Application instructionsProceed with this written application after your on-site visit by MNOSHA Workplace Safety Consultation visit is closed (see How do I join in the MNSTAR overview).
For efficient processing, your application should follow the format below, addressing each item in order. In Sections B through E, describe how each program element is implemented at your worksite. If provided in an appendix, or if available on-site, appropriate documentation should be referenced after the narrative description.
Use of the numbering system in the MNSTAR application for employers helps speed the review of your application. Where existing policies, guidelines, forms, etc., describe your programs, we encourage you to enclose them rather than to write new material for this application.
1. Site/company name
Site/address
Site manager
Title
Site MNSTAR contact
Title
Phone number
2. Company/corporate name (if different than above)
Corporate MNSTAR contact (if applicable)
Title
Address
Phone number
3. Collective bargaining agent(s) (list information on each separately)
Union name and Local #
Name of agent
Address
Phone number
4. Number of employees
Site employees
Routinely used temporary employees
Routinely used contract employees
5. Type of work performed and products produced
6. Site's standard industrial classification (SIC) code (three- or four-digit number)
7. Total recordable case rates (TRCR)
a. For regular site employees, including temporary employees you supervise, provide rates for each of the last three years, plus the average for all three years combined.
b. For smaller employers -- include the best three, out of the last four, years.
c. For contractors whose employees worked 1,000 or more hours in any quarter at your site, provide one combined rate as described in 7a (above) for all contractors' employees who qualify.
Total recordable case rates are calculated (N/EH) x 200,000 where:
N = number of recordable injuries/illnesses in one year.
EH = total number of hours worked by all employees in one year.
200,000 = equivalent of 100 full-time workers working 40-hour weeks, 50 weeks/year.
Lost-workday case rates are calculated with the same equation where:
N = number of injuries/illnesses resulting in lost workdays or restricted work activity.
8. Lost-workday injury/illness rate (LWDIIR)
Provide the same kind of information for lost-workday injuries/illnesses as listed in 7 above.
Rate reduction
If your injury/illness or lost-workday incidence rates are above your industry average, specify your short- and long-term goals for reducing these rates to a level below the industry average. (Small employers may use the best three of the prior four years). Include specific methods you will use to address this problem.
Section F contains a sample statement regarding management commitment to safety and health and to participation in the MNSTAR program. Submission of such a statement is required for MNSTAR application.
1. Commitment: Attach a copy of your site's established occupational safety and health policy, goal and objectives.
2. Organization: Describe how the site's safety and health function fits into your overall management organization. An organization chart is preferred but not required.
3. Responsibility: Describe how your site assigns line and staff safety and health responsibility.
4. Accountability: Describe the accountability system you use for line managers, supervisors and employees. Appropriate examples include forms and job performance evaluations. Explain how the system is documented.
5. Resources: Describe personnel, training, equipment and other resources devoted to your safety and health program.
6. Planning: Describe how planning for safety and health fits into your overall management planning process.
7. Contract workers: Describe your program for ensuring all contract workers who work at your site are provided the same safe and healthful working conditions and the same quality protection as your regular employees. Include information about how the contractors work history was reviewed.
8. Employee involvement: List the ways employees are involved in your safety and health program. Provide specific information about decision processes that employees impact, such as hazard assessment, work analysis, safety and health training or evaluation of the safety and health program.
If you have a safety and health committee, complete the following information where applicable. (Construction applicants must provide information for every item.)
a. Date of committee inception
b. Method of selecting employee members
c. Name, job and length of service of each member
d. Average length of service of employee members
e. Description of committee meeting requirements
- frequency
- quorum rules
- minutes (you may attach samples)
f. Description of committee role
- frequency and scope of committee inspections
- procedures for inspecting the entire worksite
- role in accident investigation
- role in employee hazard notification
- other
g. Describe the hazard recognition training provided to committee members or any nonmanagerial employees with duties involving hazard recognition.
h. List the safety and health information available to and used by the committee. Define its structure. Indicate if there is equal representation of labor and management.
9. Annual evaluation of your safety and health program: Provide a copy of the most recent evaluation of your safety and health program. Include assessments of the effectiveness of the elements listed in these application guidelines and documentation of recommendations completed.
10. Employee notification: Describe how you notified employees about site participation in MNSTAR, their right to register a complaint with MNOSHA, their right to obtain self-inspection and accident investigation results upon request, etc. (Various methods may include one or more of the following: new employee orientation, bulletin boards or tool-box or work-group meetings.)
11. Site plan: Please attach a site map or general plant layout.
1. Pre-use analysis: Explain how new facilities, equipment, materials and processes are analyzed for potential hazards prior to use.
2. Comprehensive surveys: Indicate how you search the site for potential safety and health hazards. Examples include: industrial hygiene surveys, comprehensive safety reviews and project safety reviews at the time of design.
