9. Name of employer. Nombre del empleador.
10. Address. Direcci6n.
I I. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesi6n o accidence.
12. Date claim form was provided to employee. Fecha en que se le entregd at entpleado to petition. _
13. Date employer received claim form. Fecha en que el empleado devolvi6 to petition at entpleador.
14. Name and address of insurance carrier or adjusting agency. Nombre y direcci6n de la compania de seguros o agencia adminstradoro de seguros.
15. Insurance Policy Number. E/ ntimero de la p6liza de Seguro.
16. Signature of employer representative. Firma del representanle del empleador.
17. Title. Tilulo.
18. Telephone. Teldfono.
Employer: You are required to date this form and provide copies to Empleador: Se requiere que Ud feche esta forma y que provea copias a set can -
your insurer or claims administrator and to the employee, dependent I parka de seguros, administrador de reclamos, o dependientelrepresenionle de recla-
or representative who riled the claim within are working day of mos y at empleado que hayon presentado esia petici6n dentro del plazo de un dia
receipt of the form from the employee. lrcibil desde el momenta de haber sido recibida la forma del entpleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
❑ Employer copy/Collin del l:inpleadar ❑ Employee copy/( ( apiade/hiup/eado
EL FIRMAR FSTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
❑ Claims Adminisvalor/Adminismndm de Redd ar ❑ Temporary Receipt//tccibn de//;)rip/cadu
6/10 Rev. 20
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EXHIBIT D — SUPEVISORS REPORT OF ACCIDENT
CITY OF VERNON
SUPERVISOR'S REPORT OF ACCIDENVEXPOSURE
1. Name of injured
Job title
2. Department Supervisor
3. Address where accident
4. What was employee doing when injured?
5. Names of witnesses
6. How did accident I exposure occur?
7. If exposure, product I chemical involved?
8. Duration of exposure: _ hrs. _ min. r UNKNOWN
9. Object or substance that directly injured employee?
10. Nature of injury or illness and part of body affected?
11. Date of injury/illness/exposure Time
12. Has employee returned to work? F- NO r YES Date Returned
13. Who gave first aid, if any?
14. Did the employee go to the doctor? I- NO
Doctor's name:
15. Did employee commit an unsafe act? Explain
Sex r- MALE r FEMALE
r YES I- Treatment was offered but refused.
16. Explain factors that could have contributed to the accident (improper attitude, physical impairment is., eyesight, hearing, fatigue,
etc., or lack of knowledge or skill)
17. What have you personally done to prevent similar accidents?
DEPARTMENT HEAD DATE
041
CV.1.1r C __ rnDnn Cnin
Smile of esorns,
ease comps n rp e e (type possible) we copies o:
S ACASE NO.
EMPLOYER'S REPORT OF
AIj1c]1S AdIninistralOI'S
OCCUPATIONAL INJURY OR ILLNESS
P.0 Box 696. (onC01'd, CA 9452J Telephone (866) 482-3i35
❑
FATALITY
Any person who makes or causes to be made any
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
knowingly fake or fraudulent material statement of
date of the incident OR requires medical treatment beyond first aid. if an employee subsequently dies as a result of a previously reported injury or
material representation for the purpose of obtaining or
iUness, the employer must file Within live days of knowledge an amended report indicating death. In addillon, every serious injury, illness, a death
denying workers compensation benefits or payments is
must be imported immedlately by telephone or telegraph to the nearest office of the Califomm Division of Occupational Safety and Health.
guilty of a felony.
1. FIRM NAME
la. Policy Number
Please do not use
Enlp. 1139-
this column
E 2. MAILING ADDRESS: (Number, Sunni City, Zip)
2a. Phone Number
So
CASE NUMBER
P
L 3. LOCATION if tliNvrent/mm Melling Address (Numbeq.51rea1, City and Zip)
L. Location Cede
0
Dept Code -
OWNERSHIP
EA NATURE OF BUSINESS; e.g., Painting contractor, wholesale Bracer, sawmill, note, etc.
6. Stale unemployment Insurente aml.no
R
S T IFEOF EMPLOYER:
❑Privalo
❑Stlk ❑County
❑Cty
❑Schad DIslrim
[:]Other
Gov'45pecly:
INDUSTRY
7. GATEOPRLDRyl CNSEYOF ILLNESS
S. TIME INJURYALLN EBB OCCU BRED
9. TIME EMPLOYEE BEGAN WORK
10. IF EMPLOYEE DIED, DYE OF DEATH(mmlddW
OCCUPATION
Immlddryy) _
pea
- AM
11.10ABLETOWVRKFCRATLEASTONE
12. DATE LAST WORKED(mmlddlyy)
13. DATE RETIAMEOTOWORK(mmkidyy)
14. IF STILL OFF
WORK, CHECK THIS BOX:
FULL DAY AFTEp1���TEI OF INJURY?
I INo
1-1
❑Yes
-
15. PAID FULL DAYSWAGESFOR DATE OF
1S.SAt1Y
BEING CONTINUED?
7. DATE OF EMPLOYERS KNOWLEDGE (NOTICE OF
18. DATE EMPLOYEE WAS PROVIDED CLAIM FORA
SEX
NJUKYORLAST
[:]No
yes �No
INJURYOLLNESS(mmiddlyy)
FORM(mmlddlyy)
DAY WORKED?Yes
19. SPECIFIC INJU RYSLLNESS ANO PART OF BODY AFFECTED, MEDICAL DIAGNOSIS If available, e.g.. Second degree burns an right arm, lendonitis on left elbow, lead poisoning
I
AGE
J20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED(Numbm, Skeet, City, Zip)
20m. COO NTY
21. ON EM P LOYER'S PREMISES?
DAILY HOURS
U
Yes ElNo
R
Y 22. DEPARTMENT WHERE EVENTOR EXPOSURE OCCURRED. e.g.. Shipping deportment, machine shop. 3.Ott, Workers Injured or ill In lhla pyenn
Dyer No
DAYS PER WEEK
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
0
R
WEEKLY HOURS
26, SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes notebook.
WEEKLY WAGE
L
L 28. NOWINJURVAINESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECTOR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS,e.g.. Worker Stopped back to Impact work
N antl elipPed an scrap mFwrisl. ASMIFII,MbrvsMtl aOainsteKb cold eM bwmd tl0hthmd, USE SEPARATE SHEET IF NECESSARY
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NATURE OFINJURY
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PI �InpaHent 6vernfght7 NCI '; Yga Tfy�,Hlb,},ggmp4Rd,ed?Iraa3offios`pl¢((eumk,str�cet
PART OF BODY
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ATTENTION This form contains In formatlop retating to employee health aitl mottles used In a manner that protects thee onlltlmtlallly of am ployeaa to the e8lenl Possible
SOURCE
while the information Is being used for occupational safety and health purposes. Sae CCR Title 814300.29 (b)(B).(10)614300.36(b)(2)(E)2.
