Safety Program Development Intake Questionnaire

Safety Program Development Intake Questionnaire
Information needed before EA Safety Services drafts company-specific written safety programs
Why this questionnaire matters: A written program only works when it reflects the company's real operations. Please answer based on what the company actually does today. If a process is not established yet, write "Not established" rather than describing what you think the answer should be. EA Safety Services will use the responses to build practical procedures and identify items management still needs to decide.
How to complete this form: Answer every question based on what the company does today. If a question does not apply, write "N/A". If a process is not established yet, write "Not established". You can save your progress and finish later. Please also email your requested documents (see Section 14) to eric@easafetyservices.com.
SECTION 1 - Company Information
1.1 Legal company name
1.2 DBA / trade name (if different)
1.3 Main business address (street, city, CA ZIP)
1.4 Mailing address (if different)
1.5 Main phone
1.6 Main email
example@example.com
1.7 Website
1.8 Owner / principal (name, title) - person with overall authority
1.9 Primary safety contact (name, title, phone, email)
1.10 Contractor license number and classification(s) (if applicable)

SECTION 3 - Workforce & Supervision
3.1 Job titles / classifications (title, how many, main duties)One per line: title | count | duties
3.2 Supervisors / foremen / leads (Name, Title)One per line
3.3 Typical crew size and number of simultaneous jobs/shifts
3.4 Languages employees understand best for training and written instructionsOne per line
3.5 Any literacy or communication considerations for training
3.6 How are new employees currently trained, and by whom?
3.7 Approximate annual turnover / seasonal hiring
SECTION 4 - Program Responsibilities (Management Decisions)
Enter 'Name, Title'. If one person holds several roles that is fine.
4.1 Person with authority and responsibility for implementing the IIPP (Program Administrator)
Name, Title
4.2 Person responsible for maintaining safety records and Cal/OSHA logs
Name, Title
4.3 Person responsible for coordinating employee training
Name, Title
4.4 Person responsible for chemical inventory / SDS
Name, Title
4.5 Person responsible for heat illness supplies and procedures
Name, Title
4.6 Person responsible for the Workplace Violence Prevention Plan
Name, Title
4.7 Person responsible for emergency planning
Name, Title
4.8 Person responsible for first-aid supplies / kits
Name, Title
4.9 Person who issues and replaces PPE
Name, Title
4.10 Respiratory Protection Program Administrator (if respirators are used)
Name, Title
4.11 Competent person(s) for fall protection / ladders (usually foremen)
Name, Title
4.12 Qualified person for fall protection systems / anchorages / Fall Protection Plans (engineer or experienced person)
Name, Title
4.13 Qualified/competent person who erects, moves and inspects scaffolds
Name, Title
4.14 Competent person for silica-generating work
Name, Title
4.15 Competent person for lead-disturbing work
Name, Title
4.16 Competent person for confined spaces (if confined spaces are entered)
Name, Title
4.17 Competent person for excavations/trenches (if any)
Name, Title

4.18 Employees authorized as qualified persons for electrical work (names) - if any
Name, Title
4.19 Person who authorizes employees to operate lifts / forklifts / powered equipment
Name, Title
4.20 Person responsible for company vehicles / driver rules
Name, Title
4.21 Person who investigates incidents and collects photos/witness statements
Name, Title
4.22 Person responsible for correcting hazards and purchasing/replacing safety equipment
Name, Title
4.23 Person with authority to discipline employees for unsafe practices
Name, Title
4.24 Person who may approve changes to safety procedures
Name, Title

SECTION 5 - Communication, Inspections, Discipline & Records
5.1 How often are safety/toolbox meetings held and who leads them?
5.2 How can employees report hazards (supervisor, phone/text, form, app, anonymous box, etc.)?
5.3 Anonymous reporting option (if any)
5.4 Who inspects work areas/jobsites for hazards and how often?
5.5 How are safety violations handled today?
5.6 Where will employees access written programs and SDS (office binder, vehicle binder, shared drive/app)?
5.7 Where will safety records be kept?
5.8 How long should internal field forms be kept when no specific legal period applies? (recommended: at least 3 years)
5.9 What records should supervisors complete daily/weekly?

