OSHA Field Safety and Health Management System (SHMS) Manual
CHAPTER 3. SAFETY AND HEALTH PROGRAM EVALUATION
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Purpose
The purpose of this chapter is to provide a way to measure and track the safety and health performance of all OSHA offices and organizational units that are covered by the OSHA Field Safety and Health Management System (SHMS) Manual, and to identify best practices and opportunities to improve and promote safety and health in and outside of the workplace.
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Scope
The program applies to all OSHA Field personnel within regional, area, district, or satellite offices or other OSHA organizational units (i.e., Cincinnati Technical Center (CTC), Salt Lake Technical Center (SLTC), Office of Training and Education (OTE) covered by the OSHA SHMS Program.
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Definitions
Safety and Health Tracking Metrics: Metrics used to track office inspections, vehicle inspections, hearing protection fit tests, respiratory fit tests, OSHA Medical Examination (i.e., CSHO physical/exam), emergency drills and exercises, SHMS training, and emergency response training.
Abatement: A corrective measure taken to mitigate an identified hazard.
Lagging Indicator: An indicator that measures the occurrence and frequency of events that occurred in the past, for example the number or rate of injuries, illnesses, and fatalities.
Leading Indicator: An indicator that is a proactive, preventive, and predictive measure that provides information about the effective performance of safety and health activities. It measures events leading up to injuries, illnesses, and other incidents and shows potential problems in a safety and health program.
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References
Department of Labor Manual Series (DLMS) 3- Building Management and Safety and Health DLMS 3- 1400: DOL Safety and Health Program
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Roles and Responsibilities
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The Regional Administrator and Directorate Director are responsible for:
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Establishing appropriate safety and health goals and objectives each calendar year;
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Ensuring OSHA field personnel complete all safety and health-related training and other activities as required by the OSHA Field SHMS Program;
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Timely submitting all safety and health-related tracking metrics; and
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Notifying the OSHA Field Personnel of all SHMS-related activities, including safety and health evaluations, metrics completion, and inspections and allowing their participation.
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Area Directors, Assistant Regional Administrators, and Office Directors are responsible for:
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Setting, pursuing, and tracking safety and health goals annually with quarterly monitoring;
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Tracking and completing all required safety and health-related training and other activities (exercises and drills) for their staff as required by the OSHA Field Safety and Health Management System Program; and
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Reporting and investigating all incidents and promptly completing all recommendations resulting from these investigations using the Hazard and Incident Investigation Worksheets. (See SHMS Chapter 2: Safety and Health Management System.)
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The Regional Safety and Health Manager, with the assistance of the Regional Safety and Health Committee, is responsible for:
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Compiling and maintaining injury and illness records, incident reports, and investigations for the Region and using the data to analyze trends;
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Assessing the safety and health program evaluation and determining the lagging and leading indicators;
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Providing safety and health performance status updates twice a year to the Regional Administrator and applicable Directorate Director, as outlined in the procedure below in Section VI. Procedure;
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Sharing recommendations and success stories quarterly to the Regional Administrator and applicable Directorate Director; and
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Compiling information and data from the Hazard Report and Incident Investigation Worksheets from each office and providing updates quarterly to the Regional Administrator and applicable Directorate Director and upon request from the Safety and Occupational Health Manager (SOHM).
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OSHA Field Personnel Responsibilities: All shall abide by the requirements and recommendations of SHMS Chapter 2 – Safety and Health Management System.
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Procedure
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Each office in the Region and Directorates will evaluate annually the following metrics:
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Progress towards safety and health goals;
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Percent completion of training;
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Percent completion of annual physicals;
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Percent completion of fit tests (i.e., respirators and hearing protection devices (ear plugs));
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Percent completion of annual exercises (i.e., Active Shooter/Hostile Intruder Plan, Continuity of Operations Plan, Local Contingency Plan, Shelter in Place Plan, and Occupant Emergency Plan) (see SHMS Chapter 7: Emergency Contingency Plan);
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Percent completion of required inspections (i.e., office inspections, vehicle inspections, SCBA inspections SLTC – Health Response Team (HRT), etc.);
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Number of incidents investigated per the Hazard and Investigation Worksheets and percentage of incidents with timely reporting (within 5 days of supervisory knowledge); and
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Number of “open” versus “closed” action items listed on the “Hazard Tracking Log” (see SHMS Chapter 2: Safety and Health Management System – Appendix B – Hazard Tracking Log).
