Fillable Workplace Safety Program Questionnaire Submission Tips (Department of Technology and Information)

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Workplace Safety Program Questionnaire Submission Tips (Department of Technology and Information)

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Workplace Safety Program Questionnaire Submission Tips
This Questionnaire (PDF) allows for you to complete this form online but in order
for the Submit button at the bottom of the last page to work properly you must use
Internet Explorer as your web browser.
If you are using any web browser other than Internet Explorer (Firefox, Chrome,
Safari, etc.) you will need to download the Questionnaire, complete it and then
submit it via email (or fax).
If you do not receive a confirmation email from a Workplace Safety Program staff
member within 3 full business days of submitting your Questionnaire, please call
302-674-7377 to confirm that your form was received.
Please submit your inspection fee by mail and include the top page of your
questionnaire with your check. See the fee schedule page for additional
instructions.
Thank you,
Delaware Department of Insurance
Workplace Safety Program
STATE OF DELAWARE
WORKPLACE SAFETY PROGRAM QUESTIONNAIRE
Please submit your application five months prior
to your policy renewal date.
.
PLEASE SUBMIT YOUR INSPECTION FEE at
the
time of application.
GENERAL INFORMATION
Business Name: ____________________________________________________________________________
Attention (Mr., Mrs., Dr., Name ): _____________________________________________________
Job Title: _________________________________________________________________________
Mailing Address: ___________________________________________________________________________
City/Town:_______________________ Zip: ________________
Physical Address: __________________________________________________________________________
City/Town: _______________________ Zip:________________
Telephone #: ________________ Cell Phone #: ________________ Email: ___________________________
Is any off-site work done? ☐ Yes ☐ No If yes, please complete Job Site Addendum.
Do you have a Drug Free Program? ☐ Yes ☐ No If yes, please complete Drug Free Program Addendum.
Hours of Operation: _________________________________________________________________________
Are you seasonal? ☐ Yes ☐ No If yes, please provide the dates you are open for business:
____________________________________________________________________________________________________________
Describe Operation: _________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Delaware Location(s): _______________________________________________________________________
_________________________________________________________________________________________
Depa
rtment Use Only
RENEWAL DATE:__________________ FILE#:______________________ #OF YEARS:__________ PERCENTAGE__________
INSPECTION DUE DATE:_______________ CHECK: ____________________ AMOUNT: ______________
AMOUNT PAID LAST YEAR:_____________ LOCATION (S): ____________________ INSPECTION(S):____________
COMMENTS:________________________________________________________________________________________________
___
_________________________________________________________________________________________________________
____________________________________________________________________________________________________________
1 Revised 03/2020
WORKPLACE SAFETY INSPECTION FEE SCHEDULE*
For Propert
y Management, Artisans, and Contractors (General, Building, Custodial, Lawn Service, etc.):
EFFECTIVE AS OF NOVEMBER 1, 2003
1
st
YEAR ALL CONSECUTIVE YEARS
Home Base plus 2 Sites or Less
$700 $350
Home Base plus 3 to 5 Sites $1,000 $500
Home Base plus 6 to 10 Sites $1,500 $750
Home Base plus 11 to 15 Sites $2,000 $1,000
Home Base plus 16 or More $3,000 $1,500
For Most Other Businesses:
1
st
YEAR
ALL CONSECUTIVE YEARS
One Building $300 $150
One Building Plus CDLs $400 $200
Two Buildings/ Car
Dealerships/Country Clubs
$600 $300
Four Buildings $1,200 $600
Six Buildings $1,800 $900
Eight Buildings $2,400 $1,200
Ten Buildings $3,000 $1,500
*
Only Delaware work sites are eligible for the Workplace Safety Program. The
safety
credit applies to Delaware premiums in multi-state policies.
FEES MAY BE ADJUSTED UNDER CERTAIN CIRCUMSTANCES
Please send in a minimum of $150 if you are unsure of your fee. You will be invoiced for the balance due or
refunded, if necessary upon completion of your inspection.
Not applicable for inspections conducted by workers compensation insurance carriers.
Make your check payable to Delaware Insurance Department.
Sign and date your check.
The amount must be written out in type-written words as well as numbers.
2 Revised 03/2020
EMPLOYEE, WORKPLACE INJURY, AND WORKERS COMPENSATION CLAIMS DATA:
Number of full-time employees: Part-time employees:
Have you had any Workers Compensation Claims in the last 36 months? ☐ Yes ☐ No
If yes, please indicate which year (s):
Please provide an estimate of lost workdays*:
*(Begin counting the day after the incident occurs. If a single injury involves both days
away from work and days of restricted work activity, enter the total days for each. Stop
counting once the total of either or the combination of both reaches 180 days for that injury.