NOW: ShAded boxes indicate oenrider itl omployoa Information as AM" in COX TRIOS 14300.31(MI2KEst'.
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O D'TE OF'fJiRE m/Qq 4'�
O 'Bpele ❑Fe}nAlc
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37. EMPLOYEE USUALLYWORKS
37a. EMPLOYMENT STATUS
370. UNDER WHAT CLASS CEDE SFYSUR
E
Qregul0q fulHlme part-Ume
VM84FVAWASASSIGNM
E _hours per day, days per week, _ total weekly hours
❑temporary seasonal
EXTENT OF INJURY
e& GROSS WAGESWIARY
3R OTHER PAYMENTS NOT ItEPOfOEDASVUkGMSAlARY(ag Mps, rrmiq ow2Hme, bonuses ate)
S Per
❑Yes No
Completed By (type or print)
Signature & Title
Date(mmlddfyy)
f for peoae of r«aand -workers' corrpeneaOon or Other insurance
• Conficernal information Trey be disclosed orgy to the errpl asfarrNr employee, orthor personal represerdathe(MRMile (�TMIeto g Others p Mp
a health ory.;emoreenni agency or to acerrwHant hlred by the e I I g1 40 ulres prowslon upon request In commit stale and
claim; and under certain chcorretancesto public
federal workplace safety agencies.
FORM W20 (RevT) June 2002 FILING OF THIS FORM 16 NOT AN ADMISSION OF LIABILITY
CHAPTER 7
ACCIDENT INVESTIGATION AND ANALYSIS
ACCIDENT INVESTIGATION
Good accident investigation starts long before the accident happens and ends after the accident
occurred. WE MUST KNOW THE CAUSE IF WE WANT TO CORRECT THE PROBLEM.
If we use a step-by-step guideline process, investigations can be effective. First, look at the steps
to accident investigation:
You must clearly understand the need to investigate
2. You must be prepared to do the investigation
3. Gather all the facts about the accident
4. Analyze the facts you gathered
5. Based on facts, develop your conclusions
6. Then analyze the conclusions
7. Document conclusions in a report
8. Make specific recommendations to get action
9. Sell your recommendations to get action
10. Follow-up on the recommendations to get compliance
I l . Then critique your whole investigation
12. Follow-up again in the corrective action
Usually accident investigation only involves gathering facts about the accident and making
conclusions. This is not enough. An investigator must get the big picture and prevent
reoccurrences.
THE STEPS ARE:
THE NEED- Do you really want to prevent further accidents? Or are you just going
through the process?
2. PREPARATION If you wait until the accident happens it is too late for preparation. You
need a pre -plan to follow and a few tools. The pre -plan should be short and only cover a
few things.
YOUR PROGRAM SHOULD INCLUDE:
Prompt accident reporting system to let certain people know immediately.
22
2. Get emergency people to the scene as soon as possible.
3. Procedures to preserve evidence at the accident site.
4. Notify the investigator immediately.
The investigator should arrive at the scene prepared with procedure checklist, pen, paper, camera,
tape, and proper clothing.
GATHER FACTS
When you go to the accident scene, expect to go to work, following your pre -plan. As you
approach the accident site, evaluate what you see. Immediately notify Police and Fire if there is
any question about the need for their involvement.
Look for potential risks to your safety before entering the area. Depending upon the type of
accident, there may be continuing threats to your safety, such as moving debris, fire, chemical
exposure, unstable structures, vehicular traffic or the potential for secondary explosions.
Keeping yourself safe will help you to better serve those who might need you.
Once you have determined that it is safe for you to enter the area, assess the damage and the
needs of people at the scene. If nobody is in charge, then take charge until someone can take
over. Request additional personnel and resources as needed. Your first consideration should be to
locate those in need of medical attention and provide assistance to them. Next, determine how
large the accident area is and what might be necessary to protect the public from unnecessary
involvement or exposure and to protect the scene as well.
If police or fire personnel are present or enroute to the scene, do not move or touch debris
or other evidence unless it is necessary to provide medical aid. Keeping the scene "intact" can
be crucial to making a determination about how or why an accident occurred. Do not disturb any
physical evidence without first preserving it by diagrams, photos, measurements, etc.
Once medical aid has been rendered (if necessary), attempt to gather information. Obtain statements
from witnesses and other involved parties. This is a good time to get their names, addresses, phone
numbers, driver's licenses and other information that will enable you to contact them at a later time.
If vehicles are involved, obtain license plates, vehicle descriptions and insurance information.
Photograph the scene from all directions. If possible, make a sketch of the scene and take
measurements.
Prior to leaving the scene, be sure that you have all of the information you will need to complete
a report on what happened, including the details of your involvement.
If you are organized and have a pre -plan, you will be better prepared to take the appropriate
action.
ANALYZING THE FACTS
You have already mentally weighed the facts as you uncovered them, weigh all witness
23
statements for credibility and how they support the evidence. Include analysis of all facts
gathered, including management and supervision procedures. As you analyze the facts
search for more facts and contributing factors. DOCUMENT EVERYTHING. This will
help to get the big picture.
CONCLUSIONS
Start to reach conclusions about what happened and what caused the accident. Write a statement
on conclusions then turn back to analysis.
ANALYSIS
This step was ongoing up to now and has not really stopped. Next, get any additional
information that you might need and analyze or discard it.
THE REPORT
This is where you put it together. You gathered information from the beginning to the end.
You've analyzed it and reached conclusions. Start by just briefly telling what happened in
narrative style, such as:
"On September 20,. 1990, at 8:15 AM, in the Public Works Yard, a hydraulic 10-ton
jack was being used to remove the dual rear wheels. The mechanic was seriously
injured".
When you state the narrative, leave out information that is not relevant. Make
recommendations that are supported in the report. Your report needs to be clear and
concise. The reader must understand what happened. Do not include anything that is not
needed. Pictures and diagrams must contribute meaning to the report, if not, leave them
out.
RECOMMENDATIONS
The investigation is not done when the conclusions are made to the cause of the accident.
Corrective action must be taken. Specific recommendations are needed for each cause factor
or situation. This way management can easily determine who's responsibility it is to take
corrective action. The best way, is to hold one person accountable for correction. On most
accidents, you should have many specific recommendations for corrective action to straighten
out the problems.
CORRECTIVE ACTION
The conditions and casual factors that allowed the accident to occur is the action step of
investigation. Someone should demand corrective action to keep this accident from happening
again. Accountability of action is in order. Sometimes corrective action is not easy to carry
out. But if each recommendation is clear, you can take action to check up on each one of them.
24
FOLLOW THROUGH
Do not stop. Keep checking and follow up on the corrective action to see if the
recommendation was corrected or implemented. If it is corrected, your investigation is still not
finished.
