Forms

Casefile Routing Slip

Some quick facts:

• "Submitted to Supervisor Date" — CSHOs should leave this empty. It's reserved for the date the admin sends the case file to the supervisor.
• Timestamp
  • In-Office Staff: The timestamp machine provides a record for when the report was submitted for review.
  • Field Staff: Since the timestamp machine is inaccessible, the date the report is to be mailed can be handwritten in the timestamp area.

Medical Information Release Form

Download

This form is to be provided to any employee about whom you need to gather medical records and medical information. It will need to be completed by that employee or the employee's representative and returned to you.

Two important pieces of information that are not on this form (as of October 2017) that need to be gathered from the employee or employee representative are:

• the employee's date of birth; and
• the specific dates during which the employee received treatment as it pertains to the inspection.

An obvious alternative to using this release form is to have the employee gather any pertinent medical records and submit them directly to you.

OSHA-1

• Largely correlates to the "Inspection" tab in OSHA Express.
• Needs to be completed for every inspection, even for those where the company could not be found (e.g., temporary construction site).
• When printing out hard copy, write State CSHO ID and EIN.

Submittal

• Refer to the Routing page.

Original Paper Version of the OSHA-1

• Assignment Nr. is located on the OSHA-168 Assignment form. The OSHA-168 is also now integrated into OX.
• Ownership — Private or Public
• Legal Entity — Corporation, Sole Owner, Partnership, Subsidiary
• Previous Activity — Has there been previous Health inspections with this company by KYOSH—not just at this site.
• Related Activity
  • Type — C[omplaint], R[eferral], F[ollow-up]
  • Number — The complaint no., referral no., etc.
  • Satisfied — Health or Safety
• Inspection Type — Complaint, Referral, Follow-up, etc.
• Scope of Inspection — Partial, Complete
• Entry → Case Closed — Dates of each
• Days On Site — How many days on-site as of OSHA-1 submission
• Substance information — If there are any substances mentioned on the OSHA-168 and/or they are being considered in the inspection:
  • Type — Refers to the IMIS classification.(?) This is — N, typically
  • ID — Refers to the IMIS classification number.
  • Optional Information
    • Includes name of material in question (Lead, Chrome(VI), etc.)
    • N-11-LOG... information does NOT go on the OSHA-1.
• Controlling Corp, Employer ID, Warrant info — Leave blank.
• Classification, Strategic Initiatives, National Emphasis, Local Emphasis — Leave blank unless specified or needed.
• Extra Information
  • If the inspection is a follow-up to a settlement agreement, put N 20 SETTLEMENT in optional information.

Additional Information

From D.M.'s email on 1/27/14

When you open an inspection, a labeled blue file is created and put in a file cabinet up front. This is done for a number of reasons (we put extra paperwork, like warrants, etc.) in there, waiting there expectantly for the day the file is turned in for review. Then when the file is turned in, Jenifer pulls the blue file and fills it with all the hard work you’ve done, and ships it on to me or Clayton. The key to this whole choreographed dance is turning in the OSH-1. Lately, when Jenifer has gone to the file cabinet to pull the blue file, there is no blue file. So, please, please, please---when you first create your OSH-1 in OSHA Express, route a copy to Jenifer so she can make the file. She has no way of knowing you opened an inspection (hence, make the blue folder) unless she see an OSH-1.

Now, for the encore.....if you get one of those inspections with a name that is too long to fit in the 45-character-limited name field, please print out a copy of your OSH-1 and fill in the rest of the name on the “Establishment Name” line, and give her a paper copy so her file label is right (and we can find the darn thing when we have to go looking for it later in legal or imaging).

