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PROGRAM CONTACT PERSON LIST

Asbestos Management.........................................................Mark Peters


AWAIR..........................................................................Carla Quiring
Bleacher Safety............................................................... Mark Peters
Bloodborne Pathogens......................................................Jane Berkholz
Community Right-to-Know..................................................Mark Peters
Compressed Gas Safety......................................................Mark Peters
Confined Space Entry........................................................Mark Peters
Emergency Action Planning...............................................Pam Anderson
Employee Right-to-Know/Hazard Communication.......................Mark Peters
Facilities Safety Management................................................Mark Peters
First Aid/CPR ...............................................................Jane Berkholz
Hazardous Waste Management.............................................Mark Peters
Hearing Conservation........................................................Mark Peters
Indoor Air Quality..............................................................Mark Peters
Integrated Pest Management...............................................Mark Peters
Laboratory Standard/Chemical Hygiene Plan.....................................Wade
Nelson
Lead Management............................................................Mark Peters
Lockout/Tagout ..............................................................Mark Peters
Machine Guarding ............................................................Mark Peters
Personal Protective Equipment.............................................Mark Peters
Playground Safety.............................................................Mark Peters
Radon Gas Safety.............................................................Mark Peters
Respiratory Protection.......................................................Mark Peters
USTs/ASTs......................................................................Mark Peters
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Mark Peters

Is the Asbestos Management Plan in place? Yes No N/A

Is the Plan current for all buildings? Yes No N/A

Has the Plan (or Plans) been reviewed this school year? Yes No N/A

The Plan is located at affected building Yes District Office.

Training for Asbestos Awareness was conducted July, 2008 .

New PT employees received training on July, 2008 .


(date)

Annual written notification has been prepared; Fall, 2009 .


(date)
Notification appeared in the following publication(s):

Name of publication Date


Mt. Lake School News Fall, 2009

Three-year re-inspection Surveillance was conducted: 2/08/2006

6-month Periodic Surveillance was conducted: 11/19/078


(first date)

5/11/09
(second date)

All caution labels have been posted.


Label locations: Boiler room

Tunnel system

Boiler room door

Air handlers

Are supplies of repair materials adequate to meet the requirements of


maintenance and repair of ACM? Yes No N/A
Asbestos Maintenance Supplies on Hand

Tyvek Respirators Signage Glove Disposal Safety


Warning bags bags tape
lables
10 pr. 3w/ heap Adequate 0 3 adequate
filters

Is documentation of Operations and Maintenance available? Yes

Location: With other asbestos files with safety documents

Status of the Asbestos repair and maintenance Work Order System: N/A
Established, Pending

Comments: Click here to access 6-month periodics

**For information regarding the medical review and questionnaire, see the
Respiratory Protection Program.**
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Carla Quiring

Is the AWAIR Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is the Safety Committee organized? Yes No N/A

How often are meetings held? Monthly during school year

Are minutes of the meeting maintained? Yes

Location: Custodial office

Posted: Not at this time

How is the program communicated to employees? Staff meetings and


possible use of the intranet

Who is the Contact Person for OSHA 300? Carla Quiring

Is the OSHA 300A Log completed for the previous calendar year? yes

Have the Logs been maintained for five (5) years? yes

Location: Carla’s office and H&S Activity Manual

Is the Log posted from February 1 until April 30? yes

The location/s of the posted log: District office bulletin board

Is information on injuries recorded on the Log with five (5) working days? Yes
No N/A
Safety Committee – Meeting Schedule

Date Location Time

Monthly meetings High School 7:30 am

.
.

District Safety Committee Members

Member Position Building


Tim Snyder Instructor K-12
Mark Peters Custodial K-12
Patty Miller Instructor K-12
Nancy Nelson Instructor K-12
Jerry Loque Board Member K-12
Dave Bucklin Board Member K-12

Note: The Safety Committee meets monthly in concurrently with Cleaner


Plant, Safety, IAQ, and Surrounding Area Task Force committees.