CRITIQUE
In investigations, just like accidents, usually a lot of things are found wrong. Things can be
found wrong with the way the investigation went, such as initial planning, gathering facts and
analyzing them. In emergencies, these always show up, .maybe you had a wrong phone number
of a key witness. Now is a good time to critique the investigation process and take action so the
same things do not happen again.
DOUBLE CHECK
Nothing seems to get done the way it is supposed to. Double check every item that people were
responsible for and follow up on what they said they were going to do to be certain it actually gets
done. The same goes for your critique step. Frequently, a triple check or follow-up is needed to
actually get things done.
SUMMARY
Many accidents do not justify a very extensive investigation. But you still must investigate if
you want maximum accident prevention benefit. By following these steps you will do the
investigation as thoroughly as possible.
EMPLOYER LEVEL INVESTIGATION
Investigate when an injury appears to be questionable, such as two or more employees are involved
or there is a possible third party. This could include:
Monday morning injuries
2. Off -premise injuries
3. Injuries which are reported late
4. Injuries with unauthorized treatment
5. Injuries where there is a dispute as to the time, place and manner in which the accident occurred
6. Automobile accidents; generally
7. Special errand injuries
8. Injuries which occur en route to a second job site
9. Injuries which occur while an employee is driving his own car
10. Injuries which occur while an employee is driving to or from work
1 l . Injuries which occur while an employee is driving a vehicle
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12. Injuries without witnesses
13. Injuries which are reported by very new or short term employees
14. Injuries which are reportedbyemployees who have several prior claims
15. Injuries which fall under the five statutory defenses of:
a. INTOXICATION
b. SELF-INFLICTED INJURY
c. INITIAL PHYSICAL AGGRESSOR
d. OFF -DUTY RECREATIONAL ACTIVITY
e. SUICIDE
Make inquiries to supervisors. If appropriate talk to witness and witnesses and fellow employees.
Ask around for information.
ACCIDENT/EXPOSURE INVESTIGATIONS CHECKLIST
Procedures for investigating workplace accidents and hazardous substance exposures include:
✓ Interviewing injured workers and witnesses
✓ Examining the workplace for factors associated with the accident/exposure
✓ Determining the cause of the accident/exposure
✓ Taking corrective action to prevent the accident/exposure from reoccurring and;
✓ Recording the findings and actions taken.
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ACCIDENT INVESTIGATION
DATE:
DATE OF
ACCIDENT: TIME:
EMPLOYEE:
ACCIDENT CHARGEABLE:
DISCIPLINARY ACTION:
PREVENTION OF FUTURE INCIDENTS:
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EXHIBIT F
Department#
Respectfully Submitted,
Department Head
CHAPTER 8
AUTOMOTIVE ACCIDENTS
AUTOMOTIVE ACCIDENT PROCEDURES
Every employee driving, in control of, or responsible for any City-ownedmotor vehicle involved
in an accident (NO MATTER HOW SLIGHT), must do the following:
Notify the Police Department to respond and make an accident report. They will be
responsible for photographing involved vehicles. This rule applies whether on public
or private property.
2. Notify your supervisor.
Under no circumstances will an employee sign any statements concerning their
involvement in an automobile accident. You should report the facts of the accident only to
the officer making the report.
4. The employee will immediately file a detailed written report of the accident with
their supervisor.
5. The Department Head will review all accidents to determine preventability
and responsibility.
6. The Department Head will forward their findings to the Finance/Risk Division for further
action.
7. The glove compartment of each vehicle will contain materials relative to reporting
procedures. Employee should complete information and return to Finance/Risk Division.
Finance/Risk Division will issue a new packet for auto accident reporting.
m
VEHICLE ACCIDENT
INVESTIGATION FORM
DATE:
DATE OF ACCIDENT
TIME OF ACCIDENT:
LOCATION:
EMPLOYEE:
ACCOUNT NUMBER:
DAMAGE:
VEHICLE:
SPECIAL REPORTS:
EXHIBIT G
Department#
PURPOSE OF INVESTIGATION: Review all aspects of incident.
Report all findings and recommendations to the City Administrator and Finance/Risk Division.
AGENDA:
1. Primary cause of accident.
2. Is accident chargeable?
3. Will disciplinary action be recommended?
4. Prevention of future accidents.
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CHAPTER 9
SAFETY AND HEALTH ENFORCEMENT
SAFETY AND HEALTH WORK PRACTICES ENFORCEMENT
GOAL: The elimination of on-the-job injuries due to equipment, materials, methods used,
safety devices, and acts of individual employees.
To accomplish this goal, the department head and supervisor must make the employee conscious
of the importance of safety to the employee, fellow employees, and City property.
The Human Resources Department will provide a workers' compensation loss analysis
to each department head on a monthly basis. The department head will review the repot
and take whatever steps appropriate to curtail or eliminate workers' compensation
injuries.
2. In the event of a work related injury, the employee will sign the Supervisor's Report of
Accident(Exposure acknowledging the fact that he/she has read the report and
agrees/disagrees with its content. The supervisor will counsel the employee on ways the
injury/accident could have been prevented. Employee may submit a supplemental
statement if he/she disagrees.
3. Injury/accident repeaters are employees who have had two or more on-the-job injuries
within the preceding six months. Safety counseling will be conducted by the
department head to discuss corrective action which may include but is not be limited
to:
A verbal reprimand,
A letter of reprimand to the employee, a copy of which will be placed in
his/her personnel file,
Suspension, and/or
Termination
All recommended corrective action will have prior approval by the City Administrator.
30
CHAPTER IO
OPERATIONS IN THE PUBLIC WAY
TRAFFIC CONTROLS/BARRICADES
Whenever operations are taking place in streets, parkways, sidewalks or other places where
citizens as well as employees may be endangered, the Supervisor or crew leader on the work site is
responsible for the safety of the public and completion of the job. He must spend ample time
before, during and after the work to protect employees and the public from the hazards created
by this work. The following procedures are to be followed:
If street work is to be done, preparations shall be made for traffic and pedestrian
safety before work actually begins.
2. If traffic is affected by the operation, proper signage will be used to warn in advance of
work area (construction ahead). Traffic control signs in and around the work area will be
properly placed and maintained through the period when work or traffic obstructions
exist.
3. Signage will be in accordance with the "State of California Department of Transportation
Traffic Manual' and departmental policy.
4. Where barricades and signs are used overnight, before leaving, supervisors will examine
the work area for proper placement of the barricades and signs at the end of the workday.
5. Lighted barricades or reflectorized cones will be used for overnight protection.
6. Where traffic must be periodically stopped or obstructed by workers or equipment in the
traveled portion of the roadway, a flagman with protective vest will be used.