SECTION 6 - Emergency Action, First Aid & Incident Reporting
6.1 Who do employees call first for a work emergency (after 911 when needed)? Name & phone
6.2 Who is authorized to call 911? (Recommended: any employee, any time immediate help is needed)
6.3 Emergency contact list
One per line: role | name | phone
6.4 Occupational clinic / medical provider for non-emergency injuries (name, address, phone)
6.5 Occupational medicine provider for respirator medical evaluations, fit testing, audiograms, blood lead / silica exams (name, address, phone)
6.6 Cal/OSHA district office for the main work area (name, phone, email) - for serious injury reporting
6.7 Nearest hospital/ER to main location (name, address)
6.8 Employees trained in first aid / CPR (name, card expiration)
One per line: name | expires
6.9 Where are first-aid kits kept (vehicles, shop, jobsite)?
6.10 Is an AED available?
6.11 How do crews obtain and communicate the exact jobsite address to 911?
6.12 Evacuation assembly point(s) for fixed locations
6.13 Who accounts for employees after an evacuation?
6.14 How are employees alerted to an emergency (alarm, air horn, voice, text)?
6.15 Where are fire extinguishers located (vehicles, shop, office)? Who inspects them?
6.16 Existing procedures for fire, earthquake, spill, evacuation (write 'Not established' if none)
6.17 Who must an employee notify when injured or after a near miss?
6.18 Who contacts the workers' comp carrier / clinic?
6.19 How are corrective actions assigned and tracked?

SECTION 10 - Personal Protective Equipment
10.1 PPE provided by the company (glasses, goggles, face shields, gloves, hearing protection, hard hats, hi-vis, coveralls, footwear, respirators, fall protection)
One per line
10.2 PPE required by task
One per line: task | ppe
10.3 How do employees report damaged/missing PPE?
10.4 Is employee-owned PPE allowed? Which types?

SECTION 11 - Heat Illness Prevention
11.1 Who ensures drinking water is available and replenished, and how (coolers, bottles, refill source)?
11.2 How is shade / cool-down access provided (canopies, vehicles with A/C, building shade)?
11.3 Who monitors weather/temperature and how (app, thermometer, NWS)?
11.4 How are employees observed / communicated with during high heat (voice, cell, radio, buddy system)?
11.5 How are new or returning employees acclimatized / closely observed?
11.6 Current response if an employee shows heat illness symptoms

SECTION 12 - Workplace Violence Prevention
12.1 Who should employees contact to report threats, harassment, aggressive customers or violence concerns?
12.2 Have employees encountered aggressive customers, occupants, public or other contractors? (describe without personal details)
12.3 Are employees ever sent alone into occupied homes or businesses?
12.4 How should an employee stop work / leave if a customer or site becomes threatening?
12.5 Who investigates workplace violence concerns and decides corrective action?
12.6 How are known site-specific security/violence hazards communicated to crews?
12.7 Existing security measures (locks, cameras, lighting, panic buttons, check-in)
12.8 How will employees be involved in developing/reviewing the plan (meetings, surveys, committee)?

SECTION 13 - Commercial Work & General Contractor Requirements
13.1 General contractors / property managers the company works for or plans to pursue
13.2 Safety documents GCs have requested (IIPP, OSHA logs, EMR, training cards, JHAs, SDS, competent-person forms, etc.)
One per line
13.3 Are site-specific orientations or daily pre-task / JHA forms commonly required? Describe.
13.4 Does the company need bilingual forms / training materials?
13.5 Upcoming commercial project and start date (so required documents can be prioritized)
13.6 Experience Modification Rate (EMR) if known

SECTION 15 - Management Certification of Intake Information
I understand that EA Safety Services will use the information provided in this questionnaire to tailor written safety programs, training and field forms to the company's actual operations. I have answered the questions to the best of my knowledge and have identified items that are not currently established rather than representing that a practice exists when it does not.
Completed by (name)
Title
Signature
Date

MonthDayYear
Should be Empty:

Safety Program Development Intake Questionnaire

SECTION 1 - Company Information

SECTION 2 - Operations & Work Environment

SECTION 3 - Workforce & Supervision

SECTION 4 - Program Responsibilities (Management Decisions)

SECTION 5 - Communication, Inspections, Discipline & Records

SECTION 6 - Emergency Action, First Aid & Incident Reporting

SECTION 7 - Equipment, Access & Tools

SECTION 8 - Chemicals & Hazard Communication

SECTION 9 - Health Exposures

SECTION 10 - Personal Protective Equipment

SECTION 11 - Heat Illness Prevention

SECTION 12 - Workplace Violence Prevention

SECTION 13 - Commercial Work & General Contractor Requirements

SECTION 14 - Documents / Files to Provide

SECTION 15 - Management Certification of Intake Information