The Surrounding area task force has been discontinued. The Health and Safety
Committee has been reorganized. Lee will be serving on the committee. LC 4-
16-09
Checklist of E/OHS Activities for Bleacher safety

Program Contact Person: Mark Peters

Is the BSM Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has an annual survey of school bleachers been conducted? Yes No N/A

Is the five-year recertification required by December 31, 2007 complete and


submitted to the Minnesota Department of Labor and Industry? Yes No N/A

Note: The 5 year bleacher Safety inspection was conducted 10/25/2007. All
bleachers were found to be in good condition. Documentation was prepared
and sent to the Minnesota Department of Labor and Industry.

Openings and gaps:

Openings limited to four-inch gap between the railings and between the footboards
and seat boards, starting at a height of 56 inches or more.

Retractable bleachers:

They may contain openings of 9 inches or less

If exempt from standards must have a safety management plan in place and an
amortization schedule to plan for their future replacement

Approved netting:

Netting may be provided to prevent persons from falling through the bleachers
between the seat and footboards

Chain link fencing may be used but must be secured tightly to the underside of the
bleachers.

Railings:

Bleachers 55 inches and under are exempt from railing requirements

Bleachers with guardrails over 30 inches above grade must not contain openings
greater than four inches, unless safety nets are installed.
State building inspectors shall determine whether the safety nets and guardrail climb
ability meet the requirements of the alternate design section of the State Building
Code.
Periodic inspections:

Bleacher footboards and guardrails must at a minimum be reinspected at least every


five years and a structural inspection at least every ten years. The equipment has no
rust, rot, cracks, or splinters, especially where it comes in contact with the ground

There are no broken or missing components on the equipment (e.g., handrails,


guardrails, protective barriers, steps, or rungs on ladders) and there are no damaged
fences, benches, or signs on the playground
Mt. Lake Public Schools
450 12th Street
Mt. Lake, MN 56159

October 25, 2007

Building Codes & Standards Division


443 Lafayette Road North
St. Paul, MN 55155-4341

Dear Sir or Madam:

This letter is given in response to requirements of Minnesota Statue 16B.616,


Bleacher Safety Act. As Lead Custodian for Mt. Lake Public Schools located at
Mt. Lake, Minnesota I have reviewed our public bleachers for the following
criteria:
1. Openings in railings to be 4 inches or less,

2. Guard rails provided at over 55 inches in height,

3. The bleacher footboards and guardrails have been inspected and if


required repaired,

4. The equipment is free of rust, rot, cracks, or splinters,

5. There are no broken or missing components on the equipment.

6. The bleachers located at the football field (BL 1951) have been retrofitted
to meet standards contained in the Minnesota Bleacher Safety Act. Nylon
braded safety netting has been installed under the entire bleacher
section. While currently safe, plans are to replace the existing bleachers
as funds become available.

All bleachers are currently in good condition and have been maintained in a high
state of repair.
If you would have questions you may contact the Mt. Lake School District at 507-
427-2325.

Sincerely,

Mark Peters
Buildings and Grounds
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: _ Jane Berkholz

Is the Bloodborne Pathogens Written Plan in place? Yes No

Has the Plan been reviewed this school year? Yes No

List job categories that may be at risk to exposure:


School Nurse Paras/Playground supervisors
Custodians Laundry
Secretaries Art
Transportation Industrial arts
Coaches

What is this school’s policy regarding Hepatitis B vaccinations for employees


considered at risk versus employees considered not at risk in the Exposure
Control Plan? The three part vaccination series is offered at no cost to “at risk”
employees

Is training provided at this school on methods and techniques to reduce


exposure incidents? The school offers training to all staff during fall staff
development days.

New Employees: prior to employment

Have the employees identified as first-aid responders been given at a minimum


Red Cross First Aid Training? Yes No N/A

Are Exposure Control Kits available to staff? Yes No N/A

Location(s): The kits are located in each classroom. Typically used on an


emergency basis.

Status of Declination forms: Carla Q. maintains these records at the District


office

How is blood or bodily-fluid-containing materials handled at this facility?

