Health And Safety Plan Coversheet
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Health And Safety Plan Coversheet Form. This is a Arkansas form and can be use in Workers Comp.
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Tags: Health And Safety Plan Coversheet, HS-32-B, Arkansas Workers Comp,
ARKANSAS WO RKER S’ COMPENSATION COMMISSION
F O RM HS-3 2-B
HS32-B
HEALTH & SAFETY DIVISION
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
ARK. CODE ANN.
§11-9-409 & AWCC
RULE 32
REV. 1-1-2008
AWCC File Number________________
Health and Safety Plan Cover Sheet
1) Company name:
2) Address:
3) City:
4) State:
5)Zip:
M andator y Safety P rogram Administration Co mponen ts
Components
6)In Place
7)Effectiveness
8)Com ments
Yes
No
Yes
No
A. M anagement-includes written Safety Policy
Statement, assignment (by position/title) of
health and safety responsibilities and authority
B. Analysis-include s identified health and safety
hazards
C. Safety program record keeping
D. Safety and health education and training
E. Audit/Inspection-includes identification
(title, position) of person(s) qualified to conduct
audit/inspection.
F. Accident investigation-include s metho ds to
investigate, identify root causes, and corrective
actions taken
G. Periodic review and revision-includes
methods to determine effectiveness of program
and corrective actions
Signature/Statement
9) Emplo yer's Statem ent:
Agree Disagree (Attach additional sheets as needed)
10) Employer's Signature:
11) Consultant's Signature:
12) Date:
13) Date:
HS -32-B
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