Now for the instruction portion of our presentation..... To print a paper copy of the OSH-1:

1. Complete all the information on the OSH-1 in OSHA Express.
2. SAVE the information (the form will look blank when you pull it up until you save the information).
3. CLICK on the SHEET OF PAPER icon on the menu bar (It’s the 11th one from the left, right before the one that looks like a hand writing on the back of an envelope).  You should now see an OSH-1 form.
4. CLICK on TOOLS at the top of the screen (3rd word from the left at the top of the screen).
5. CLICK on PRINT from the drop-down menu.  (It’s the last choice in my drop-down menu.)
6. WRITE IN all the EXTRA LETTERS of the ESTABLISHMENT NAME.
7. TAKE or MAIL this form to Jenifer.  Make a copy for yourself if you want.

That concludes this email, and in the words of the Gallo brothers, “Thanks for your support”.

OSHA-1-MOD

Download

• Complete everything from 1 through 4 and 8. Only complete that which is to be changed for numbers greater than 8.
• Complete the MOD Date field as the date of MOD/submission.
• Circle number for any section that’s changed.
• If a National Emphasis Program code is left off, for example, it should be submitted on an OSHA-1-MOD and not left for the OSHA-167 I. Everything but the total days on-site, citations recommended, and activities satisfied needs to be updated/corrected through an OSHA-1-MOD.
• Make sure to sign and date at the bottom.
• Submission
  • Timestamp and give to Jenifer H..
  • It should be returned to you after the data has been corrected in OSHA Express.
  • Place it in the case file after it's returned.
  • You may also submit the OSHA-1-MOD with the case file. However, place it on the very front so that it is noticed first thing by the admin. They correlate the employer name on your case file with the name on the folder they made after receiving the OSH-1.

OSHA-7: Employee Complaint Form

Download

The one available for public usage is available on the Labor Cabinet website. However, the one being linked to above is English only and, therefore, uses less paper to print.

IMPORTANT: When report is finished and ready to be submitted, the OSHA-7 has a Comments section that must be completed. It includes the following:

• Dates contact was made with complainant.
• Brief summary of what was done across each span of dates.
  • Typically: when you discussed the case and/or walkaround; when you discussed the closing/citations; and anything else of importance.

OSHA-31

This has been relegated to OSHA Express, titled Weekly Program Activity Report.

• Friday date = Friday of the week for which hours are being calculated.
• Optional Information is NOT required.

• Conferences, OTI classes, other classes, and webinars are considered Formal Training.
  • Travel time to and from training facilities that are away from the workstation is to be included in Formal Training hours.

Trainee Completion of OSHA-31

While in trainee status, all leave hours and formal training hours are entered no differently than a fully effective CSHO. However, all other hours should be listed as Field Training.

OSHA-36: Fatality/Catastrophe Report

This form is tied to the OSHA-170 "Investigation Summary" form. The OSHA-170 always designates an event, which is designated on the OSHA-36.

These two forms have been relegated to OSHA Express, as described below.

OSHA Express

• OX has this form listed as the Accident/Event form.
• The OSHA-170 form is integrated into this form as the Investigation tab.

OSHA-90: Referral Report

• This form is used when a referral is made between Safety and Health Branches or when a referral is made by this office to an outside agency.
• This form has been made a part of OSHA Express.

OSHA-91(S)

Download

• Refer to Chapter 23 of the IMIS manual for specifics of entry procedure.
  • Here is a PDF that includes only the pertinent directions.
• When there are more than 4 analytes, which would require using multiple OSHA-91(S) pages, perform the following steps to save from having to re-write the information that is the same across the forms:
  1. WORK IN PROGRESS
  2. But, basically, type or write in all the information that will remain the same on the fillable 91(S), make/print however many copies you need to cover the number of analytes, then you'll only have the citation section to complete.

OSHA-93 Direct Reading Report

Download

• This form is for recording data from shift sampling where direct reading instruments are used.
  • Essentially, if you're not doing air sampling to a media (such as MCEF, PVC, charcoal tube, etc.) that must be sent for sampling, you're using an "instant read"-type instrument. It performs its own analysis.
• The lines under "Direct Reading Data" are for marking measurements throughout the sampling where you observe the sampled employee at a certain location, including remarks related to what they were doing at the time, what PPE they were wearing, what other processes were occurring around them, etc.