Policy regarding cleanup: Custodial staff provide cleanup service. Swimming


pool staff and bus drivers are required to clean up that occur in their
respective areas.
Location of biohazard bags at school: Nurses office and Custodial office

Approved disposal location for biohazardous waste: Mt. Lake Clinic.

Click here to view plan


Checklist of E/OHS Activities for Compressed Gas Safety

Program Contact Person(s) Mark Peters

Department Contacts:

Maintenance N/A

Metals Shop Tom Appel

Is the Compressed Gas Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has the facility been surveyed for compressed gas inventories? Yes No N/A

Has training been conducted for affected personnel? Yes No N/A

Are records established/maintained to monitor gas inventory? Yes No N/A


COMPRESSED GAS FIELD REVIEW
Compressed Gas Inventory

Date: Program Contact Person: Lee Carlson

Department: Metals Shop Department Responsible Person:

Location:

Cylinders:
 O2 ___1_________  CO2 ____________
 Acetyl ____1________  Argon ____________
 NH4 ____________  Argon/CO2_____2_______
 Other ____________

Compliance Check List


Yes
No
1. Are cylinders in well-ventilated area? X
2. Are cylinders stored separate from flammable by at least 20 feet? X
3. During storage are oxygen cylinders separated from fuel gas X
cylinders, unless on welding cart?
4. Are cylinders kept away from sources of heat (below 130 F)? X
5. Are safety chains used at all times on both full and empty X
cylinders? (2/3rds from top of cylinder)
6. Are empty cylinders maintained separate from full cylinders? X
7. Are cylinders kept away from sources of ignition such as electricity, X
excessive heat or oily rags?
8. Are carts designed specifically for gas cylinders available? X
9. Are damaged cylinders, valves/hoses removed from service? X
10. Are all cylinders properly labeled with the contents? X

Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Mark Peters


Is the Confined Space Entry Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Have confined space areas been identified? Yes No N/A

Have measurements to include CCI/ft been completed? Yes No N/A

Are permit entry forms in place? Yes No N/A

Location: Activities Manual

Are confined space labels in the proper locations? Yes No N/A

Is a list of employees eligible to enter confined spaces complete? Yes No N/A

Has training for affected employees completed? Yes No

Date of completion: Summer 2007

Confined Space Inventory


Building: Mountain Lake School

Building Contact: Mark Peters Program Contact: Lee Carlson

Completed By: _Lee Carlson Date: 2-19-2008

Room Identification Opening Dimension Potential Permit/ Labeled Photo


Name Given Space Dimension Of Confined Hazards Non- ID #
Space Permit

Checklist of E/OHS Activities for Community Right-to-Know

Program Contact Person: Mark Peters

Is the Community Right-to-Know Plan in place? Yes No N/A


Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Are quantities of stored and used designated hazardous materials documented


and verified? Yes No N/A
Where are the documents stored? Activities Manual

Have the State Emergency Response Commission and local fire department
been notified of hazardous materials on school grounds? Yes No N/A

When were they notified? 1/30/08


(date)

Has training been provided? Yes No N/A

Date:

Presenter:

Note: Mark Peters sent the Tier Two form to the Emergency Response
Commission on 1/30/08. The Mt. Lake fire Department was notified at the
same time. A copy of the form was posted in the Activities Manual.

The Tier Two was updated by Mark. The form was updated online. I will be
locating the user name and password. Hard copies are to be prepared for the
local fire department.LC 3-16-2009
Inventory Form

Client: Mt. Lake Area Schools

Contact Person: Mark Peters Date: 2/19/2008

Hazardous Reported on Installation


Material Quantity Location Tier Two Date(s)
#2 Fuel Oil 6,000 gal North of Yes 2 19 1998
building
Chlorine 100 gal Pool pump Yes
room

Inventoried 2/19/2008 LRC


Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Pamela Anderson

Is the Emergency Action Planning program in place and as outlined in the


Minnesota Executive Order 93-27 and Model Crisis Management Plan? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Are information maps posted to indicate travel routes in the event of fire,
tornado shelter locations, and procedures during lockdown? Yes No

Located where? Maps are located in each classroom.

