Written safety program templates
The following documents are draft templates of written programs for various workplace safety and health topics.
Each template has a welcome page with information on how to use the template, as well as DSH Assistant comments that provide added guidance, best practices, or links to resources or reference standards. Additionally, each offers supporting documents for training, checklists, definitions, and more.
For further ease of use, the templates are laid out identically. If you want to know about training, simply look in Section C of each template. If you want to know about specific program elements, look in Section B of each template.
As you develop your own customized programs tailored to your workplace, review and edit the contents of each template to meet your safety needs and specifications. Be sure to read the cover page for all downloaded templates.
You are invited and encouraged to reach out to your BWC safety consultant for assistance, or call 1-800-644-6292. Your workers’ compensation policy includes a wide range of services for all industries including safety consultations, safety education & training, and the BWC Safety & Video Library.
Hazard Communication Program
- Sample Written Hazard Communication Template (Word .docx)
- HAZCOM Resources (Word .docx)
- HAZCOM Definitions (Word .docx)
- Attachment A Hazard Communication, Chemical List Template (Excel .xlsx)
- Attachment B Hazard Communication, Non-Routine Task List Template (Excel .xlsx)
- Attachment C Training Sign-In Sheet (Word .docx)
Driver Safety Policy
- Sample Written Driver Safety Template (Word .docx)
- DSP Additional Resources (Word .docx)
- DSP Attachment A Driver Policy Agreement and MVA Consent Form (Word .docx)
- DSP Attachment B Distracted Driving and Electronic Device Agreement (Word .docx)
- DSP Attachment C Driver Point System (Word .docx)
- DSP Attachment D Driver Safety & Security (Word .docx)
- DSP Attachment E Pre-Trip Vehicle Inspection Form (Word .docx)
First Aid Program
- Sample Written First Aid Template (Word .docx)
- First Aid Resources (Word .docx)
- Attachment A First Aid Training Sign-In Sheet (Word .docx)
Emergency Action Program
- Sample Written Emergency Action Program Template (Word .docx)
- EAP Resources (Word .docx)
- Attachment A EAP Notifications (Word .docx)
- Attachment B Facility Diagram (Word .docx)
- Attachment C Training Sign-In Sheet (Word .docx)
Personal Protective Equipment (PPE) Program
- Sample Written PPE Template (Word .docx)
- PERRP PPE Checklist (Word .docx)
- PPE Resources Document (Word .docx)
- Attachment A Hazard Assessment Checklist and Certification Form (Word .docx)
- Attachment B Training Sign-In Sheet (Word .docx)
Respiratory Protection Program
- Sample Written Respiratory Protection Template (Word .docx)
- Respiratory Protection Resource Document (Word .docx)
- Definitions (Word .docx)
- Attachment A Respiratory Hazard Assessment (Word .docx)
- Attachment B Medical Questionnaire (Word .docx)
- Attachment C Medical Release (Word .docx)
- Attachment D Fit Test Results (Word .docx)
- Attachment E Voluntary Use (Word .docx)
- Attachment F IDLH Locations (Word .docx)
- Attachment G Respirator Maintenance Inspection Checklist (Word .docx)
- Attachment H Respirator Filter Change Schedule (Word .docx)
- Attachment I Training Sign-in Sheet (Word .docx)
- Attachment J Program Evaluation (Word .docx)
Bloodborne Pathogens Program
- Sample Written Bloodborne Pathogens Template (Word .docx)
- Bloodborne Pathogens Resource Document (Word .docx)
- Attachment A Definitions (Word .docx)
- Attachment B Exposure Determination Form (Word .docx)
- Attachment C Cleaning Schedule Form (Word .docx)
- Attachment D Hepatitis Consent-Declination Form (Word .docx)
- Attachment E Exposure Incident Report Form (Word .docx)
- Attachment F Exposure Follow-up Form (Word .docx)
- Attachment G PERRP Sharps Injury Form SH-12 (Public Employers) (Online application)
- Attachment H Training Sign-in Sheet (Word .docx)
Lock Out Tag Out Program
- Sample Written Lock Out Tag Out Template (Word .docx)
- LOTO Resources Document (Word .docx)
- Attachment A Energy Control Procedure Sample Workbook Templates (Excel .xlsx)
- Attachment B Minor Service Exception Checklist (Word .docx)
- Attachment C Absent Employee Device Removal Form (Word .docx)
- Attachment D Training Sign-In Sheet (Word .docx)
- Attachment E LOTO Periodic Inspection Form - ECP Audit Written Program Audit (Word .docx)
Powered Industrial Truck Program
- Sample Written Powered Industrial Truck Template (Word .docx)
