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); *