Are all drills timed and recorded? Yes No

Responsible person: Pamela Anderson_______________________________

Location of records: High School Office and Elementary office__________

Forms provided: Yes No

Does this school coordinate drills with local government authorities to assure
sheltering in school, evacuating to their homes or use of congregate care
centers? Yes No N/A

Has this school completed the Fire Marshall required Fire Safety and Emergency
Evacuation Plan? Yes No N/A

Training provided for affected staff? Yes No N/A

Note: the cameras have been installed and now waiting for final adjustments.
Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Mark Peters

Is the Employee Right-to-Know/Hazard Communication Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the chemical inventory been completed for the following functional areas?

Location of Chemical Inventory


Form

Art Instruction Yes No N/A Art Room

Custodians Yes No N/A Custodial Office

Food Service Yes No N/A Food service office

Science Rooms Yes No N/A Science room

Shop (metals, wood, auto) Yes No N/A Shop area

Are MSDS available and located with the chemical inventory? Yes No

Do the MSDS concur with the chemical inventory? Yes No

Has training been provided for the following staff?

Art Instructors Yes No N/A Science Yes No N/A

Custodians Yes No N/A Shop Yes No N/A

Food Service Yes No N/A Transportation Yes No N/A

Note: Training is provided for custodial staff during the summer. Taher provides
training for the kitchen staff. Chemical inventories are completed each year by
Musser Environmental Consulting Inc.
Contact List for Employee Right-to-Know Program

Key Contact for Department


Department (person responsible for locating MSDS)
Nancy Nelson
Art

Wade Nelson
Biology

Connie Riskey
Consumer Life Science

Mark Peters
Custodial/Maintenance

Joan Nickel/Taher
Food Service

Donna Peterson
Photo

Wade Nelson
Chemistry/ Science

Tom Appel
Shop—Welding

Donna Peterson
Shop—Wood

Mark Peters
Transportation

Completed by: Lee Carlson Date: 10/25/2007


Checklist of E/OHS Activities for Facilities Safety Management
and Fire Safety in Schools

Program Contact Person: Mark Peters

Is the Facilities Safety Management program in place? Yes No

Does this school use contracted services for the Management Assistant
Program? Yes No N/A

If no, who is the designated person or persons? N/A

Fire and Life Safety in Schools

Program Contact Person: Mark Peters

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
district building? Yes No

Most recent date of sprinkler electronics inspection__12/27/06 N/A

Most recent date of alarm inspection__12/27/06 N/A

Most recent inspection of fire extinguishers: July, 2007 N/A

Most recent inspection of fume hoods with fire suppressant: New hood installed
in 2007. A contract for inspection has been signed for inspections with Fairmont
Fire and Safety

Are emergency lights tested at least biannually? Yes No N/A

Science safety Checklist completed? Yes No N/A

Note: The Science Safety Checklist was delivered to Wade Nelson 2-19-2008.
Facilities Safety Review

Building: Mountain Lake Public Schools

Mock-OSHA Review Date Review


Area Completed N/A Recommendations
Art

Dark Room

Wood Shop

Kitchen

Metal Shop

Halls, Gym, etc.

Graphic Arts

Maintenance/Custodial

Transportation

Grounds/Garage

Chemistry/Life Science

Fire and Life Safety Checklist

ART
X Emergency phone numbers posted and MSDS available
X Flammable liquids and combustibles stored properly

COMPRESSED GAS
X Cylinders chained in place so they cannot fall over
X Valve covers in place when cylinder not in use
SPRAY BOOTH
X Fire control sprinkler heads kept clean
X Mechanical ventilation provided when spraying is done in enclosed area
X ‘NO SMOKING’ signs posted in spray areas, paint rooms, booths, and storage
X Spray area at least 20’ from flames, sparks, operating electrical motors

BOILER ROOM
X Fire extinguisher mounted and accessible
X No combustibles stored in boiler room
X Two exits