- Powered Industrial Truck Resources Document (Word .docx)
- Attachment A - Definitions (Word .docx)
- Attachment B - Workplace & PIT Inventory Evaluation Sheet (Word .docx)
- Attachment C - Training Sign-In Sheet (Word .docx)
- Attachment D - Training Completion Certificate (Word .docx)
- Attachment E - PIT Operator Certification Card (Word .docx)
- Attachment F - Pre-Operation Checklist (Word .docx)
Accident Analysis Program
- Sample Written Accident and Incident Reporting Analysis Template (Word .docx)
- Accident and Incident Reporting & Analysis Resources Document (Word .docx)
- Attachment A.1 Private Employer SAMPLE Report Form (Word .docx)
- Attachment A.2 Private Employer SAMPLE Report Form 2 (Word .docx)
- Attachment B Public Employer Forms Workbook (Excel .xlsx)
- Attachment C Witness Detail Report Form (Word .docx)
- Attachment D SAMPLE Accident Investigation Process (Word .docx)
- Attachment E Training Sign-In Sheet (Word .docx)
- Attachment F SAMPLE Definitions (Word .docx)
Fall Prevention in General Industry Program
- Sample Written Fall Protection (General Industry) Template (Word .docx)
- Fall Protection Resources Document (Word .docx)
- Definitions (Word .docx)
- Attachment A- Fall Prevention Inspection Form (Word .docx)
- Attachment B Quick Tips Personal Fall Arrest Systems (Word .docx)
- Attachment C.1 Rescue Document (Word .docx)
- Attachment C.2 Rescue Planning Worksheet (Word .docx)
- Attachment D Training Sign-In Sheet (Word .docx)
Fall Prevention in Construction Program
- Sample Written Fall Prevention Program for Construction Template (Word .docx)
- Fall Protection Resources Document (Word .docx)
- Definitions (Word .docx)
- Attachment A Fall Prevention Inspection Form (Word .docx)
- Attachment B Quick Tips Personal Fall Arrest Systems (Word .docx)
- Attachment C.1 Rescue Document (Word .docx)
- Attachment C.2 Rescue Planning Worksheet (Word .docx)
- Attachment D Training Sign-In Sheet (Word .docx)
Ergonomic Safe Patient Handling Program
- Sample Written Ergonomic Safe Patient Handling Template (Word .docx)
- Ergo and Safe Patient Handling Resources Document (Word .docx)
- Attachment A Job Safety Analysis (Word .docx)
- Attachment B Job Description (Word .docx)
- Attachment C Facility-Wide Transfer Needs Audit (Word .docx)
- Attachment D Facility-Wide Equipment Audit (Word .docx)
- Attachment E Mobility Assessment Tool (PDF .pdf)
- Attachment F Competency Checklist (Word .docx)
- Attachment G Training Sign-In Sheet (Word .docx)
Fire Prevention Program
- Sample Written Fire Prevention (for General Industry) Template
- Fire Prevention Plan Resources
- Attachment A Fire Risk Survey
- Attachment B General Fire Prevention Checklist
- Attachment C Flammable and Combustible Material Checklist
- Attachment D Training Sign-In Sheet
- Attachment E Annual Evaluation Report
Welding, Cutting, Brazing, Hot Work Program
- Sample Written Welding, Cutting, Brazing, and Hot Work Template
- Welding Resources
- Attachment A - Hot Work Permit
- Attachment B - Hazard Assessment Form
- Attachment C - Training Sign-In Sheet
Confined Space and Permit Required Confined Space Program
- Sample Written Confined Space and Permit Required Confined Space Template
- Confined Space resources
- Attachment A Definitions
- Attachment B Confined Space Flowchart
- Attachment C Confined Space List
- Attachment D Confined Space Evaluation Checklist
- Attachment E Entry Procedure Form
- Attachment F Entry Permit Form
- Attachment G Alternate Entry Reclassified Entry Procedure
- Attachment H Emergency Rescue Contact List
- Attachment I Trained Employee Roster
- Attachment J Safety Training Sign In
Fire Extinguisher Program
- Sample Written Fire Extinguisher Fixed Extinguishing Policy Template
- Fire Extinguishers Resources Document
- Attachment A NFPA Standards
- Attachment B Training Sign-In Sheet
Violence in the Workplace Program
- Sample Violence in the Workplace Policy Template
- VIWP Resources
- Attachment A - List of Duties and Responsibilities
- Attachment B - Team Roles and Responsibilities
- Attachment C - Physical Assessment
- Attachment D - Sample Incident Report Form
- Attachment E - List of Training Topics
- Attachment F - Definitions
- Attachment G - Training Sign-In Sheet
Hearing Conservation Program
- Sample Written Hearing Conservation Program Template
- HCP Resources
- HCP Definitions
- Attachment A - HCP
- Attachment B - Noise Monitoring
- Attachment C - Noise Map
- Attachment D - Training Sign In
- Attachment E - Program Evaluation Checklist