7. Department issued uniforms consisting of reflective vests shall be worn by all workers at
or near the roadway or work site.
8. Flagmen will be used to slow or direct traffic where approach to work area does not
provide adequate visibility by drivers.
9. Assistance in setting up signage or barricading is available at any time from the Community
Service Department.
10. All plates used to cover holes in the street on a temporary basis will be spiked in place.
11. In any case where streets are significantly obstructed or closed for any period of time, the
Police and Fire Departments will be notified of the situation and approximately how
long the closure will be in effect.
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PEDESTRIAN SAFETY
I . When pedestrian traffic is impeded by City operations, barricades, restrictive tape or rope,
or other restraint will be used to protect the public from the work.
2. If pedestrian traffic must be routed into the street, protection from traffic will be provided
by cones, barricades and signs, if necessary.
3. Holes in the sidewalk or parkway which will be left open shall be covered, whenever
possible, along with perimeter protection. Every possible means of preventing accidental
entry into the hole should be used.
4. Where an unusual situation exists that cannot be easily resolved, or when personal injury or
damage to equipment or property occurs as a result of operations, contact the Supervisor
immediately.
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CHAPTER 11
SAFETY REGULATIONS
PRINCIPAL CAUSES OF ACCIDENTS
We can eliminate unsafe actions and conditions, and thereby decrease the possibility of accidents, by
gaining a better understanding of the common causes of accidents. The following list represents the
ten principal causes of accidents:
Improper lifting
Material Handling
Slips and falls
Falling or flying Objects
Bumping into stationary objects
Improper tools or equipment
Failure to use protective equipment
Failure to observe rules and instructions
Improper work procedure
Poor Housekeeping
GENERAL SAFETY RULES
Fighting, horseplay and practical joking is prohibited.
No work shall be started in any unit, or any equipment, without the knowledge and
consent of supervisor assigned.
An employee shall immediately report any unsafe conditions or practices to his supervisor.
4. All injuries occurring on the job, no matter how slight, must be reported to the
supervisor immediately.
5. Running except for emergency purposes is prohibited.
6. Obey all warning signs; they are there for your protection.
7. Keep working areas clean and in anorderly condition. Equipment and material will
be neatly arranged.
8. Be constantly on the alert for unsafe conditions and report such conditions to
your supervisor.
Place airlines, cords, water hose, etc., so as to avoid tripping hazards.
33
10. Keep clear of suspended or swinging loads.
IL When carrying or handling material with others, make sure you understand each other
to avoid injury that might be caused by unexpected shifting or dropping without
warning.
OFFICE SAFETY
Every employee shall be responsible to see that his own desk and work area is clean and
orderly. Pick up items such as pencils or paper clips and wipe up any spilled liquids.
Good housekeeping is the key to a safe office environment.
2. Keep an eye open for loose or rough floor covering.
3. Be extra cautious when you come up to a door that can be pushed toward you. Take it
easy when pushing one open and slow down when coming to a blind corner.
4. Haste when walking between desks results in bruises and falls. Watch out for electrical
and telephone cords and keep them out of aisles. Electrical and telephone cords should not
be under plastic floor mats.
5. All file, desk and table drawers shall be kept closed when not in use. As soon as you
leave them, close them. Never open more than one file drawer at a time.
6. Overloading the top drawer or opening two drawers at the same time of unsecured file
cabinets has caused many an injury and damage. If unfamiliar with a file cabinet, test
the drawers and be careful not to pull them out too far if there is no locking device on
them.
7. Furniture such as tables, desks and chairs must be maintained in good condition and
free from sharp corners, projecting edges, wobbly legs, etc.
8. Tilting chairs can be a hazard when improperly used and care should be taken to assure
that they are in good condition. Learn the limits. Be sure your chair is behind you before
you sit down.
9. Never use chairs, desks or other office furniture as a makeshift ladder. Use a step ladder.
Do not overreach and lose your balance.
10. Message spindles are a frequent source of puncture wounds to hands and other parts of
the body. When used, the point shall be protected by a suitable blunt cover, or preferably,
the point should be bent at a horizontal angle.
IL Keep paper cutter blades closed when not in use.
12. Pencils are safest when carried point down in pockets.
34
13. Scissors, paper cutters, glass and razor blades can cause painful injuries.
Report such injuries at once and take precautions from infection.
14. Keep your hands clear of electric typewriter carriages while they are in motion.
15. Paper can cut and it hurts. Use a sponge or other wetting device for envelopes. Use
rubber finger guards when working with stacks of paper.
16. Keep paper clips, thumb tacks and pins in a place where they cannot injure you.
Keep razor blades or exacto blades covered. Even a little scratch can get infected.
17. Be sure equipment is grounded and the cord is in good condition. If a machine
gives you a shock or starts smoking, unplug it and report it.
18. The City of Vernon maintains a non-smoking policy in the work environment.
19. Hot plates are not permitted.
CLOTHING AND SAFETY EQUIPMENT
Employees shall dress suitably for the work in which they are engaged.
Wearing apparel that may contribute to injury or disability shall not be worn.
2. Employees shall not work with bare head, bare arms of exposed body parts in
areas where they may be exposed to bums from corrosives, hot substances or
hot equipment.
3. Minimum requirements for work shoes are substantially constructed shoes. The
wearing of moccasins, tennis shoes, house slippers, thongs, etc. will not be
permitted. Work boots are mandatory where foot hazards are apparent.
4. Certain working conditions and areas require the use of protective
equipment, such as respirators, gas masks, face shields, goggles, etc. An
employee so engaged shall use such protective devices and special wearing
apparel as niay be required.
5. Employees must be familiar with all protective devices and wearing apparel that
they may be required to use. They shall make certain that such equipment is in
good condition and adequate before it is used.
6. The proper type of goggles and/or face protection shall be used by
employees while performing any of the following duties:
a. Operating pneumatic tools.
b. Using a hammer or other tools to remove scale, rust, paint, cinder, dust, etc.
35
C. Using wire brushes or other tools to remove scale, rust, paint, cinder, dust, etc.
d. Using a grinding, polishing or burnishing wheel.
e. Sandblasting, paint spraying or power sanding.
f. Handling acids, hot liquids, caustics, or other corrosive substances.
g. Working around machinery or equipment where loose particles will endanger the
eyes.
h. Welding and cutting.
7. Employees working with/or in the near vicinity of any hazardous material or substance
including but not limited to chemicals, acids, solvents, grinding or polishing equipment,
shall wear appropriate eye protection.
8. All employees using hazardous chemicals, etc must.be familiar with the location and use
of eye wash equipment.
1/ 1 MIXIMO_►
I. Tools shall be kept in good condition and free from grease.
2. Tools shall not be thrown, dropped, laid on moving machinery, or left lying around
when not in use.
