Or. Admin. R. 437-001 app A
This worksheet is provided to analyze the employer's loss prevention needs, and shall be completed jointly by the insurer and the employer. The information is for use by the employer in developing a comprehensive, written loss prevention plan to assist in lowering the employer's occupational injury and illness rate. The insurer is required to assist the employer in developing a loss prevention plan. A copy of this worksheet, including the results from the hazard assessment survey(s) completed by the insurer, must be provided to the employer.
Note: Insurers may use alternate worksheets to document the development of employer loss prevention plans, if they have been approved in advance by the Department of Consumer and Business Services.
Please attach any additional information if space provided is inadequate.
Date
Employer
Insurer
Name of Employer Representative
Name of Insurer Representative
1. Did the employer agree to develop a loss prevention plan? Yes/No? If not, how is this confirmed by the insurer?
2. Is management committed to occupational safety and health? How is this communicated to employees and supervisors?
3. Explain in detail how supervisors and employees are held accountable for occupational safety and health.
4. How are training programs and practices developed? How are training needs determined? What recordkeeping system is used to determine which employees have had training? What follow-up measures will be used to determine if training is effective?
5. Explain the employer's system for hazard assessment and control. Who is in charge of this system? How will the employer document the system's implementation and use?
6. Describe the employer's system for investigating accidents. Who investigates the accidents and analyzes results? How are findings communicated and to whom?
7. What personal protective equipment do employees need? Describe the employer's system for evaluating, obtaining and maintaining all personal equipment. Who keeps what types of records on maintenance of personal protective equipment?
8. Explain and provide specifics on evaluation of the employer's workplace design, layout, and operation from an ergonomic approach. What assistance will the insurer provide to the employer for job site modifications from an ergonomic approach?
9. How is employee involvement in the occupational safety and health effort demonstrated? How is the opportunity for involvement communicated to employees? If meetings are held, how often? What is the scope of the meetings and who attends them? Who takes the minutes of the meetings? How are meeting results communicated?
10. A hazard assessment survey must be conducted. (See ORS 656.451(3): "Such services shall include the conduct of workplace surveys to identify health and safety problems)." What are the specific findings of this survey? How will hazards identified or suspected be addressed in tailoring the plan to meet specific needs of the employer? How will hazards be corrected?
11. After completing this analysis of the employer's loss prevention management plan, who will be responsible for writing the plan: the insurer, the employer, or both? In what time frame will this plan be written?
12. The insurer must assist the employer in implementing the loss prevention plan. Has the employer requested such assistance? If so, when will the insurer meet again with the employer to assist in this ongoing effort?
This form is provided as a service to workers' compensation insurers by the Department of Consumer and Business Services, Oregon Occupational Safety and Health Division (OR-OSHA). Photocopying is permitted.
Or. Admin. R. 437-001 app A