CORRIDORS, ENTRANCES, STAIRS


X All decorations, artwork in corridors limited to 25% of wall surface
X All EXIT corridors and hallways free of obstructions
X All EXIT doors open in the direction of exit without effort
X All EXIT doors posted as exits with letters 5” high and ½” wide
X All EXIT signs visible and with working lights, if lighted
X Appropriate fire extinguishers are mounted within 75’ of outside areas
containing flammable liquids and within 10’ of any inside storage area for
such materials
X Buildings over two levels have doors that close automatically in stair tower
X Fire extinguishers free from obstruction or blockage
X Fire extinguishers provided for the types of materials in the area where
used
Class A Ordinary combustible material fires
Class B Flammable liquid, gas, or grease fires
Class C Energized-electrical equipment fires

X Fire extinguishers serviced, maintained, and tagged every year


X No dead-end corridor >20’
X Non-exit doors, passages, and stairways labeled, “NOT AN EXIT”
X Panic hardware on all exit doors and rooms with occupancy of 50 or more
X Sprinkler heads protected by metal guards, when exposed to physical
damage

ELECTRICAL
X Extension cords used for permanent wiring
X 36” clear access to all electrical control panels for emergency shutdown

EXTERIOR
X Dumpsters stored at least 5’ from any combustible buildings, doors, and
windows

GYM
X Stage curtain must be flame retardant

HOME EC
X Outlets within 6’ of a water source must be GFC

KITCHEN
X Exhaust hood, ducts, and filters clear of any grease accumulation

X Fire extinguisher within 30’ of cooking equipment (min. 40BC)


X Hood with auto fire extinguishing system inspected every 6 months
X Means to shut off gas supply to the cooking equipment for emergency
X MSDS available
X Outlets within 6’ of a water source must be GFC

SCIENCE LABS
CHEMICALS
X Chemicals stored in open lab work area kept to a minimum
X Neutralizing chemicals and spill kits readily available

FIRE SAFETY
X Aisles serving work areas on 2 sides at least 42” wide; those serving work
areas on one side only must be 36”
X Flammable liquids stored in refrigerated equipment in closed containers
X Flammable/combustible liquids and chemicals must not be stored in fume
hoods or on the floor, except in original container
X Refrigerators, freezers, or coolers that store or cool flammable liquids must
be of explosion-proof construction and properly labeled
X 2A-20BC or larger rated fire extinguisher for each 3,000 feet of lab; travel
distance must not exceed 50’ from anywhere in room

STORAGE
X Acids stored in approved cabinets
X Chemical storage area must have inventory
X Chemical storage area properly ventilated
X Chemicals properly labeled
X Chemicals stored in approved containers (original shipping package)
X Flammable liquids stored in approved cabinets
X Shelves used for chemical storage should have lip or guard to prevent
chemicals from falling off
X Storage cabinets and rooms locked against unauthorized entry

VENTILATION
X Hood tested every year
X Lab hoods achieve 100 lfm
X Means provided for manually shutting down ventilation equipment

STORAGE ROOMS
X Room used for storage of combustibles must have 1-hour fire-rated walls
(sheet rock or plaster) and fire-rated doors (or solid core 1.75” thick wood
doors) with self-closer (or automatic fire sprinklers in them)

TECHNICAL LAB AREAS


X Compressed gas cylinders (oxygen, acetylene, propane, etc.) secured so
they cannot fall over
X Emergency stop buttons colored red
X Fire extinguishers located within 30’ of hazardous processes (painting,
welding, and woodworking)—mounted and inspected
X Flammable liquids stored in approved cabinets
X Oil-soaked, greasy, or paint-soaked rags stored in metal containers with lids
X Solvent wastes and flammable liquids are kept in fire-resistant, covered
containers until they are removed from the worksite
X Worksite clean and orderly with clear paths to exit

Completed by ___________________________Date
Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): Jane Berkholz _

Is the First Aid/CPR program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Has the District determined a provider in the event of a medical emergency?


Yes No

The local provider determined travel time was estimated to be within the 4-8
minute limit. Therefore Mt. Lake Ambulance Service will be the
designated emergency response provider.

The local provider determined travel time was estimated to be in excess of the
4-8 minute limit. Therefore N/A will be the
designated emergency response person located within the district.