3. Use the proper tool for the job.
4. When tools break, wear out or otherwise become dangerous to use, they will be
replaced.
5. Keep impact tools free from mushroomed heads.
6. Power inachinery and power tools shall be operated only by employees who are
properly trained and assigned such duties.
7. All machinery and power tools shall be operated within their respective load and
speed limits.
8 Power shall not be turned off or on without proper warning and caution to see that
no person is exposed to danger.
9. No employee will ride a load or the blocks of any hoisting device.
36
10. Machinery guards shall be in place and properly adjusted before and while machinery
is in motion. Missing or defective guards shall be reported immediately.
1 1. Machinery shall not be cleaned, adjusted or repaired while in motion.
12. Machinery and power tools shall be properly grounded.
MATERIAL HANDLING
1. Do not try to lift objects that are bulky or too heavy to lift comfortably; secure help.
2. Use the following technique to lift:
a. Get a firm footing.
b. Bend at the knees to grasp the object.
C. Keep the back straight and as nearly upright as possible.
d. Get a firm hold on the object.
e. Lift gradually by straightening the legs keepingthe back straight and upright.
f. Similar safe procedures will be followed when putting a load down.
3. Use power assist equipment where possible when material must be moved.
4. Store material in such a manneras to prevent collapsing or tipping.
5. Loads on forklifts, trucks, etc. shall be stable to prevent skips, slides, or tip overs.
6. Material will not be stored on top of lockers.
T. Use proper tools when opening boxes, barrels or other containers.
ELECTRICAL
1. Electrical work and repairs shall be done by trained employees only.
2. Electrical cords shall not be spliced.
3. Circuits shall not be overloaded.
4. Fuses shall not be wired across, plugged, or replaced with higher amperage fuses.
5. Electrical equipment or lights shall not be altered except by authorized personnel.
37
6. All electrical equipment shall be properly grounded.
No material or equipment shall be stored or placed within 30 inches of any electric panel or
controller.
HOUSEKEEPING
Good housekeeping is essential for efficient operation and prevention of accidents.
2. All areas shall be kept clean and free from trash and accumulation of waste materials.
3. Trash receptacles shall be used and emptied regularly.
4. Scrap metal shall be placed in separate but appropriate containers.
5. Oil -soaked rags shall be kept in containers with tight -fitting lids.
6. Containers shall be labeled as to what they contain.
Floors, working areas, and platforms shall be kept free of dangerous projections
or obstructions and shall be maintained in good repair and reasonably free from
oil.
8. Proper cleaning material and methods shall be used for the task.
9. Gasoline or other volatile liquids shall not be used for cleaning purposes.
AUTOMOTIVE
Movement of various pieces of mobile equipment and vehicles in and around sharp carriers
require, adherence to home motor traffic regulations. Return
All traffic signs, signals, speed limits, and road marking shall be okay.
Seatbelts shall be worn at all times when writing and or operating any vehicle.
4. Operators of motor vehicles shall have a current operators permit in their possession for the
vehicle being driven. This does not apply to a mechanical must move a vehicle to and from
parking areas to repair bays. However, supervisor shall ensure that the mechanic is qualified
to operate the vehicle.
Courtesy and consideration is expected of all employees operating motor vehicles.
In
PORTABLE LADDERS AND WORK PLATFORMS
Inspect all ladders and work platforms before using them. Report any defects to your
supervisor immediately.
2. Makeshift ladders or work platforms shall not be used.
3. When necessary to work overhead, use a ladder or work platform of sufficient length or
height to be able to reach your work.
4. Work platforms of 30 inches or higher shall be provided with hand and guardrails.
5. Metal ladders shall not be used for electrical work.
6. Metal ladders shall be labeled with a warning,"Do Not Use For Electric Work."
7. Never use a ladder without safety feet suitable for the floor or ground it stands on.
Exception: Stepladders.
8. Ladders shall be placed so that the base is placed from the wall or object 114 of the vertical
distance from the bottom to the top support of the ladder.
9. Never place a ladder on another object such as a barrel or box to gain added height.
10. Tie or secure the ladder at the top where possible, and either tie or brace it at the bottom.
IL . Be sure your shoes are not greasy, or otherwise slippery before you climb a ladder or work
platform. When climbing or descending, face the ladder and use both hands. Do not reach
out more than an arm's length ladder.
12. Never work from the top rung of a ladder.
PNEUMATIC TOOLS AND LINES
Use of compressed air on or about your body or the body of another is forbidden.
2. Use of compressed air or gases for blowing dust or chips from your body, clothing or
work area is prohibited.
3. Attach air hoses only to compressed air lines.
4. Hoses shall be kept neatly coiled, when not in use, to prevent tripping hazards.
5. Turn off valves on airlines and tools when not in use.
6. Wear eye protection when using pneumatic tools and when cracking or opening valves.
39
7. Frequent inspections shall be made of all air lines and their connectors to insure that
they can withstand the pressure. Defective air lines and connectors shall be removed
from service.
8. Wear ear protection when required.
BURNING AND WELDING
Oxy-Acetylene Equipment
a. Only authorized and properly trained personnel shall be permitted to install or
remove special fitting on oxygen and acetylene cylinders.
b. Oxy-acetylene equipment shall be used only by authorized employees.
C. Extreme caution shall be observed when handling oxygen and acetylene
cylinders.
d. Safety caps shall be secured in place on all compressed gas cylinders when not
in use.
e. Gas cylinders shall not be moved by means of magnets or slings.
f. Gas cylinders shall be used or stored in a vertical position and securely fastened
to prevent them from tipping or falling over.
g. Oxygen and acetylene cylinders shall be stored at least 20 feet apart.
h. Oxygen and acetylene cylinders shall not be stored where they are subjected to
unusual heat sources, oil or grease.
i. Empty cylinders shall be returned to their proper storage area.
j. Cylinders and personnel shall be protected from sparks and slag.
k. When burning or welding, make sure that sparks and flames shall not start a fire
in nearby material.
I. Excess hose lengths shall be coiled or arranged to prevent tripping hazards.
M. When working overhead, enough hose shall be used so that cylinders may be
kept on the ground or other secure location.
M
n. Welders shall wear eye, face, hand, respiratory, foot and body protection as
required.
o. Welding shall not be done in confined spaces without adequate ventilation or
an
approved type respirator.
2. Electric Welding
a. Welding shall not be done without a shield fitted with filter glass of the
proper shade.
b. Never look at a welding arc with the naked eye.
C. Welding screens or shields shall be set up between welders and other employees.
d. Eye protection shall be worn when chipping, scaling, and peening.
e. Material to be welded and all components including the welding machine shall
be adequately grounded to a common grounding system.
f. The safety ground attached to the welding machine or transformer shall be
connected to "ground" before equipment is energized.
