SB198 EVALUATION INFORMATION

FOR A NO COST EVALUATION OF YOUR COMPLIANCE WITH SB198 (THE
MANDATORY INJURY PREVENTION ACT OF 1989) FAX OR MAIL THIS COMPLETED
FORM TO:

    The Special Projects Group
    200 Marina Drive
    Seal Beach, CA 90740
    Fax (213) 799-3342, Tel (213) 799-3344

Company: _____________________________________________________

Name: __________________________________________________ 

Title: _______________________________________

Address: ____________________________________________________ 

HQ or Branch

City: _________________________ State: ________ Zip __________

Tel: _______________________ Fax: ___________________________

Primary Business: ____________________________________________ 

SIC Code: ________

TPA or Comp Carrier: _________________________________________ 


Background Information:

Number of non-management employees: ______________

Number of 1st-level supervisors: _________________

Total Population: ___________________

# of OSHA recordable injuries or illnesses: '87______, 
'88______, '89_____, '90 _____

Statement of Safe Work Practices updated: ____________________

Posted In All Facilities?     Y     N

Is OSHA Form 200 maintained?  Y     N

Emergency Action Plans & Last Update (list):

_________________________________________________________________

_________________________________________________________________
_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Do all employees know and understand these plans? Y     N

Describe Employee/Management Relations:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Are employees covered by 1 or more collective bargaining 
agreements?  Y     N

Do agreements include provision for Safety & Health 
Committees?  Y     N

Attached is a copy of the Safety Committee charter or 
guidelines. Y    N


RATE THE EFFECTIVENESS OF ANY OF THE FOLLOWING ELEMENTS USING 
THE SCALE:

0=Not Using; 1=Ineffective; 2=Poor; 3=Acceptable; 4=Very 
Effective; 5=Excellent.


1.    For ensuring that employees comply with safe and healthy 
work practices:

[    ]  Incentive Program
[    ]  Discipline
[    ]  Training & Retraining

Comments: 

___________________________________________________________________

_________________________________________________________________

_________________________________________________________________
_________________________________________________________________

_________________________________________________________________

__________________________________________________


2.    For communicating with employees on occupational health 
and safety matters:

[    ]  Meetings
[    ]  Training Programs
[    ]  Postings
[    ]  Written Communications
[    ]  Anonymous hazard notification system
[    ]  Safety & Health Committees

Comments: 
___________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

____________________________________________________

3.    For identifying and evaluating work place hazards:

[    ]  Scheduled Periodic Inspections
[    ]  Notification by employees

Comments: 
___________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

____________________________________________________

4.    Your occupational safety & health training program that:

[    ]  Instructs employees in General Safe & Healthy 
Work Practices
[    ]  Provides Specific Instruction with respect to 
Hazards Specific to Each Employee's Job
[    ]  Trains All Employees when the Program is 
implemented
[    ]  Trains all New Employees and Employees given a 
new job assignment
[    ]  Trains all Employees whenever new substances, 
processes, procedures or equipment are introduced to the 
workplace and represent a new hazard and whenever you 
receive notification of a new or previously unrecognized 
hazard.

      Comments: 

___________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

____________________________________________________

5.    [    ]  Your methods and procedures for correcting 
unsafe or unhealthy conditions and work practices in a timely 
manner (based on the severity of the hazard)

Comments: 

___________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

____________________________________________________


THE FOLLOWING REQUIRE YES/NO RESPONSES

6.    [    ]  Do you have records (and a system of recording) 
steps taken to implement and maintain your Program?

7.    [    ]  Do you have a person or persons named with the 
authority and responsibility to implement and maintain the 
Program?

8.    [    ]  Is your Program Written and does it contain all 
of the above elements?