Has training been provided for affected staff? Yes No


Checklist of E/OHS Activities for Hazardous Waste Management

Program Contact Person(s)

Primary Contact Person: Mark Peters

Secondary Contact Person: Mike Peters

Is the Hazardous Waste Management program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Did this school generate ten gallons of waste per year? Yes No

Note: In Greater Minnesota, schools generating ten gallons of waste per year or
less do not need a license.

Did this school generate 220 pounds or less per month hazardous waste (about
½ drum or less liquid)? Yes No

Note: Wastes that do not count include antifreeze, cathode ray tubes,
fluorescent lamps, lead acid batteries, pcb ballasts, photo fixer reclaimed on
site, used oil and oil filters.

Training for VSQG’s do not have training requirements however MPCA strongly
recommends persons handling wastes be given training on best handling and
safety risks associated.

Has training been provided for affected persons? Yes No N/A


Date Conducted: N/A
Date Scheduled: N/A

Has annual report and license application sent in? Yes No N/A
Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Mark Peters

Is the Hearing Conservation Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the school been surveyed for noise hazards? Yes No

Have sound level measurements been collected? Yes No

Have the results been documented? Yes No

Location: Activities Manual

Has training been scheduled or completed for affected individuals this school
year? Yes No N/A

Date:

Presenter:

Have regulatory changes occurred that may affect this program? No


Sound Level Monitoring

Sound Level Monitoring

Client: Mountain Lake Schools

Measuring Device: Digital Sound Level Meter Calibration: Pre___________


Post___________

Reason for Testing: General Survey

Affected Personnel: Custodial, maintenance,

Location Equipment Results Recommendations


Custodial Office Compressors 73-75 dBA
Wood Shop Drill Press 76.9-71.4dBA
Wood Shop Radial Arm Saw 81.4-80.9 dBA
Wood Shop Rockwell Drill
Press 81.7-79.4 dBA
Wood Shop Drill Press 75.4-70.4 dBA
Wood Shop Planner 78.8-77.1 dBA
Wood Shop Stationary 81.9-80.6 dBA
sander/disk

Completed by Lee Carlson Date 3-16-2009

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Tim Snyder


Is the IAQ Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has an IAQ Committee been established? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Has the annual cursory walk-through been conducted? Yes No

Have the districts key building systems been evaluated? Yes No

When was the evaluation completed? Jan, 2007

Who conducted the evaluation? Lee Carlson

Were occupied areas of the district evaluated using the EPA’s Tools For Schools
check list or equivalent?
• Teachers check list? An information fact sheet was provided all –staff.
# of forms distributed 55 # of Forms returned: 29

• Building maintenance checklist? 1


• Building ventilation checklist? 6

Training conducted Aug. 2006


(date)

Training has been scheduled for _____N/A__________.


(date)

Has the District determined the mechanical ventilation rate of each occupied
space? Yes No.

Supportive technical services were conducted on: summer, 2001


(date)

Results of technical services are located? Unavailable

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Mark Peters


Is the IPM Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the annual monitoring been conducted to determine location and degree of
infestation? Yes No

A map of the problem area/areas has been developed. Yes No N/A

Has notice been given to parents regarding application activities? Yes No N/A

Location or publication used to notify parents Mt Lake School News.

Checklist of E/OHS Activities for Laboratory Standard/Chemical


Hygiene Plan

Program Contact Person: Wade Nelson , CHO


Is the Laboratory Standard/Chemical Hygiene Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Fume hood was tested on ___N/A____________.


(date)

The results indicate air velocity to be: satisfactory, unsatisfactory. N/A

Chemical inventory:

Date of most recent survey

Location of inventory listing

Are Material Safety Data Sheets (MSDSs) located with inventory? Yes No N/A

Are the MSDS readily accessible? Yes No N/A

Has the Science Safety Lab Checklist been completed? Yes No N/A

Is training for affected personnel complete? Yes No N/A

Date(s) of instruction:

Roster signed? Yes No N/A

Lesson plan outline available with roster? Yes No N/A

Status of Emergency Eye Wash/Deluge Shower:

Is flushing conducted weekly? Yes No N/A

Is descriptive signage properly posted? Yes No N/A

Is flushing activity documented? Yes No N/A

Checklist of E/OHS Activities for Lead-in-Water Management

Program Contact Person: Mark Peters


Is the Lead-in-Water Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

This school completed testing of water supply taps _Feb.8, 1990_________.