For clarification please see OSHA Recordkeeping at www.osha.gov)
The following information will be explicitly considered in determining
whether you receive your Workplace Safety Credit in accordance with
the new Delaware law:
Workplace injuries which have occurred during the last three years:
(use additional paper if needed)
Date
Specific Nature
of Injury
Fines or Findings
Relating to
Workplace Safety
Safety Measures Taken by Employer MDA**
**Please have all applicable Modified Duty Availability Reports available for your inspector to review.
3 Revised 03/2020
The requirements of 2013 House Bill 175 regarding the
Workplace Safety Program remain in effect. In addition to
hazard recognition observations based on the physical walk through of
your workplace and abatement of previously made recommendations,
where applicable, three years of workplace injury data will now
also be considered when determining if you will be awarded the
Workplace Safety Program Credit. For compliance, please ensure all
information is filled out completely and accurately.
IMPORTANT INFORMATION – PLEASE READ CAREFULLY
The purpose of a Workplace Safety Program inspection is solely to determine if the
participating business qualifies for the Delaware Workplace Safety Program insurance premium
discount. Conditions considered include, but are not limited to, the following: an effective
health and safety program, adequate and effective employee training, identification and
elimination of potential hazardous conditions, and three years of workplace injury data.
Although the inspector might cite Occupational Safety & Health (OSHA) standards, other
regulations or guidelines, the Delaware Workplace Safety Program is not the same as an OSHA
inspection. The purpose is not to determine compliance with OSHA or any other safety
regulations or standards of care; it is simply to determine whether the health and the safety of
employees are an important part of businesses participating in the program and that hazards
are routinely and regularly identified and corrected.
No liabilit
y or responsibility is assumed by the person or entity preparing the report or
performing the inspection, for any injuries to employees, subcontractors or other persons
injured at the businesses participating in the Delaware Workplace Safety Program. It remains
the sole responsibility of the participating business to assure their premises are safe for their
employees, subcontractors and all other persons at their businesses and facilities. No contractual
relationship exists between the parties performing the inspections and preparing the reports and
the participating businesses, their employees, subcontractors and all other persons on their
premises.
4 Revised 03/2020
DELAWARE EMPLOYERS’ WORKPLACE HEALTH AND SAFETY INCENTIVE PROGRAM
I. SAFETY PROGRAMS/PHILOSOPHY
1. Do you have a complete safety program with a written policy statement? ☐ Yes ☐ No
(Please attach a copy of the index; have complete copy available for the inspector)
2. Who is your Safety Director/Coordinator? _____________________________________________
3. Do you have a safety committee? ☐ Yes ☐ No
4. How often do you conduct safety meetings? ___________________________________________
5. Do you follow OSHA records keeping procedures? ☐ Yes ☐ No
(Please have your latest OSHA 300/300A log available.)
6. Do you maintain written programs on the following?
☐ a. Emergency Plan and Fire Prevention Plan
☐ b. Occupational Noise Program
☐ c. Tag/Lockout Program
☐ d. Chemical Hazard Communication (MSDS)
☐ e. Driver/Vehicle Safety
☐ f. Industrial Truck Operators’ Program
☐ g. Respiratory Protection Program
☐ h. Personal Protective Equipment/Clothing
☐ i. Lifting/ Back Safety
☐ j. Ergonomics
☐ k. Blood Borne Pathogens
N/A ☐ l. Portable ladders and stairway safety training
☐ m. Scaffold Safety
☐ n. Fall Pr
otection
☐ o. Cranes/Hoists (material/personnel)
☐ p. Welding and Cutting
☐ q. Steel Erection
☐ r. Excavations
☐ s. Aerial Lifts
☐ t. Confined Space
☐ u. Drug & Alcohol* If yes, please complete Drug Free Program Addendum.