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All offices and units should be at 100% completion of these actions by the end of the calendar year or have an approved project plan for completion of significant projects.
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SHMS Self-Evaluation
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The DTSEM Director distributes the SHMS Annual Self-Evaluation to the Regional Administrators and Directorate Directors on or around December 15. SHMS Annual Self-Evaluation is due to the SOHM by January 15. When completing the self-evaluation, input from a team consisting of management and non-management employees must be included. To assist with the completion of the self-evaluation, please refer to the SHMS Annual Self-Evaluation Checklist (Appendix A). This checklist provides examples of information collected in the self-evaluation. The SOHM will review the self-evaluation and checklist annually, and changes will be incorporated. Recommended changes should be submitted to the SOHM at fieldshms@dol.gov for the OSHA Field SHMS ESC's consideration.
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During the self-evaluation process, input from additional employees should be encouraged, and comments/recommendations/corrective actions noted where applicable in the self-evaluation. Upon completion of the annual self-evaluation, a representative of management and labor (Bargaining Unit Employee) shall sign the SHMS Annual Self-Evaluation Signatory Page (Appendix B) and attached any comments as appropriate.
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The self-evaluations will be submitted to the SOHM upon completion via FieldSHMS@dol.gov or as directed by special instructions noted within the self-evaluation. Signatory pages and Summary of Work-Related Injury & Illness OSHA Form 300A shows the total of work-related injuries and illnesses for the year in each category. The Summary of Work-Related Injuries and Illnesses OSHA Form 300A should be sent to the SOHM via FieldSHMS@dol.gov. The SOHM will provide the Regional Safety and Health Managers (RSHM) and SHMS Representatives all the completed evaluations for their respective offices as well as the compiled version(s) for their Region/Directorate by February 15 of each year. The RSHM and SHMS Representatives will present a consolidated summary report to the Regional Administrator and/or applicable Directorate Director by February 15 of each year.
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Appendix A – SHMS Annual Self-Evaluation Checklist
SHMS ANNUAL SELF-EVALUATION CHECKLIST -
The SHMS Annual Self-Evaluation is a safety and health (SH) program evaluation. Things to consider for completion*:
| Office Self-Inspections^ | |||||||||
| Frequency of self-inspections: | |||||||||
| □ | Eye wash stations | □ | AED | ||||||
| □ | Fire extinguishers | □ | Emergency lighting | ||||||
| □ | GFCI | □ | Government-owned vehicles | ||||||
| □ | SCBA | ||||||||
| □ | Percentage of employees in your office who participate in inspections |
□ | Frequency of checklist use during inspections | ||||||
| □ | Percentage of hazards corrected immediately or scheduled for correction | □ | Number of announced and unannounced inspections completed | ||||||
| □ | The frequency that inspections are be analyzed to detect patterns of hazards | ||||||||
| Rules and Work Practices^ | |||||||||
| □ | Types of SH rules and safe work practices that are in place | □ | How employees report hazards | ||||||
| □ | Number of anonymous hazard reports received | □ | Number of hazard reports received that were not anonymous | ||||||
| Hazard Incident Analysis^ | |||||||||
| □ | Manager, SH professional (non-management), & non-SH professional awareness of hazard data | □ | The frequency that Managers, SH professionals & non-SH professionals use/analyze incident data | ||||||
| □ | Type of information included in your office's incident data | □ | SH activities supported by the analysis | ||||||
| □ | Percentage of employees with access to results | □ | How incident data are communicated to workers | ||||||
| Safety & Health Management System^ | |||||||||
| □ | Staff who review the overall SHMS | □ | Leading and lagging indicators included | ||||||
| □ | Best practices achieved during the audit/evaluation (e.g., written product) | ||||||||
| Safety & Health Staff Knowledge^ | |||||||||
| □ | Knowledge/skills of staff performing SH duties | □ | Type of training provided to employees with SH responsibilities | ||||||
| □ | Resources that SH staff are knowledgeable about requisitioning | ||||||||