(date)

Is a map of all potable water taps available for review? Yes No N/A

Checklist of E/OHS Activities for Lead-in-Paint Management

Program Contact Person: Mark Peters

Is the Lead-in-Paint Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Testing for lead in paint on playground equipment: Note: All playground


equipment has been replaced with lead free.

Date completed: N/A

Yet to be tested: N/A

Results of evaluation for paint condition in rooms K-1:


Building constructed post-1978; facility not applicable
Building constructed prior to 1978; paint determined to be in
___good__ condition

Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Mark Peters


Is the Lockout/Tagout Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is LO/TO equipment available? Yes No N/A

Is the equipment appropriate for application? Yes No N/A

If available, where is the equipment located? Green file cabinet in custodial


office

Is the equipment maintained in an orderly and readily usable condition? Yes No


N/A

Have affected personnel been trained as to methods and technique of use? Yes
No N/A

Are written procedures available for affected staff? Yes No N/A

If available, the procedures are located where? Activities Manual

Has the annual audit of energy control procedures been completed? Yes No

Date or dates of completion: Summer, 2007, Custodial Seminar


Checklist of E/OHS Activities for Machine Guarding
Program Contact Person:

Is the Machine Guarding Plan for each affected work area in place? Yes No

Is the plan/plans current? Yes No

Has the Plan been reviewed this school year? Yes No

Has a survey of all district fixed equipment been conducted?


Yes No

When was the evaluation completed? _______________________

Who conducted the evaluation? _______________________

How are corrections documented? _______________________________

Is all fixed equipment safeguarded to meet OSHA criteria? Yes No

Has the alternative MDE “best practices” criteria used to safeguard equipment?
Yes No

Has equipment determined not in compliance scheduled for repair or


replacement? Yes No

If replaced, was “best practices,” bid specification criteria used for


procurement? Yes No
Identified Fixed Equipment Locations

Location Building/Buildings Staff Affected # of item


Automotive Shop
Wood Shop
Custodial/Maintenanc
e
Welding Shop
Ag Shop
Bus Garage
Art
Scene shop
Science

Contracted technical services to review and recommend?


__________________.

Name of person or contractor conducting survey? ___________________.


(date)

Results of technical services located where? ________________________

Checklist for minimum requirements:


• Power outage protection provided for required equipment
• Emergency stops provided for required equipment
• Safe work practice placards at applicable fixed tool stations
• Proper guards provided and used
• Color coding as prescribed by OSHA standards
• Non-slip surfaces by each piece of equipment
• Fixed equipment secured to prevent “walking” or movement

Has a log of employee accidents and near misses been established and used?
Yes No
Annual training for affected staff is provided? Yes No

Training conducted ____________.


(date)
Training has been scheduled for ____________.
(date)
Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Mark Peters

Is the Playground Safety program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Surfacing:

X The equipment has adequate protective surfacing under and around it


and the surfacing materials have not deteriorated

X Loose-fill surfacing materials have no foreign objects or debris

X Loose-fill surfacing materials are not compacted and do not have


reduced depth in heavy use areas such as under swings or at slide exits

General Hazards:

X There are no sharp points, corners, or edges on the equipment

There are no missing or damaged protective caps or plugs

There are no hazardous protrusions and projections

There are no potential clothing entanglement hazards, such as open S-


hooks or protruding bolts

There are no pinch, crush, and shearing points or exposed moving parts

There are no trip hazards, such as exposed footings on anchoring


devices and rocks, roots, or any other environmental obstacles in the
play area

Deterioration of the Equipment:

The equipment has no rust, rot, cracks, or splinters, especially where


it comes in contact with the ground
There are no broken or missing components on the equipment (e.g.,
handrails, guardrails, protective barriers, steps, or rungs on ladders)
and there are no damaged fences, benches, or signs on the playground

