Please Fill out This Questionnaire As Completely As Possible and Forward All Requested

PRE-SHARP Review

This form is designed to help you and your consultant prepare for the SHARP process. It contains a list of information and documents that will help start the process. Please review this form. A consultant will contact you soon to discuss how to proceed with your goal of becoming a SHARP participant.

A. Company/Contact Information:

Company Name

Contact person/title

Email address

Mailing Address

Phone Number

Union local if applicable

B. Facility Information

• Facility floor space in square feet (include multiple floors in calculations)

• Facility layout/floor plan of building(s)

▪ Organizational chart

C. Types of Activity/Processes at facility

Activity/process No of Employees

▪ Process Descriptions:

- Sample Process Flow Charts D. Safety and Health Information

If you have any of these documents or information mentioned below, please have them available for our first visit.

• Safety & health related policies, procedures, manuals, goals and objectives. May include: -Hazard Communications Program -Respirator Program - Confined Space Program - Exposure Control Program - Hearing Conservation Program - Electrical Safety Plan - Preventive Maintenance Plan - Management of Change Program - Ergonomics program -Sling/Crane Program - Control of Hazardous Energy (Lockout/tagout) - Emergency procedures (medical plan, emergency action plan, fire prevention plan) - Personal Protective Equipment Assessment and Training documentation -Job Safety/health Analyses (JSA)

▪ Employee Handbook

▪ Safety committee operations, minutes, members, inspection records, accountability, training

▪ Accident/incident reports

▪ Industrial hygiene program, sampling records, list of hazardous chemicals used at the facility

▪ Safety and health training program and records

▪ Internal audits or evaluations of safety and health program

▪ Standard Industrial Classification (SIC/NAICS) Codes & Classifications under which the facility operates

▪ OSHA 300 and Logs for the last five years (801s if OSHA 300 log not required)

▪ Days Away, Restricted or Transferred (DART) rate for the last five years (Fill in attached table)

2 Claims Data

Remained at work

NUMBER OF CASES WITH ..... e y t a l a a w R n

i s n e r t y y f e e a a s a d

h i N t n s D w c r a S r a O r n u

t o s I C

I e b d d y e s H h A e s e a o

a t t J a k e c a N c D r

n e i C e k e T o r

o y l r t l i D R t o s b o a W l t c e a A i p w - o

r R t d D T m d r s m e e e E o o r r c g r r

f e a r e r r f o e s v n a A r T Year (G) (H) (I) (J) DART TCIR

Formulas for calculating DART and TCIR can be found here: http://www.orosha.org/consult/sharp/sharp_appendix-e.pdf