| Safety & Health Committee | |||||||||
| □ | SH committee compliance with 29 CFR Part 1960, Subpart F | □ | SH committee changes made based on your office's prior annual report | ||||||
| Management Commitment and Employee Involvement^ | |||||||||
| □ | Actions taken by managers to support SHMS | □ | Participation in Field Federal Safety and Health Councils | ||||||
| □ | Process to solicit/receive employee input | □ | Information covered in new employee orientation | ||||||
| Product Safety | |||||||||
| □ | Ways your office ensures products/ services comply with product safety requirements | ||||||||
| Whistleblower Protections | |||||||||
| □ | Existence of a written anti-retaliation policy for whistleblowers in the office | □ | Changes made to your whistleblower program | ||||||
| □ | Ways employees can report retaliation | □ | Cases of retaliation reported | ||||||
| □ | Ways reported retaliation was investigated (including findings and impact to the program) | ||||||||
| Workplace Violence | |||||||||
| □ | Number of workplace vilence incidents that occurred in your office or the field | □ | Individual(s) responsible for the workplace violence incidents | ||||||
| □ | Types of violent incidents that occurred | □ | Steps taken to prevent/address workplace violence | ||||||
| Field SHMS Training | |||||||||
| □ | Frequency of training on field SHMS Chapters | □ | Field SHMA chapters includent in annual training | ||||||
| □ | Percentage of OSHA personnel who completed required training | □ | Other SH training initiatives completed | ||||||
| Safety Activities | |||||||||
| □ | Status of annual/interim physicals for the year (up to date) | □ | Percentage of respirator fit testing that is up to date for employees who need them | ||||||
| Resource Allocation^ | |||||||||
| □ | The frequency that your office practices prevention by design | □ | Resources used to prevent exertion injuries | ||||||
| □ | Resources used to prevent slips, trips, & falls | □ | Approaches taken to do root cause analysis | ||||||
| □ | When your office SH program was last audited by the Regional/National Office | □ | Recommendations from the last audit/inspection | ||||||
| Motor Vehicle Programs | |||||||||
| □ | Number of motor vehicle accidents (MVAs) experienced by employees with injuries | □ | Number of MVAs experienced by employees without injuries | ||||||
| □ | Office compliance with E.O. 13043, which requires wearing a seatbelt | □ | Office compliance with E.O. 13512, which bans texting while driving | ||||||
| □ | Changes made to your motor vehicle program | □ | Initiatives your office implemented | ||||||
| □ | Frequency staff take the Defensive Driving Course | □ | Staff who participate in the Defensive Driving Course | ||||||
| Special Roles in SHMS | |||||||||
| □ | Regional Safety & Occupational Health Manager (RSHM) and SHMS Coordinator | □ | Regional Respiratory Protection Program Coordinator (RRPPC) | ||||||
| □ | Hearing Conservation Coordinator/Committee | □ | OSHA Record Keeper | ||||||
| □ | Regional Safety & Health Committee (RSHC) | □ | Other Regfional Coordinators (e.g., Ergonomics, HAZCOM (GHS), Bloodborne Pathogen and Workplace Violence) | ||||||
| Communication | |||||||||
| □ | Signed U/M SHMS Commitment statement posted in your office | □ | Ways your organization communicates SH policy to employees | ||||||
| □ | Responsibilities of your office's SH coordinator/manager | □ | Ways that employees' SH concerns are addressed by management | ||||||
| □ | Ways the resolution of an issue is communicated to employees | □ | Ways your office assures completion and accountability of delegated SH duties | ||||||
| Ways employees are made aware of the: | |||||||||
| □ | SHMS Program | □ | Results of investigations/audits/etc. | ||||||
| Manager participation in SH-related activities: | |||||||||
| □ | Training | □ | Quarterly S&H inspections | ||||||
| □ | Office meetings | ||||||||
| Employee participation in SH-related activities: | |||||||||
| □ | Training | □ | Quarterly S&H inspections | ||||||
| □ | Office meetings | ||||||||
| Injury and Incident Investigations | |||||||||
| □ | Number of incidents in your office that were investigated | □ | Number of the incidents that were investigated within 5 working days | ||||||
| □ | Number of corrective actions generatedfrom these incidents (open and closed) | □ | OSHA 300A completedand posted in the workplace | ||||||
| □ | The person who maintains the forms for recording work-related injuries and illness | □ | Staff that sign the OSHA 300A form | ||||||
