Oregon Administrative Rules › Chapter 437 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, OREGON OCCUPATIONAL SAFETY AND HEALTH DIVISION › Division 1 - RULES FOR THE ADMINISTRATION OF THE OREGON SAFE EMPLOYMENT ACT › Appendix A - (See OAR 437-001-1040(2)(a)) Mandatory Loss Prevention Plan Worksheet

Current through Register Vol. 63, No. 7, July 1, 2024
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.