ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SMALL EMPLOYER SELF-EVALUATION

Employer Name:
Address:
Contact Name: / Phone No. Fax No.
WCB Account No. / WCB Industry Code:
Number of Employees: / Audit Date:
Signature of Evaluator:
/ Certified Auditor:
Authorized
Company Signature: / Commissioner for Oaths:
Date Submitted:
______
Association Reviewer: / Review Date:
Type of Evaluation: COR Maintenance Renewal of COR Approved: Yes No
(Circle One) (Circle One)

COMPANY PROFILE

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SMALL EMPLOYER SELF EVALUATION DOCUMENT

Completion Instructions

Read each question and verify whether the answer is “Yes” or “No”. for questions that have “D” in the verification column a document is required to answer “Yes”. For other questions observation (O) or interview (I) is required to verify. Follow the instructions in the Supporting Information column. Documentation provided may consist of examples of completed reports, policies, and/or notes made on the Comment page provided with this document.

There may be times when the small employer’s personal knowledge can be used for verification if it is a recent activity or there are only 1 or 2 employees.

Example: Question 1.4 in element #1 would be easy to verify if the legislation was just purchased and provided to employees.

The only questions that may not apply are those referring to contractor/subcontractors, no other questions can be marked Not Applicable, other than the self-evaluation then Element 8 questions 8.2 & 8.3 may not apply(first year only). If contracting organization questionnaires are not completed by the small employer then question 8.4 & 8.5 will also be n/a.

All questions apply, to some extent, to all employers. No questions can be deferred to another employer or contracting organization.

Example: If a contracting organization has a mandatory orientation, does not mean that “Yes” can be answered for Element #5 – question 5.1.

Orientations specific to the small employer business are still required. Verifications methods may vary when the owner is the only

employee.

Questions with an asterisk (*) do not apply to owner/operators and will be marked N/A. More than two (2) “No’s” in any one element would mean the requirement for C.O.R. are not achievement. Maintenance audits are not required to achieve the 80% overall however, companies are encouraged to maintain the standard every year.

The self-evaluation process must be completed and delivered to the ASCSH Office within 15 days from start to finish and must include all appropriate documentation.

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Program
Element /
Verification
Process / Yes / No / Supporting Information
Element #1
/
Management Leadership and Commitment
1.1 / D / Is there a written health and safety policy for the
Company which is signed by the Owner? / Attach a copy of the policy.
1.2 / D / Have I written health and safety responsibilities for my employees and myself? / Attach a copy of the Assignment of Responsibilities.
1.3 / D/I / Do both owner and employees know and understand the policy and assigned responsibilities? / Include a list of employees, they should be able to support your answer and may be contacted.
1.4 / D/O / Is the current OH&S legislation readily available to workers? / Note where the legislations is located. i.e. Shop, office, trucks, coffee room, etc.
1.5 / D/I / Are employees aware of the Occupational Health and Safety Regulations relevant to their workplace? / Employees may be contacted and should be able to support your answer. Provide information verifying this process. i.e. Orientation checklists, safety meetings, excerpts in employee handbooks.
1.6 / D / Is there a policy which outlines health and safety performance requirements and corrective measures? / Attach a copy of the disciplinary/enforcement policy.
Element #2 / Hazard Identification and Assessment
2.1 / D / Do I have an inventory of job tasks? / Attach a copy of the inventory.
2.2 / D / Has a formal assessment of the job tasks been completed identifying health and safety hazards? / Attach a copy of the hazard assessment process such as a completed matrix.
2.3 / D / Have all the health and safety hazards been evaluated according to risk? / This should be included on the matrix, if not include an example of the evaluation process.
2.4 / D / Have all the job tasks been prioritized according to risk? / Submit a copy of the job task inventory as prioritized according to risk.
2.5* / D/I / Are the employees involved in the hazard identification and evaluation process? / Provide proof of involvement such as job tasks analysis signed by the employee; on-going hazard reporting
2.6 / D / Is there provision for continuous hazard reporting, follow-up and corrective action taken? / Attach a copy of several hazard reports which indicates what was reported and corrective action.
ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Element #3 / Verification Process / Hazard Controls / Yes / No / Supporting Information
3.1 / D / O / Have engineering, administrative and personal protective controls been identified and implemented? / Attach a copy of how controls have been identified. This could be included on the matrix.
3.2 / D / Have safe work practices and procedures been written for the tasks listed in the task inventory? / Attach several examples of safe work procedures for the tasks in the inventory.
3.3* / D/O / Does management enforce the use of the controls and safe work practices and procedures? / Provide evidence of how this is accomplished. i.e.: inspections, tool box meetings, reprimands, noted explanation. May be verified by the Certifying Partners through a phone call.
3.4 / D / Have I ensured the workers are sufficiently trained in safe work practices and procedures? / Attach a copy of the training records. Include on the job training.
3.5 / D/O / Is the required PPE used consistently? / Copies of work permits, inspection reports could verify. May also be verified by the Certifying Partner through a phone call or visit.
3.6 / D/O / Is the required PPE properly maintained? / Provide a copy of the PPE Requirement and Maintenance Policy.
Element #4 / Ongoing Inspections
4.1 / D / I / Have I developed a policy clearly stating the requirement for work site, vehicle and equipment inspections? / Attach a copy of the policy.
4.2 / D / Have I developed an appropriate inspection form(s)? / Attach a copy of the form(s).
4.3 / D / Have inspections been carried out consistent with the policy requirement. / Attach a sample of completed inspections.
4.4 / D / Is there a system in place to track deficiencies and record follow-up action? / Attach a copy of an action list or the method in which deficiencies are tracked.
4.5 / D / Is there a preventative maintenance program for equipment and machinery? / Submit an example of work orders; maintenance logs etc.