| □ | Frequency hazard incident reports and investigationworksheets compiled for Regional Administrators (RAs)/participating Directorate Directors | □ | Frequency recommendations/success stories shared with Regional RAs/participating Directorate Directors | ||||||
| □ | Total Case Incident Rate (TCIR) | □ | Days Away Restricted or Transferred (DART) | ||||||
| Planning and Resources | |||||||||
| □ | Example of how resources (time & money) were devoted to the SH program | □ | Prediction of resource changes for next year | ||||||
| □ | Your office's top 4 SH goalsfor last year and this year | □ | Status of each of those goals (completed, in progress, or withdrawn | ||||||
| □ | Ways employees are involvedin the SH goal-setting process | □ | Ways that established SH goals are communicated to employees | ||||||
| Hazards | |||||||||
| □ | Procedures in place (per SHMS Chapter 2) to assure identified hazards are corrected | □ | System in place to identify and document routine SH hazards to field staff | ||||||
| □ | Ways your office ensures a maintenance system is in place for GSA vehicles | □ | Ways your office ensures a maintenance system is in place for technical equipment | ||||||
| □ | Number of CSHO monitoring samples collected last year (e.g., air, noise, water) | ||||||||
| Emergency Preparedness and First Aid | |||||||||
| □ | Percentage of personnel participating in required annual exercises | □ | Availability of on-site/off-site access to first aid & emergency treatment | ||||||
| □ | Location of office first aid kit(s) | □ | System in place to maintain and restock the first aid supplies | ||||||
| Organization participation in required training: | |||||||||
| □ | Continuity of Operations Plan | □ | Shelter in Place | ||||||
| □ | Occupant Emergency Plan | □ | Local Contingency Plan | ||||||
| □ | Regional Emergency Management Plan | □ | Active Shooter/Hostile Intruder Plan | ||||||
| Written Procedures/training in annual exercises: | |||||||||
| □ | Continuity of Operations Plan | □ | Shelter in Place | ||||||
| □ | Occupant Emergency Plan | □ | Local Contingency Plan | ||||||
| □ | Regional Emergency Management Plan | □ | Active Shooter/Hostile Intruder Plan | ||||||
| Hazard Abatement/Control | |||||||||
| Process to review SH considerations when: | |||||||||
| □ | Purchasing equipment, furniture, PPE, etc. | □ | Relocating office space | ||||||
| □ | Developing new emphasis programs | ||||||||
| □ | Ways non-OSHA personnel/contract or activities in your office/building are overseen | □ | Ways the office determines and analyzes patterns of near misses/injuries/illnesses | ||||||
| □ | Injury/illness or near-miss patterns detected over the last three years | □ | Types of engineering controls in place | ||||||
| □ | Types of administrative or work practice controls in place | □ | Person conducting/certifying PPE | ||||||
| □ | Employee involvement in PPE assessment | □ | Availability of appropriate PPE types/sizes | ||||||
| □ | Proper PPE use | □ | Existence of written PPE inventory | ||||||
| □ | Frequency PPE inventory reviewed and restocked | ||||||||
^ For additional information about how to evaluate these attributes please refer to the OSHA Federal Agency Annual Report Template.
Appendix B – SHMS Annual Self-Evaluation Signatory Page
The SHMS Annual Self-Evaluation including the SHMS Annual Self-Evaluation Signatory Page is distributed by DTSEM Directorate Director by December 15 to the Regional Administrators and Directorate Directors. This page is due to the SOHM by January 15. Completion of the self-evaluation must include input from a team consisting of management and non-management employees. The self-evaluation will be reviewed annually, and changes incorporated as appropriate.
During the evaluation process, input from additional employees should be encouraged, and comments/recommendations/corrective actions noted where applicable in the self-evaluation. Upon completion, the SHMS Annual Self-Evaluation Signatory Page, with or without comments, should be signed by the office's management and labor representative (Bargaining Unit Employee) to certify the completion of the SHMS Annual Self-Evaluation. The purpose of the signatory page is to ensure that the employees are aware of the completion of the SHMS Annual Self-Evaluation.
Please electronically sign your office's SHMS Annual Self-Evaluation Signatory Page and send a copy of the report to your Regional Safety and Occupational Health Manager or SHMS Coordinator upon completion of the report.
If there are any questions, please contact the National Office Safety and Occupational Health Manager or send the inquiries to FieldSHMS@dol.gov.
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