CHEMICALS
Extreme care shall be exercised by all personnel handling or working with acids, caustics,
solvents, petroleum products, or chlorine.
2. In mixing acid and water, always pour the acid into the water slowly. Never pour the water
into the acid.
3. Handle tools carefully while working around acid or other chemicals to avoid dropping
them which may cause a splash.
4. After tools have been used near corrosive chemicals, clean them thoroughly by neutralizing
with lime baking soda.
5. Wear protective goggles, respiratory equipment, and protective clothing when the inhalation
of fumes or hazardous substances or injurious bodily contact with acids or other corrosive
materials may occur.
6. Wash out eyes with large quantities of clean water immediately if chemicals splash into
them, and report to a doctor or emergency room immediately.
7. All spilled acids or caustics shall be cleaned up immediately. Spilled acid shall not be
41
mopped up with organic materials such as sawdust, waste, or cloth. Use neutralizing agents
such as lime or baking soda. Clean up and properly dispose of residue.
8. Containers of injurious chemicals or hazardous substances shall be plainly labeled,
indicating hazards and precautionary measures to be observed.
9. Only authorized personnel shall use pesticides, herbicides, fungicides, or any agricultural
chemicals having critical toxicity.
10. Rules stating the proper safety equipment required shall be posted in the storage area of
chemicals, hazardous substances, pesticides and herbicides.
EXCAVATIONS STREET REPAIRS, SUB -SURFACE OPERATIONS, AND
CONFINED SPACES
The foreman or person in charge of an excavation to a depth of five (5) feet or more
shall see that it is effectively shored and guarded in accordance with the State
Construction Safety Orders.
2. Excavated material shall be kept at least one (1) foot from excavations of less than five (5)
feet in depth and two (2) feet from the edge of deeper excavations.
3. The foreman or person in charge of an excavation to a depth of five (5) feet or more shall
provide a sturdy ladder for access. The ladder shall be placed within twenty-five (25) feet
from the working area.
4. The foreman in charge of an excavation shall see that there is work done which could cause
the undermining of foundations, retaining walls, or other structures until adequate safety
measures have been taken.
5. Excavating machinery shall be kept away from electrical, gas, and water lines. Where
excavation is necessary, the operator of the equipment shall first determine the location of
electrical, gas and water lines that may be in the area of excavation, and a qualified observer
must be present to guide the operation.
6. Only one man should direct the operation of excavating machinery.
7. All persons working around excavating machinery shall be in a safe position so as not to be
in danger of falling into or otherwise contacting the machinery.
8. The supervisor or lead worker shall make tests in all closed compartments, manholes,
storm drains, tanks, voids, and other confined spaces for oxygen deficiency, explosive
gases, and other dangerous gases which may be present. Employees shall not enter such
areas until the supervisor or lead worker has issued an "all clear." This must be done at each
time of entry or re-entry.
9. Smoking or open flames are prohibited in or about open manholes or sewers. "No
42
Smoking," "No Open Flames" signs shall be posted.
10. Hard hats shall be worn at all times by workers in or around excavations, trenches, tunnels,
sewers, or other sub -surface operations.
11. Employees entering a sewer, storm drain or other confined space shall be tethered with a
lifeline or harness so that they can be pulled out in case of emergency.
FIRE PREVENTION
Prevention of fire is a responsibility shared by all, regardless of the type of job.
2. Whenever you suspect or detect a fire, the Fire Department shall be notified. Contact the
Vernon Communication Center at Ext. 351 or dial9l 1 from an outside telephone.
Calmly report the location and extent of the fire. In addition, priority must be given to
the safe evacuation of personnel from the affected area.
3. If you have followed the preceding procedures and have been trained in the use of
available Portable Fire Extinguishers you are encouraged to attempt to suppress a small
fire in the beginning stage.
4. If you have the slightest doubt whether or not to fight the fire --DO NOT --instead,
GET OUT, closing the door behind you. Remember, NEVER jeopardize your safety
or the safety of others around you by attempting to put out a fire.
Flammable liquids shall be stored or handled in approved hazardous locations, cabinets
and safety containers only.
6. Keep all flammable liquids or other hazardous materials away from open flames and
other sources of ignition.
Practice good housekeeping. Without fuel a fire cannot exist.
Remove, shield or cover combustible equipment or material that will be within the range of
any activity where open flame, sparks or hot metal is produced, i.e., welding, torches, etc.
A fire extinguisher should be available where such work is performed.
9. Firefighting equipment shall not be blocked and will be easily accessible.
10. Fires are classified according to A, B, C.
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CHAPTER 12
HAZARDOUS MATERIALS
CONTINGENCY PLANS
Emergency response plans and procedures are developed for use in the event of a release or
threatened release of hazardous material. The State of California Office of Emergency Services
(OES) regulations specify that the contingency plan should be scaled appropriately for the size and
nature of the business, the nature of potential damage due to the hazardous materials handled and
the proximity of the business to residential areas and other populations. These plans must include
the following items:
Reporting and Notification
a. In the event of a spill, release or threatened release of a hazardous material,
regardless of size, the event shall be immediately reported to emergency
telephone #911.
b. Dispatch 911 will then notify the Fire Department, Police Department and
other relevant departments.
Mitigation
a. Coincident with reporting, emergency response team members will immediately
facilitate cleanup and necessary action to mitigate the release.
3. Evacuation•
a. The Police and Fire Department shall be responsible for coordinating the necessary
evacuation of any facility.
b. Upon receiving the order to evacuate, employees will shut down their machines
and immediately proceed to the nearest exit as directed.
C. All employees will report to their supervisors at a designated location.
Medical Assistance -
a. All employees affected by exposure to hazardous materials shall be transported to
the nearest medical facility. A copy of the appropriate Material Safety Data Sheet
should accompany the affected person(s) to the hospital.
CL!
HAZARDOUS MATERIALS TRAINING PLAN FOR EMPLOYEES
All employees shall be trained in the contents of the contingency plan and the
emergency plans and procedures.
2. All training shall be documented by employee signature on a training session sign up sheet.
His/her record of training will be maintained by the supervisor.
3. Refresher training shall be conducted on an annual basis and documented.
4. New employees shall be trained and documented on both OSHA Hazard Communication
and Hazardous Material Emergency Response Procedures prior to working with hazardous
substances. This training will be documented as indicated above and reflected in the new
employee's personnel record.
5. Emergency team members shall receive special training and documented in
emergency response procedures, incident mitigation and first aid treatment.
6. Employees who handle hazardous materials shall be trained and documented in the safe
handling of hazardous materials, procedures to mitigate releases or threatened releases
of hazardous materials and other appropriate emergency actions.
Management and other personnel responsible for incident reporting shall be
specially trained and documented regarding the reporting of the release or
threatened release of hazardous materials.