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Element #5 / Verification Process / Qualifications, Orientation and Training / Yes / No / Supporting Information
5.1* / D / I / Have all employees received health and safety orientations within the first week of employment, and are critical issues addressed on the first day? / Attach a copy of the three most orientation checklists signed by both the new hire and person providing the orientation training. Employees may be contacted by the Certifying Partner to verify your answer.
5.2 / D / I / Is job specific training current and is on-going training made available? (Such as H2S, confined space entry) / Attach a copy of the training records.
5.3 / D / O / I / Is appropriate personal protective equipment available and are the employees trained in the use, care and maintenance of the equipment? / Training records attached should indicate this training. Employees may be contacted to verify your answer.
5.4 / D / Are training records maintained and current? / Attach a copy of the training records.
Element #6 / Emergency Response
6.1 / D / Is there a written emergency response plan which includes appropriate phone numbers and contacts? / Attach a copy of the emergency response plan.
6.2 / D / O / Does first aid training and supplies comply with the legislative requirements? / Attach a copy of training records. Attach a copy of the first aid inventory noting what legislative schedule is required.
6.3 / D/I / Do employees understand their responsibilities in the case of an emergency? / Reference training records and legislative responsibilities. Ie. 1.3 and 5.4 Employees may be contacted by the Certifying Partner to verify your answer.
6.4* / D / O / Are emergency drills conducted in the workplace? / Attach a copy of the emergency drill report. Employees may be contacted to verify your answer.
Element #7 / Accident and Incident Investigation
7.1 / D / Is there a written policy which requires reporting and investigation of accidents/incidents (near miss)/ occupational illness? / Attach a copy of the policy.
7.2 / D/I / Are employees aware of the reporting procedures and their responsibility to report? / Orientations records should indicate employee legislative responsibility to report and procedure for reporting. Reference 5.1

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Element #7 / Accident and Incident Investigation / Yes / No / Supporting Information
7.3 / D / Are workplace injuries, illnesses and near miss incidents reported externally as required by W.C.B and Workplace Health and Safety? / Explain in the note pages how this requirement is met and what would you would be required to report to each agency.
7.4 / D / Is there an appropriate accident/incident report form available? / Attach a copy of the form, a completed form if available.
7.5 / D / Is there an appropriate accident/incident investigation form available? / Attach a copy of the form, a completed form is available.
7.6 / D / I / Are investigations conducted as described in the policy and is corrective action taken? / Attach a copy of a completed investigation form if one is available. Employees may be contacted by the Certifying Partner to verify your answer.
7.7 / D / How corrective action documented and follow-up action is tracked to completion? / Attach a copy of the documents.
7.8* / D/I / Are the results of an investigation communicated to the employees? / Attach a copy of tool box meeting minutes, notes indicating the communication takes place. Employees may be contacted by the Certifying Partner to verify your answers.
Element #8 / Program Administration
8.1 / D / Are records of safety meetings, pre-job meetings, tool box meetings, work permits kept on file? / Attach several examples of documentation to verify.
8.2 / D / Has an Action Plan been developed including target dates for completion and who is responsible to complete the action for all questions answered “No” in this audit? / Complete the attached action plan and submit a copy.
8.3 / D / Have the items on the action plan from the previous audit been implemented? / Attach a copy of the previous action plan which indicates who was responsible for the action and date of implementation.
8.4 / D / Has a plan been developed in consultation with contracting organizations for ensuring workplace health and safety? / Attach a plan from a contracted worksite, OR complete and submit a Contracting organization health and Safety Questionnaire.
8.5 / D / Have specific workplace health and safety hazards been identified at the contracted worksites and have workers been made aware of the hazards? / Attach a copy of meeting minutes where hazards were identified OR attach a copy of the Contracting Organization Questionnaire.

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Self Evaluation score is calculated by number of “Yes” responses divided by 44 x 100. Must have 80% to achieve a COR which requires 35

Yes responses, maximum 9 No responses, and not more than 2 No responses per element to submit for certification. N/A questions are to be deleted from the 44 total points possible prior to calculating the score.

Example: 44 – 2 N/A = 42 points available; if you had 37 Yes responses, 2 N/A it would be 37 divided by 42 x 100 = 88%

TOTAL POINTS POSSIBLE: ______44___

Less:

TOTAL NUMBER OF N/A‘s: ______

Equals:

TOTAL POINTS AVAILABLE: ______

TOTAL NUMBER OF “Yes” RESPONSES: ______(Points Achieved)

TOTAL NUMBER OF “No” RESPONSES: ______

EVALUATION SCORE: Points Achieved x 100 = %______x 100 = ______%

Points Available

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Action Plan

Question / Deficiency / Corrective Action / Date
Implemented / Signed
Off
.

ALBERTA SAFETY COUNCIL FOR SENIORS HOUSING

SELF-EVALUATION DOCUMENT

Comments:

______
______
______
______
______
______
______

ALL “NO” RESPONSES MUST BE PUT ONTO the ACTION PLAN TO DETERMINE CORRECTIVE ACTION. More than TWO “No” answers in any one element would mean the requirements for COR are not met even if the overall score achieved would be 80%. Maintenance audits are not required to achieve the 80% mark, however, it recommended the program be maintained to that standard. N/A responses and notes to verify questions need to be explained in the comment section.

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2018-10-03