3. Self-inspections: Describe your routine worksite safety and health general inspection procedures. Include information about inspection schedules and industrial hygiene sampling and monitoring. Indicate who performs inspections and how any hazards discovered are tracked until they are eliminated or controlled. (You may attach sample forms and internal timeframes for elimination or control.) For health hazards, summarize the testing and analysis procedures used and qualifications of personnel who conduct them.
4. Routine hazard analysis: Describe how your site routinely examines and analyzes hazards associated with individual jobs, processes or phases. How are the results incorporated in your training and hazard control programs? How are results used in your hazard prevention and control program? Include procedures or guidance techniques used in conducting these hazard analyses. In construction, relate phase planning and describe how results are used in training employees to do their jobs safely. For those worksites with complex processes or highly hazardous chemicals, describe your process safety management (PSM) program.
5. Employee reports of hazards: Describe how employees notify management of potential safety or health hazards. What is management's procedure for follow-up and tracking corrections? (Having an option for written notification must be part of your program.)
6. Accident investigations: Explain your site's accident investigation procedures. What training or guidance is given to investigators? How do you determine which accidents warrant investigation? Are near-miss incidents recorded and investigated?
7. Pattern analysis: Describe the system you use to analyze trends in injury/illness experience and hazards identified at your site.
1. Professional expertise: Provide information about your access to and the frequency of your use of certified industrial hygienists and safety professionals.
2. Safety and health rules: List your site's rules and describe (or attach a copy of) the disciplinary system used for enforcing them.
3. Personal protective equipment: Describe your site's personal protective equipment requirements. If respirators are used, attach a copy of your written respirator program.
4. Emergency preparedness: Describe your site's emergency planning and preparedness program. Include information about emergency or evaluation drills.
5. Preventive maintenance: Provide a summary of your equipment and a description of your procedures for the preventive maintenance of the equipment.
6. Medical program: Describe both your on-site and off-site medical service and physician availability. Explain how your site uses the services of occupational health professionals. Indicate the coverage provided by employees trained in first aid, CPR and other paramedical skills and indicate training they have received. Give a detailed description of how you address specific programs, such as hearing conservation, ergonomics, bloodborne pathogens, etc.
Describe the formal and informal safety and health training programs provided for managers, supervisors and employees. Include supervisors' training schedules and information about hazard communication, personal protective equipment and handling of emergency situations. Describe how you verify the effectiveness of the training given. (Sample attendance lists and tracking methods, if any, also may be attached.)
Other information
Include any other information you believe is crucial to the application.
1. Union statement -- If your site is unionized, the authorized collective bargaining agent(s) must sign a statement that supports or at least indicates no objection to the site's participation in MNSTAR. The statement should be submitted with your application and must be on file before MNOSHA will schedule an on-site visit. Expressions of the commitment of nonunion employees are welcome, but not required.
2. Management statement -- Please read the following statement carefully and either sign on the line below or attach a letter that provides the same assurances.
We agree:
all employees, including newly hired employees and contract
employees when they reach the site, will have the MNSTAR program explained
to them, including employee rights under the program and under the Act;
all hazards, discovered through employee notification,
self-inspections, an OSHA on-site review, accident investigations, process
hazard reviews, annual evaluations or any other means or report,
investigation or analysis, will be corrected in a timely manner, with
interim protection provided as necessary;
if employees are given health and safety duties as part of
our safety and health program, we will ensure those employees will be
protected from discriminatory actions resulting from their carrying out such
duties, just as section 11(c) of the OSHA Act of 1970 protects employees for
the exercise of rights under the Act; and
employees will have access to the results of self-inspections and accident investigations upon request (in construction, this requirement may be met through joint labor/management committee access to these results).
We agree to provide the following information for an on-site MNOSHA review:
written safety and health programs;
all documentation enumerated under III, 1.2.d. of the
current VPP Federal Register Notice; and
any agreements between management and collective bargaining agent(s) concerning the functions of any joint labor/management safety and health committee and its organization and any other employee involvement in the safety and health program.
We will retain these records until MNOSHA communicates its decision regarding initial MNSTAR participation.
We will also retain comparable records for the period of MNSTAR participation to be covered by each subsequent evaluation until MNOSHA communicates its decision regarding continued approval.
We agree to make available for evaluation purposes any data necessary to evaluate the achievement of goals not listed above.
By Feb. 15 of each year, we will provide MNOSHA with our: injury/illness incidence and lost-workday case numbers and rates; hours worked; estimated average employment for the past year; and a copy of the most recent annual evaluation of the site's safety and health program.
In addition, we will send our combined injury/illness incidence and lost-workday case numbers and rates, hours worked and estimated average employment for the past year for all contractors employees who worked at least 1,000 hours in any one quarter on our site during the year.
For construction sites only: Injuries/illnesses of all employees at the site, no matter who the employer is, will be recorded together. Rates will be calculated based on information for the site as a whole, as long as we participate in MNSTAR.
We understand that we may withdraw our participation at any time, for any reason, should we so desire.
Signature
Manager of the applicant worksite
(You may add the signatures of others if you wish)
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2012 Workers' Compensation Summit