CHAPTER 10
EMERGENCY PREPAREDNESS
An emergency/disaster plan describes what the employee life safety hazards are and what
actions the employer and employees must take in a life/injury-threatening emergency.
The City of Vernon's emergency plan will include the following items:
A statement of the City's emergency/disaster policy, purposes, authority, responsibility,
control measures, and an organization chart.
2. An evaluation of expected disasters and their risks.
3. Maps of the City's facilities showing locations of equipment, medical supplies, fire
equipment, shelters, a command center, and evacuation routes.
4. A list of cooperating agencies and how to contact them.
5. A warning system and the types of signals used.
6. A communications/command center with the home phone number and other pertinent
information for each employee.
7. Shutdown procedures and facility security measures.
8. Policies for handling visitors and other non -employees during an emergency.
9. Any other item(s) deemed necessary.
M.
CHAPTER 11
VIOLENCE FREE WORKPLACE POLICY
PURPOSE:
The purpose of this policy is to clearly articulate the City's zero tolerance for workplace violence and
to deter such occurrences. The policy provides examples of workplace violence, prohibits all forms
of workplace violence and provides that its occurrence will lead to discipline, up to and including
termination, establishes guidelines to assist supervisors and employees in identifying and reporting
potential or actual workplace violence, and establishes procedures for the investigation and handling
of potential and actual workplace violence.
Workplace violence includes, but is not limited to, acts of violence against the physical,
psychological, or economic interests of an individual. It also includes threats of such violence -
implied or direct, verbal or non-verbal against individuals.
Examples of workplace violence include, but are not limited to, the following:
Hitting, pushing, shoving, kicking, assaulting, or harming the physical body of an individual or
threatening such behavior.
2. Unlawfully touching an individual.
3. Making menacing, threatening, or harassing gestures or statements toward an individual. Such
statements may include inappropriate joking,or ridiculing that nevertheless constitutes a threat.
4. Making menacing, harassing, or threatening phone calls to an individual.
5. Stalking or conducting an unlawful or unauthorized surveillance of an individual.
6. Attempting to intimidate an individual through the use of body language, threatening
statements, innuendo, staring, or other direct or indirect means of communication.
7. Using firearms in an inappropriate or unauthorized manner.
8. Using tools, equipment, or other device against an individual in an inappropriate or
unauthorized manner.
9. Harming, attempting to harm, or threatening to harm the property of an individual.
10. Harming, attempting to harm, or threatening to harm the property of the City. This includes,
but is not limited to, arson, sabotage, and vandalism.
47
11. Behaving in a manner that that poses a credible threat to the bodily safety, physical or
psychological well-being, or economic interest of an individual.
12. Acting or behaving, as described above, against the family or friends of an employee.
13. Malting a statement to a third -party that evidences a credible or meaningful possibility that the
maker of the statement will commit workplace violence, including making threats of
workplace violence.
A threat of violence need not be direct but may be implied. A threat of violence may be in written
(including emails, text -messages, photos, videos or other forms of communication tools) or oral
form. A threat of violence may also be non-verbal (communicated by body language, gestures, or
other means).
Workplace violence may be evidenced from a pattern of conduct composed of a series of acts over a
period of time, notwithstanding that some or all of the acts individually may not appear to constitute
workplace violence.
Workplace violence need not be directed toward an identifiable individual. It may be directed toward
an unidentified individual, a group of employees, or employees of a protected class, e.g., race, sex,
religion, age, disability.
POLICY:
It is the policy of the City of Vernon to provide a safe workplace for its employees. All forms of
workplace violence are prohibited.
This policy applies to all persons involved in the City's operation, including but not limited to, the
following: City of Vernon .employees; contractors; temporary workers; anyone on City property;
subcontractors; vendors; any individual acting as a representative of the City of Vernon while off
City property; any individual off City property whose actions involve City's business or interests.
Places where workplace violence can occur include, but are not limited to, the following:
1. On City property, regardless of the relationship between the City and the persons involved in
the incident of workplace violence.
2. Off City property, if the assailant is a City employee, worker, representative, agent, contractor,
subcontractor, vendor, and the incident involves or is connected to any City business or
interest.
Non -employees are encouraged to report known incidents of workplace violence or potential
workplace violence, including any threats or acts of violence.
City employees, workers, representatives, agents, contractors, subcontractors, and vendors must
report any known incidents of workplace violence or potential workplace violence pursuant to the
procedures set forth herein and any other policies or procedures adopted by the City.
I' U
In order to promote compliance with this policy and maximize the City's efforts to provide a safe and
secure workplace that is free from violence, the City will establish security measures and practices as
needed. It will also provide related training programs as appropriate.
The City management team will review the implementation of this policy and offer advice to City
supervises to offset and prevent incidents of workplace violence.
Compliance with the Violence In the Workplace Policy is a condition of employment and will be
evaluated, together with other aspects of an employee's performance.
In order to avert future acts of workplace violence, managers are expected to implement the
following practices:
Reference Checks: Prior to the selection of a job applicant for a position, a reference check should be
completed. Basic employment should be verified. This includes, but is not limited to, prior position
held, duties of the position, dates of employment and reason for leaving. The information received
should be documented and factual with no subjective comments. The Human Resources Department
will offer assistance in the completion of reference checks.
Employee Privacy: Supervisors are encouraged to refer all requests for information concerning
current employees to the Human Resources Department. Information concerning an employee's
workplace location shall not be given to anyone who cannot demonstrate a business necessity for this
information.
Workplace Security: Managers are encouraged to solicit assistance from the Police Department
and/or Director of Human Resources for an inspection of the workplace facilities. This inspection
would include recommendations to managers on securing the workplace against potential acts of
workplace violence.
Observations: Supervisors and others should rely on their own judgment, personal observations, and
corroborating information when assessing the likelihood that an employee or other person will
commit workplace violence. Behavior of particular significance includes antisocial behavior (e.g.,
recurring hostility or excessive aggression), erratic behavior, irrational behavior, behavior evidencing
use of drugs or alcohol (e.g., incoherent or impaired speech, dilated pupils, lack of coordination when
walking or other physical task, alcohol on the breath), and out of ordinary work mistakes or behavior.
Acts that may individually appear harmless may, in conjunction with other behavior, indicate a
possibility of (or potential for) workplace violence.
Supervisors and others should consult with their supervisor, Human Resources, the Department
Head, and other appropriate personnel regarding behavior that may not constitute workplace violence
but that may nevertheless indicate a significant increase in the likelihood of workplace violence.
It is important to be careful when drawing assumptions or relying on any of the above behaviors as
indicators of violence. Many people experience stress, loss or illness at some point. All but a very
few people handle these disruptions and conditions without resorting to violence. Intervention
should focus on supporting the employee through these disruptions and managers should be trained
to deal with these difficulties.
