Fillable STATE OF DELAWARE WORKPLACE SAFETY PROGRAM QUESTIONNAIRE PART (Department of Technology and Information)

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STATE OF DELAWARE WORKPLACE SAFETY PROGRAM QUESTIONNAIRE PART (Department of Technology and Information)

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1D Revised 07/26/19
STATE OF DELAWARE
WORKPLACE SAFETY PROGRAM QUESTIONNAIRE – PART II
Please submit your application five months prior to your policy renewal date.
Remember to include your inspection fee when mailing.
JOB SITE ADDENDUM
*Please include General Application with submission
Business Name: ___________________________________________________________________________
I. SAFETY EQUIPMENT/PROTECTIVE CLOTHING AND EQUIPMENT N/A
This section deals with protective clothing necessary for the job or jobs performed.
1. List Personal Protective Equipment (PPE) for your industry:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
a.) How do you enforce? ___________________________________________________________
b.) How is PPE maintained? ________________________________________________________
c.) Is equipment subsidized? ☐ Partially ☐ Fully ☐ Not at all
II. EYE PROTECTION N/A
You should complete this section whenever employees are exposed to such hazards as chemical fumes,
vapors, splashes, intense heat, molten metals, wood and metal chips, and high dust levels.
1. Are safety glasses worn which meet or exceed ANSI standards? ☐ Yes ☐ No
a) Do they have side shields? ☐ Yes ☐ No
b) Are goggles worn when they are needed? ☐ Yes ☐ No
c) Are all glasses regularly cleaned after each use, particularly the goggles? ☐ Yes ☐ No
2. Are safety shields worn over safety glasses (for protection against chemical
splash, glass breakage & severe impact hazards)? ☐ Yes ☐ No
3. Are there eye or eye/face wash stations in areas where chemicals are handled? ☐ Yes ☐ No
III. HEARING PROTECTION N/A
Complete this section if your business has a DBA level of 85 or more.
1. Do you have a hearing conservation program? ☐ Yes ☐ No
a) Do you comply with all OSHA or Delaware state standards where
employees are exposed on a regular basis to high noise levels? ☐ Yes ☐ No
b) How and when are workplace noise levels monitored? _______________________________
c) Do you give your employees annual hearing tests, with records maintained? ☐ Yes ☐ No
d) Is proper hearing protection (ear muffs or plugs) furnished and/or required
to be worn? ☐ Yes ☐ No
e) How is this enforced? _________________________________________________________
2D Revised 07/26/19
2. How often are employees given rest periods or alternate work away from the
noise? ________________________________________________________________________
3. Do you rotate or transfer personnel who show evidence of a significant shift in
hearing threshold? ☐ Yes ☐ No
IV. RESPIRATORY PROTECTION N/A
This section applies if your business has an exposure to respiratory hazards.
1. Do you have an oxygen deficiency hazard? ☐ Yes ☐ No
2. Do you have vapor and particulate hazards (dusts, sprays, fumes, mists, fogs,
smoke or smog)? ☐ Yes ☐ No
3. Are employees exposed to any gaseous contaminants? ☐ Yes ☐ No
4. Are work areas monitored regularly for contaminant levels? ☐ Yes ☐ No
5. Are respirators required? ☐ Yes ☐ No
a) Are they properly fitted? ☐ Yes ☐ No
b) Are instructions given in proper use? ☐ Yes ☐ No
c) Are they cleaned, inspected and disinfected after each use? ☐ Yes ☐ No
d) Are filters replaced on a regular, routine basis? ☐ Yes ☐ No
*** If the answer to any of the above questions 1 through 5 is “yes,” do you have a written respirator
program in compliance with Federal Regulation 29 CFR 1910.134 ? ☐ YES ☐ NO ***
V. MACHINE GUARDING N/A
Complete this section only where machinery is in use.
1. List the types of equipment you have on hand:
______________________________________
______________________________________
______________________________________
2. Do you keep adequate machine guards in place where required? ☐ Yes ☐ No
3. Do you have only trained individuals operating or repairing machinery? ☐ Yes ☐ No
4. Do you implement a preventative maintenance program? ☐ Yes ☐ No
5. Are any defects remedied immediately? ☐ Yes ☐ No
6. Do you have maintenance employees on site? ☐ Yes ☐ No
7. If an employee removes a guard or disengages a safety device, what
corrective action is taken? __________________________________________________________
8. Is the anchoring secure for fixed-location machinery? ☐ Yes ☐ No
3D Revised 07/26/19
Name, title and employer of person completing this questionnaire:_______________________________
____________________________________________________________________________________
Date: _______________________________________________________________________________
If not an employee of company, please provide relationship:____________________________________
Information Verified by: ________________________________________________________________
(*Management Level Employer Representative)
Please visit our website at: insurance.delaware.gov
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Attn: Workplace Safety
1351 West North Street
Suite 101
Dover, DE 19904
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STATE OF DELAWARE WORKPLACE SAFETY PROGRAM QUESTIONNAIRE PART (Department of Technology and Information)

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Completed 27 January 2021

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