ARKANSAS WO RKER S' COMPENSATION COMMISSION FO RM HS-3 2-B HEALTH & SAFETY DIVISION ARK. CODE ANN. §11-9-409 & AWCC RULE 32 REV. 1-1-2008 AWCC File Number________________ 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS32-B Health and Safety Plan Cover Sheet 3) City: 4) State: 5)Zip: 1) Company name: 2) Address: M andator y Safety P rogram Administration Co mponen ts Components 6)In Place Yes No 7)Effectiveness 8)Com ments 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: 10) Employer's Signature: Agree Disagree (Attach additional sheets as needed) 11) Consultant's Signature: 12) Date: 13) Date: HS -32-B