All equipment is securely anchored

Security of Hardware:

There are no loose fastening devices or worn connections, such as S-


hooks

Moving components, such as swing hangers or merry-go-round bearings,


are not worn

Drainage:

The entire play area has satisfactory drainage, especially in heavy use
areas such as under swings and at slide exits

Leaded Paint:

The leaded paint used on the playground equipment has not


deteriorated as noted by peeling, cracking, chipping, or chalking

There are no areas of visible leaded paint chips or accumulation of


lead dust

General Upkeep of Playgrounds:

The entire playground is free from miscellaneous debris or litter such


as tree branches, soda cans, bottles, glass, etc.

There are no missing or full trash receptacles


Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Mark Peters

Is the Personal Protective Equipment Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has a survey of potential workplace hazards been completed? Yes No N/A

Date(s) activity was conducted:__________________________

Have recommendations been completed for appropriate equipment? Yes No

Has training been completed for the following departments?

Art and Photo Yes No N/A


Custodial Yes No N/A
Grounds keeping/Garage Yes No N/A
Kitchen Yes No N/A
Maintenance Yes No N/A
Science Laboratories Yes No N/A
Technical Education Yes No N/A
Transportation Yes No N/A
Checklist of E/OHS Activities for Radon Gas Safety

Program Contact Person: Art Schweitzer

Is the Radon Gas Safety Plan in place? Yes No N/A

Is the Plan current? Yes No N/A


Has the Plan been reviewed this school year? Yes No N/A

Testing was last conducted: No records on file.


(date)

Results of tests:

Room Name & No. Level Tested Recommendation

Has training is not requirement of this program. However if elevated levels are
determine present training of affected persons is recommended.

Date training complete: N/A

Testing is / is not now in progress:

Note: No records could be located that indicated testing for radon in the past.
I recommend that areas below grade be tested.
Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: Mark Peters

Does this school provide respirators for voluntary use? Yes No N/A
If the school allows employees to use respirators voluntarily the following is
mandatory.
1. Read and follow instructions provided by manufacturer.
2. Choose respirators certified for use against contaminants of concern.
3. Do not wear respirators in atmospheres containing contaminants not
designed to protect from those contaminants.
4. Keep track of respirators so that you do not mistakenly wear someone
else’s respirator.

Is the Respiratory Protection program in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Date of review: __May, 2009

Are all employees in this program identified? Yes No N/A

Employee Intended Type of Medical Exam/ Date of Date of


Use Respirator Questionnaire Medical Fit Test
Mark Peters Misc ½ mask N/A N/A N/A
AOSafety

Fit testing was completed on N/A.


(date)

Type of testing protocol; Irritant Smoke (Stannic Chloride) or


Bitrex (Denatonium Benzoate)
Condition and location of respirators:

Condition: Good, two new units

Location(s): Green file cabinet in custodial office

Are the appropriate adequate accessories on hand? Yes No N/A

Verified by: Lee Carlson/Mark Peters


Checklist of E/OHS Activities for Underground and Aboveground
Storage Tanks

Program Contact Person: Mark Peters

Is the Underground and Aboveground Storage Tanks Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have forms for inventory tracking been provided? Yes No N/A

Do existing records accurately reflect purchase use correlation? Yes No N/A

Are all USTs registered with the Minnesota Pollution Control Agency? Yes No
N/A

Are removals or additions of tanks anticipated in this facility? Yes No N/A

Notes:
Underground Storage Tank Status

Tank No. Location Size Contents Registered Install date


#1 North of 6,000 #2 Fuel oil Yes 1994
building gal/single
wall steel

Regulated Tanks: Motor fuel tanks larger than 110 gallons

Non-regulated Tanks: Heating oil tanks

Requirements for All USTs: Tank must be registered with MPCA

Requirements for Regulated Tanks: Annual tightness testing and inventory


control
Tank must be updated, replaced, or
removed by December 22, 1998

Upgrades:
--Overfill protection
--Corrosion protection STPI
approved
--Leak detection

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