49
Whenever a situation may arise in the workplace, it is important that an assessment occur to
determine the degree of risk. All threats must be treated in a serious manner. Supervisors and
employees should identify the potential perpetrator and report incidents of violence immediately. The
situation should be managed in a way that protects all employees.
Employees who have obtained a temporary or permanent restraining order to protect themselves from
another individual or who themselves are the subject of a restraining order issued on behalf of
someone else shall immediately supply a copy of the signed order to the Vernon Police Department
as well is to their department head. Employee should provide a description of the individual named
in the restraining order, (or, if readily available, a recent photograph of the named individual). The
employee should advise the court to include the city workplace and the restraining order. Employees
are to advise their supervisor or department head when any potential violent situation exist in their
lives which could result in violence at work.
Anti -Retaliation Policy; No employee shall retaliate against another employee who reports an
incident pursuant to this policy. Employees found to have violated this section may be
subject to disciplinary action up to and including termination.
False Reporting of an Incident - Any employee who makes a report under this Policy which the
employee knows or should know is false shall be subject to disciplinary action, up to and
including termination.
PROCEDURE:
Responsibility
Responding to Workplace Violence
Employee
Action
Recognize what is occurring; remain calm
and proceed in a logical manner.
2. Assess the situation in terms of degree of
threat, injury, or damage.
3. Avoid making counter -threats or agitating
the person committing the workplace
violence.
4. Take appropriate and reasonable steps to
reach a secure area and assist others, if
necessary and possible, to reach a secure
area.
5. Call 911 if:
50
Reporting Workplace Violence
Employee
Immediate Supervisor
Human Resources Department or
Department Head
a. The assailant is still violent or
threatening violence.
b. The assailant has not been detained or is
not in custody.
c. Someone is injured.
The 911 dispatcher's screen will display the
City Hall address. You will need to identify
your location. Answer the dispatcher's
questions in a calm and accurate manner.
6. Provide warning, if necessary and possible,
to any employees or persons.
7. If in a secure area, wait for security and/or
medical assistance.
When it is safe, immediately report the
potential or actual workplace violence to the
employee's immediate supervisor, other
appropriate manager, or the Department
Head. The reporting should not be delayed
because of any unavailability of a
supervisor, manager, or Department Head.
9. The immediate supervisor, other appropriate
manager, or the Department Head must
immediately report the potential or actual
workplace violence to the City
Administrator, Director of Hunan
Resources or designee.
10. Human Resources or the Department Head
should ensure that the situation is under
control, including ensuring that the assailant
is in custody or removed from the work site,
if necessary, that employees are safe, that
any required warnings are given to other
employees or persons, and that any
appropriate federal, state, or local agencies
51
Human Resources Department
Investigation of Workplace Violence
Hunan Resources Department
are contacted about the incident as required
by law.
11. if an employee or a work group has been
affected by workplace violence, Human
Resources should arrange for Employee
Assistance Services.
12. If necessary, Hunan Resources or its
designee should arrange for the drug and
alcohol testing of the employee.
13. If necessary, Human Resources should
arrange the transportation of the employee to
his or her home. If it appears that the
employee's judgment is impaired, the
employee should be prohibited from driving
him or herself home. In such an event,
Human Resources should contact a family
member or provide alternative
arrangements.
14. Return to the work site by an employee
alleged to have perpetrated any act (or
threat) of workplace violence shall only be
authorized by the Department Head (in
consultation with the City Administrator and
Director of Human Resources).
15. An investigation of the potential for actual
workplace violence or of any credible
allegations of potential or actual workplace
violence will be conducted.
16. During the investigation, subsequent
proceedings, and thereafter, all information
regarding the incident must be kept
confidential to the extent required by law
and as reasonably necessary.
17. Employees found to have committed
workplace violence will be disciplined up to
52
and including termination.
CITY CLERK'S OFFICE
INTEROFFICE MEMORANDUM
DATE: September 24, 2013
TO: Teresa McAllister, Director of Human Resources
FROM: Deborah Juarez, Records Management Assistant
RE: Resolution No. 2013-80 — A Resolution of the City Council of the City of Vernon
Adopting an Updated City of Vernon Workplace Injury and Illness Prevention Program
Manual (Safety Program)
Transmitted herewith is a copy of Resolution No. 2013-80 referenced above, which was approved by City
Council on September 17, 2013.
Thank you.
Attachment
c: Resolution No. 2013-80
°F�g ti RECEIVED
sGPT. �
RECEIVE®AUG 2-9 2013
;,..
SEP 10 2013 `•'n,W- CITYADMINI TRATION
CITY CLERK'S OFFICE STAFF REPORT r
HUMAN RESOURCES DEPARTMENT
DATE: September 17, 2013
TO: Honorable Mayor and City Council
FROM: Teresa McAllister, Director of Human Resources
RE: Adoption of an updated City of Vernon Workplace Injury and Illness
Prevention Program Manual (Safety Program)
Recommendation
It is recommended that the City Council:
1. Find that approval of the proposed Workplace Injury and Illness Prevention Program
Manual in this staff report is exempt under the California Environmental Quality Act
(CEQA) in accordance with Section 15061(b)(3), the general rule that CEQA only
applies to projects that may have an effect on the environment.
2. Adopt the updated Workplace Injury and Illness Prevention Program Manual (Safety
Program).
Background
SB 198, approved by the Governor on October 2, 1989, requires, in pertinent part, every
employer to establish, implement and maintain an effective injury prevention program. On May
21, 1991, the City Council adopted Resolution No. 5925 approving the City of Vernon Safety
Program, as revised by Resolution Nos. 6722, 7491, 8485 and 8905 on December 5, 1995,
February 15, 2000, July 14, 2004 and November 16, 2005. The purpose of the Safety Program is
to establish general methods and procedures for developing and maintaining a program of
accident prevention throughout the operations of the City.
The Human Resources Director is responsible for implementing and maintaining the City's
Workplace Injury and Illness Prevention Program and is responsible for the development,
organization, coordination and implementation of employee safety programs and safety
education. The Human Resources Director also serves in an advisory capacity to the Safety
Committee.
As such, City staff has reviewed the safety manual and has updated the manual to reflect current
procedures, responsibilities and forms. The Human Resources Director presented the updated
manual to members of the Safety Committee for their review and feedback and also to the City's
labor organizations in order to meet in good faith on policies and procedures requiring a meet
and confer process, and to receive employee comment regarding the adoption of such safety
manual.
As of August 29, 2013, City staff received input and proposed revisions from the Safety
Committee and employee labor organizations, some of which was incorporated into the manual
and presented herewith.
Budget Impact•
A printing cost of $1,200.00 for the Safety Manual for all employees is already included in the
Human Resources Department 2013-2014 fiscal year budget. Therefore; no additional fiscal
impact is anticipated.