Direct Reading Report vs. Screening Report

The main difference here can be attributed to the goal of the sampling.

• Screening is not going to result in a citation. However, its results are important since they may indicate a need for full-shift sampling and what location(s) need to be sampled; or, just as importantly, that no further sampling is necessary.
• Full-shift sampling using a direct read instrument can lead to citations.

OSHA-98 Screening Report

Download

Direct read equipment is any equipment that shows instantaneous measurements on a screen. The Screening Report is necessary when you are taking only instantaneous readings at various locations within a facility using a direct read instrument (such as a Dräger or an Edge noise dosimeter); and that same direct read instrument is not being used concurrently for personal air monitoring.

In other words, if you're performing personal air monitoring with the same instrument on which you're observing instantaneous reads, do not use the Screening Report — utilize the Direct Reading Report instead.

Direct Reading Report vs. Screening Report

The main difference here can be attributed to the goal of the sampling.

• Screening is not going to result in a citation. However, its results are important since they may indicate a need for full-shift sampling and what location(s) need to be sampled; or, just as importantly, that no further sampling is necessary.
• Full-shift sampling using a direct read instrument can lead to citations.

OSHA-167-I

Download

• This form is used to update the information submitted on the OSHA-1 when the inspection is done.
• It does not need submitted separately as the OSHA-1 is. The original stays with the case file.
• CSHO completes 2 – 7, 10, 11, 13, 14
  • Per Diane (4/14/14): 8 and 9 are also required.
• Citation No(s) (Field No. 13) — List the citation numbers from the report.
  • If there are no citations being issued, write a zero in the field.
  • If there are citations, follow the example below.
  • Example: The citations being issued are:
    • Citation 1 Item 1
    • Citation 1 Item 2a
    • Citation 1 Item 2b
    • Citation 2 Item 1
    • Therefore, the Citation No(s) field should be: 1, 2
  • Failure to Abate citations are listed as “FTA” first and then the citation number immediately after FTA.

OSHA-170: Investigation Summary

Refer to the OSHA-36 form description.

OSHA 300 Logs

• Titled “Log of Work-Related Injuries and Illnesses”
• Refer to OSHA.gov's Recordkeeping and Reporting Requirements page for information.

Recordkeeping Notable Mentions

• Do not count the day of the injury in total days.
• If a case involves both DA and RT, check only the DA box (H) but divide up the day numbers in (K) and (L).
• If a Physician or other Licensed Health Care Professional (PLHCP) recommends that the EE should take a certain number of days off, those days count as Days Away from Work whether the EE takes them or not.
• If a PLHCP determines that the EE is able to return to work, the days afterward should not be counted.

OSHA 300A

• Titled “Summary of Work-Related Injuries and Illnesses”
• If using a form other than the OSHA 300A, you must include the employee access and employer penalty statements found on the OSHA 300-A Summary form.
• Refer to OSHA.gov's Recordkeeping and Reporting Requirements page for information.

Posting Requirements

• Post the summary no later than February 1 of the year following the year covered by the records.
• The posting location must be in a location or locations that are accessible to all employees and where it's reasonably anticipated that all employees will have a chance to see it.
• Keep the summary posted until at least April 30.

OSHA 300-I

• This hard-copy form is no longer submitted. The information formerly included here is included digitally in OSHA Express.

• If non-recordables have been recorded by the employer in its 300 logs, they are to be included for 300 I calculations.
• DART Rate =
• TRC Rate =
• Refer to OSHA.gov's Recordkeeping and Reporting Requirements page for information.

OSHA 301: Injury and Illness Incident Report

• CSHOs typically do not review these unless it is warranted. However, it is never a bad idea to review these forms.
• Employers are not required to fill out the form designed by OSHA as long as the form they're using contains all the required information. (Refer to 29 CFR § 1904.)
• Refer to OSHA.gov's Recordkeeping and Reporting Requirements page for information.