Dental Health & Safety Policy Manual Order Form
Name/Location of Business
*
Business/Practice Name
Location
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Individual Completing the Form
*
First Name
Last Name
Email
*
example@example.com
Nature of Business;
*
Healthcare Provider (ie. Medical/Dental)
Manufacturing
Retail
Distribution (ie. Warehouse)
Construction
Services (ie. Trucking, Professional Offices, Educational Institution, etc.)
How many employees do you have?
*
0-4
5-19
20-99
100+
Does your business have health & safety as part of staff meetings?
Daily
Weekly
Monthly
Never, there are a lot of other meetings
Do your employees complete a pre-assessment upon hiring?
*
Yes
No
How many computers/workstations are in your office/practice?
*
Does your business/practice currently have a Health & Safety Policy Statement?
*
Yes
No
Please provide a copy of your Health & Safety Policy Statement;
When was the last workplace injury/illness incident reported?
*
Last 7 days
7-29 days
30+ days
Injury-free Workplace
Who is responsible if an employee was to become injured at work?
*
Who is Responsible for the Management/Reporting of your H&S Program?
First & Last Name
Position
Please provide the location of your Health & Safety Bulletin Board;
Please provide the location of your First Aid Kit;
Please provide the location of your SDS (Safety Data Sheets) Binder;
Please provide the location of all Sharps Containers;
Please provide the Location and Class of all Fire Extinguishers;
*
Please provide the Location and Make/Model of Eyewash Stations;
*
Do you currently have a specific procedure for the following (click all that apply); if not, a generic policy will be included in your manual.
Roles & Responsibilities
WHMIS/ Chemical Safety
Workplace Violence & Harassment Policy
Return to Work
Incident/Injury/Illness Reporting
JHSC (20+ Employees)
Please provide a copy of your Roles & Responsibilities Policy;
*
Please provide a copy of your WHMIS/Chemical Safety;
*
Please provide a copy of your Violence & Harassment Policy;
*
Please provide a copy of your Return to Work;
*
Please provide a copy of your Incident/Injury/Illness Reporting;
*
Please provide a copy of your JHSC (20+ Employees);
*
Submit
Should be Empty: