EMPLOYER NAME
2017 Monthly Action Plan
Activity
Safety Committee meeting
(date)
Safety Training (per monthly
schedule)
Manager Monthly Briefing
Report
Safety Inspections
Safety Violations
Safety policy reivew and
udpate
Injury Tracking
Owner Responsibilities
TBD
Pprepare material (Agenda,
matrix) in prep for safety
meeting. Host and direct
meeting
TBD Supervisors to provide training,
Safety Coordinator to
coordinate attendance sheets,
Safety coordinator to update
matrix for monthly review
TBD Managers required to submit
and discuss their monthly
briefing report to safety
committee. Safety Coordinator
to ensure reports are submitted
TBD
Complete a monthly inspection
of the plant/jobsite.
Ensure all violations are
accompanied with a write up
TBD (including verbal). Track repeat
offenders using the Safety
Violations tab. Safety
Coordinator to update tab
TBD
Review one safety policy per
month and customize to match
organization's procedures
Update Injury Tracking in the
TBD safety matrix with results per
month
 Material January February March

Agenda, matrix (injuries, training, 23-Mar

suggestions, violations, inspections, etc.),
briefing reports, suggestions

Matrix: updated from attendance sheets

(add dates per EE name), update # of X X X
employees at bottom of the Monthly
Safety Training Schedule tab to
accurately get % completed for month

X X X
Briefing reports. Track report completion
in the Manager Monthly Briefing tab in
the Safety Matrix

Inspection Report, update safety matrix X X X

tab with findings (corrective action
findings only)

X X X
Employee Violation Report, update the
Safety Violations tab

Develop safety policies per Cal-OSHA X X X

topic/requirment, update the
development schedule and status in the
Cal-OSHA Policy Management tab

Safety Matrix - Injury Tracking tab and X X X

Historical Loss Trending tab
 Month Safety Activity is Due
April May June July August September

20-Apr 25-May 22-Jun 20-Jul 24-Aug 21-Sep

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X
October November December

19-Oct 16-Nov 14-Dec

X X X

X X X

X X X

X X X

X X X

X X X
EMPLOYER NAME
Cal-OSHA Policy Development Schedule

Template
Policy name Established
Bloodborne Pathogens
Code of Safe Practices
Drug & Alcohol Policy
Electrical Safety
Fall Protection
Fire Prevention & Response
First Aid / CPR
Fleet Safety
Hazard Communication
Hearing Conservation Program
Heat Illness Prevention
Industrial Truck / Forklif
Injury & Illness Prevention Plan
Lockout Tagout
Material Handling / Lifing
Personal Protective Equipment
Respiratory Protection
Return To Work
Safety & Health Policy
Trenching & Shoring
Warehouse/Housekeeping

Key
 Month Assigned Final Approval
for Review Responsible Person (Y/N)

Key
Priority
Secondary
Tertiary
Date Approved Comments
EMPLOYER NAME
Injury Tracking (Frequency & Severity)

January February March April

Frequency Goals 5 0 0 0
Total by month 1
First Aid 1 0 0
Medical Only 1 0 0
Indemnity 1 0 0

Severity Goals $ 833 $ 833 $ 833 $ 833

Total by month $ 400 $ -
First Aid $ 100
Medical Only $ 200
Indemnity $ 100 $ -

Frequency Goals Total by month

6
5
5

2
1 1 1 1
1

0
Ja nua ry 0 Februa
0 ry0 0 0 March
0 0 0 0 Apri l 0 May 0

Severity Goals

$900 $833 $833 $833 $833 $833 $8

$800
$700
$600
$500
$400
$400
$300
$200
$200
$100 $100
$100
$-
Ja nuary $-
February $- Ma rch Apri l May
 May June July August September October
0 0 0 0 0 0

$ 833 $ 833 $ 833 $ 833 $ 833 $ 833

Injury Frequency
ency Goals Total by month First Aid Medical Only Indemnity

ri l 0 May 0 June 0 Jul y 0 August 0 September 0 October 0 N

Injury Severity
Severity Goals Total by month First Aid Medical Only Indemnity

$833 $833 $833 $833 $833 $833 $833

Apri l May June Jul y August September October N

 November December Totals
0 0 5
1
1
1
1

$ 833 $ 833 $ 9,996

$ 400
$ 100
$ 200
$ 100

0 October 0 November 0 December

mnity

$833 $833 $833

r October November December

EMPLOYER NAME
Historical Loss Trending

Data as of:
# of
Total # # of # of
Policy Year Carrier/TPA Medical
Claims Open Indemnity Only
2012 1 0 0 1
2013 0 0 0 0
2014 3 0 2 1
2015 0 0 0 0
2016 0 0 0 0
2017 0 0 0 0
Totals 4 0 2 2

Claim Severity Total Incurred Total Paid Total Outstanding

$40,000 $37,041
$37,041
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000 $2,981$2,981
$0 $0 $0 $0 $0 $0
$-
2012 $0 2013 2014 $0 2015 $0 2016
$0 $0 $0 2017
$0 $0
 Prior Report Total
Total Incurred Total Paid Total Outstanding Incurred 11/2016

$ 2,981
$ -
$ 37,041
$ -
$ -
$ -
$ 40,022
$ 2,981 $ -
$ - $ -
$ 37,041 $ -
$ - $ -
$ - $ -
$ - $ -
$ 40,022 $ - $ -

rred Total Paid Total Outstanding Claim Frequency Total # Claims # of Open # of Ind
3.5
3
3

2.5
2
2

1.5
1 1 1
1

0.5
$0
0 2016
$0 $0 $0 2017
$0 $0 0
020120 0 020130 0 02014 0 020150 0 0 02
 Difference from Prior California Avg.
Average Claim Cost
Quarter Indemnity Costs

$ 2,981 $ 2,981 $ 77,459

$ - $ - $ 76,081
$ 37,041 $ 12,347 $ 78,226
$ - $ - $ 80,735
$ - $ - Not Released Yet
$ - $ - Not Released Yet
$ 40,022

Total # Claims # of Open # of Indemnity # of Medical Only

02014 0 020150 0 0 020160 0 0 020170 0

 Safety Training Matrix

EMPLOYER NAME
Training Schedule

January February March April May June July August September October November December

Annual Safety Warehouse / Forklif Fall Protection: Preparation,

Fall Protection Other PPE Other Orientation S&H Other Other Confined Space Other Heat Illness Other Electrical Safety Other Other Back Safety / Material Handling Other Heat Illness Other First Aid Other Hand and Power tools Other
Policy, IIPP & COSP Safety Application, and Safety

Employee Name Department DOH Supervisor Date Completed

Employee 1 1/15/2017 2/20/2017 3/17/2017
Employee 2 1/15/2017 2/20/2017 3/17/2017
Employee 3 1/15/2017 2/20/2017 3/17/2017
Employee 4 1/15/2017 2/20/2017 3/17/2017
Employee 5 1/15/2017 2/20/2017 3/17/2017
Employee 6 1/15/2017 2/20/2017 3/17/2017
Employee 7 1/15/2017 2/20/2017 3/17/2017
Employee 8 1/15/2017 2/20/2017 3/17/2017
Employee 9 1/15/2017 2/20/2017 3/17/2017
Employee 10 1/15/2017 2/20/2017
Employee 11 1/15/2017 2/20/2017
Employee 12 1/15/2017 2/20/2017
Employee 13 1/15/2017
Employee 14 1/15/2017
Employee 15 1/15/2017
Employee 16 1/15/2017 2/20/2017
Employee 17
Employee 18
Employee 19
Employee 20
Employee 21
Employee 22
Employee 23
Employee 24
Employee 25
Employee 26
Employee 27
Employee 28
Employee 29
Employee 30
Employee 31
Employee 32
Employee 33
Employee 34
Employee 35
Employee 36
Employee 37
Employee 38
Employee 39
Employee 40
Employee 41
Employee 42
Employee 43
Employee 44
Employee 45
Employee 46
Employee 47
Employee 48
Employee 49
Employee 50

Number of Employees (enter each month) 18 18 18 39

Number of completed trainings 16 13 9 0 0 0 0 0 0 0 0 0
Percent Completed 89% 72% 50% 0% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

62
EMPLOYER NAME
Manger Monthly Briefing Report

Report Completed and Reviewed?