5 Revised 03/2020
6
Revised 03/2020
7. Which chemicals are commonly used in the workplace?
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
8. Please check any of the following tools you use to train your employees on safety:
☐ a. On the job supervised training
☐ b. Videos
☐ c. Safety Seminars
☐ d. Safety Consultant
☐ e. Insurance Agent/Carrier
☐ f. Other _________________
9. What actions have you taken within the last 6 to 12 months to enhance a safer work environment?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
II. FIRST AID
1. Are emergency phone numbers posted in prominent places? ☐ Yes ☐ No
2. Do you keep first aid supplies highly visible, close to employees, inspected
and replenished continuously? ☐ Yes ☐ No
3. Do you have an AED kit on hand? ☐ Yes ☐ No
4. Are batteries and chest pads current? ☐ Yes ☐ No
5. Who is trained in First Aid/CPR? __________________________________________________
Is training Red Cross approved? ☐ Yes ☐ No
6. Do you have ANSI approved eyewash/emergency shower facilities? ☐ Yes ☐ No
7. Do employees work outside? ☐ Yes ☐ No
8. If applicable, are first aid and fire extinguishers provided on job sites? ☐ Yes ☐ No
III. HOUSEKEEPING AND MAINTENANCE
1. Are any electrical cords strung across walkways? ☐ Yes ☐ No
a) If so, are they properly marked and guarded? ☐ Yes ☐ No
2. Are any loose floor mats safety-edged? ☐ Yes ☐ No
3. Any worn or frayed carpet, open carpet seams or curled edges? ☐ Yes ☐ No
4. Any holes, uncovered drains, protruding nails, splinters, loose boards or
projections in floors? ☐ Yes ☐ No
5. Are there any false floors or platforms used to provide dry standing & walking
surfaces? ☐ Yes ☐ No
6. Are all floors free of debris, lint, dust, oil, grease, paint or spray residue, granular
materials, sand, mud, ice or other slippery traction-robbing material? ☐ Yes ☐ No
7. Is there continual good housekeeping, including immediate cleanup
of unavoidable spills? ☐ Yes ☐ No
8. Is lighting adequate for all operations? ☐ Yes ☐ No
9. Do you have emergency lighting? ☐ Yes ☐ No
7 Revised 03/2020
10. What type of sprinkler and/or smoke detection system do you have? _______________________
a) When was it last tested? _______________________________________________________
b) Do you have specific storage areas? ______________________________________________
c) Is stock stored 18” below sprinkler heads? _________________________________________
11. Are all exits clearly marked and unobstructed?
12. Are there frequent refuse pickups?
☐ Yes ☐ No
☐ Yes ☐ No
IV. AUTOMOBILE
This section applies if you have employees who drive cars or trucks as a regular part of their
work; and where employees drive their own cars on company business.
1. Are employees taught how to inspect vehicles/equipment before use? ☐ Yes ☐ No
2. Do employees required to operate motor vehicles participate in a
Defensive Driving Program? ☐ Yes ☐ No
3. Are scheduling & driving speeds reflective of this? ☐ Yes ☐ No
4. Are employees required to have CDLs? ☐ Yes ☐ No
5. Are Motor Vehicle Reports (MVR’s) requested on all drivers at regular intervals? ☐Yes ☐ No
6. Do you have a written drug/alcohol policy program? ☐ Yes ☐ No
7. Are MVR’s requested on all prospective employees, covering all
states in which they have been licensed? ☐ Yes ☐ No
8. How do you enforce the Delaware cell phone/texting law? _________________________________
9. Are employees required to use seatbelts? ☐ Yes ☐ No
10. Are horns and back up alarms provided and operable on equipment/
vehicles that require them? ☐ Yes ☐ No
11. How often are driver training and safety meetings held? __________________________________
12. What actions are taken in connection with accidents or violations, and have they proven
effective? Describe. ______________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
13. Are there any time pressures inherent in your operations? ☐ Yes ☐ No
If “yes”, describe. ________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
14. Are fully stocked first aid kits and fire extinguishers maintained on vehicles? ☐ Yes ☐ No
V. GENERAL INFORMATION
1. When did your insurance carrier last conduct an engineering & loss control inspection of your
premises and operations. Date: _______________________________________________________
2. What worker’s compensation recommendations have been made by your insurance
carrier?__________________________________________________________________________
_________________________________________________________________________________
8 Revised 03/2020
3. Have they been complied with?
4. Has an OSHA inspection ever been done?
☐ Yes ☐ No
☐ Yes ☐ No
a) If so, were any recommendations made, citations issued; fines or
penalties levied? If “yes”, explain. ☐ Yes ☐ No
______________________________________________________________________________
_ _____________________________________________________________________________
5. What regulatory authorities inspect your operations?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
a) How often?____________________________________________________________________
(Mr., Mrs., Dr.), Name of person completing this questionnaire: ________________________________
Employer: ___________________________________________________________________________
Job Title: ____________________________________________________________________________
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
For questions, call: (302) 674-7377
Fax #: (302) 736-7910
Email us at: safety@delaware.gov
Mailing Address:
Department of Insurance
Attn: Workplace Safety
1351 West North Street
Suite 101
Dover, DE 19904
9 Revised 03/2020
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Workplace Safety Program Questionnaire Submission Tips (Department of Technology and Information)

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Completed 20 July 2020

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