<p>Safety Groups – Five Steps Worksheet </p><p>Company Name: ______</p><p>Element Name: ______Date:______</p><p>Step 1 - Set Standard</p><p> I have a written standard for the above element  The standard is current (date of standard______)  The standard is signed / approved by senior management (name on the document______title______)  The standard describes exactly how the element will be implemented in the workplace  The standard clearly describes the specific responsibilities of everyone in the workplace (e.g., management, supervisors, workers, JHSC, Safety Group contact, etc.)  It outlines exactly how the standard will be communicated  It outlines exactly what health and safety training is necessary to meet the standard  It outlines exactly how the standard will be evaluated at the end of the year  The requirements of the standard are realistic  The standard meets minimum legislative requirements.</p><p>Step 2 - Communication</p><p> The standard has been communicated to o All those responsible for implementing the standard o All those who will be affected by the standard.</p><p>Name Means of Communication Date of Communication (e.g., bulletin boards, emails, memos, meetings, etc.)</p><p>1 of 2 Step 3 – Training</p><p> The training requirements outlined in the standard have been fulfilled  Training records are available showing the following information</p><p>Name of Person Trained Job Title Training Content Date of Training</p><p>Step 4 – Evaluation:</p><p> Proposed date of evaluation of the standard: ______ Means of evaluation (e.g., quizzes, surveys, workplace inspection observations, accident statistical review, etc.): ______ Persons responsible for conducting the evaluation: ______ Actual date of evaluation: ______ Summary of the evaluation results/findings (be specific):</p><p>Evaluation Results/Findings:</p><p>Step 5 – Acknowledge Success/ Make Improvements:</p><p> The standard was successfully implemented. o Who will formally acknowledge / recognize this success? ______o How will success be formally acknowledged? ______o Date of acknowledgement: ______</p><p> Improvements recommended as a result of the above evaluation:</p><p>Recommended Improvements (be specific) Date Completed Signature</p><p>2 of 2</p>