Manager Department January February March April
Manager 1 Department 1 X X X X
Manager 2 Department 2 X X X X
Manager 3 Department 3 X X X X
Manager 4 Department 4 X X X
Manager 5 Department 5 X
Manager 6 Department 6
Manager 7 Department 7 X X X
Manager 8 Department 8 X X X X
Manager 9 Department 9 X X X X
Manager 10 Department 10 X X X X

# of Managers 10 10 10 10
# of completed reports 8 8 8 7
Percent Completed 80% 80% 80% 70%
Goal 100% 100% 100% 100%
May June July August September October November

10 10 10 10 10 10 10
0 0 0 0 0 0 0
0% 0% 0% 0% 0% 0% 0%
100% 100% 100% 100% 100% 100% 100%
December

10
0
0%
100%
EMPLOYER NAME
Safety Violations Tracking Matrix

Date Name Dept Shif

 Write Up /
Supervisor Training by
Violation
 Violation Rating

First Warning (Verbal)

Second Warning (Verbal /
Written)
Final Warning
Corrective Action / Training
EMPLOYER NAME
Safety Suggestions

Date Name Dept Shif Suggestion/Hazard Solution Notes

EMPLOYER NAME
Safety Suggestions

Date Hazard Rating Finding Location Notes Responsible Department Corrected? Photo Date Corrected
EMPLOYER NAME
Forklif Management Matrix

Forklif Driver Review

Employee Name Valid CDL? Y/N Department
Date Training Date Refresher
Completed Training Needed
ver Review
Retraining Provided?
Incident? (Date) Comments
(Date)
 Weekly Inspection Checklist Completed (Y/N)
Forklif # Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14
Completed (Y/N)
Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
EMPLOYER NAME
Employee Scorecard

Q1 Eval
Employee Name Department Supervisor Date of Hire Date

Sample 1 Safety Sup 1 1/1/2014 3/31/2014

Sample 2 Admin Sup 2 1/1/2014 3/31/2014
 ACTIVITY / SCORE (most recent quarterly score)
Q2 Eval Q3 Eval Q4 Eval
Date Date Date Safety Technial Skills Work Habits

Max Possible Score 20 20 20

18 20 15
20 20 15
 2014 Tracking
ost recent quarterly score) Add each Quarter's score into the appropriate cell
Total Score Grade (Passing =
Teamwork & 80% or higher)
Leadership Q1 score Q2 score Q3 score
Attitude
20 20 100 100% 100% 100% 100%
15 10 78 78% 89% 84% 88%
15 20 90 90% 88% 82% 78%
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14 Tracking
score into the appropriate cell
2014
Q4 score Average
100% 100%
78% 85%
90% 85%
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#DIV/0!
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#DIV/0!
#DIV/0!
EMPLOYER NAME
Vehicle Driver Checkride Scorecard

2014 Tracking
ACTIVITY Add each Quarter's score into the appropriate cell

Driver Name Date of Next Route Driving in Trafic Total Score Grade (Passing
Date of Checkride Before Starting Driving in Traffic (Attention, Use of
lef Turn Right Turn Intersections
Customer = 80% or higher) Q1 Checkride Q2 Checkride Q3 Checkride Q4 Checkride 2014
Checkride Engine (speed)
Attitude)
Controls Delivery score score score score Average

Max Possible Score 35 45 65 25 40 45 65 50 370 100% 100% 100% 100% 100% 100%
35 35 55 25 40 40 55 45 330 89% 89% 84% 88% 78% 85%
30 45 65 25 35 40 50 35 325 88% 88% 82% 78% 90% 85%
0 0% #DIV/0!
0 0% #DIV/0!
0 0% #DIV/0! A passing score is 300 ore more. An automatic failure should be imposed for any one of the following
0 0% reasons: A passing score is 300 ore more. An automatic failure should be imposed for any one of the
#DIV/0!
following reasons:
0 0% #DIV/0! (1) Any unsafe act.
0 0% #DIV/0! (2) Not knowing location and function of gauges and controls.
0 0% #DIV/0! (3) Unsatisfactory performance on “Vehicle Control Test”.
0 0% #DIV/0! (4) Undue nervousness.
0 0% #DIV/0! (5) Failure to achieve a minimum passing score
0 0% #DIV/0! (6) If the individual scores 300 or more, but the examiner feels that the individual needs additional
0 0%
training, the examiner has the right to recommend to the General Manager that the Driver’s license be
#DIV/0!
suspended until further training is completed
0 0% #DIV/0!
0 0% #DIV/0! Whether the driver passes or fails any portion of the test, the examiner will review the results of the
0 0% #DIV/0! road test with him or her, and bring to the driver’s attention any weaknesses that require further
0 0% #DIV/0! practice or training. Record the main points of this review in the space below.
0 0% #DIV/0!
0 0% #DIV/0!
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