COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... Implementation of THE PEOPLE OF THE STATE OF NEW YORK Safety & Health Connecticut Administrative Regulations 31-40v-1 through 31-40v-11 TO Safety Program Officers (SPOs) from the Workers’ Compensation Commission are GREETINGS:Connecticut employers to assist them in complying with the State’s recently effective visiting safety and health committee regulations, pursuant to C.G.S. Section 31-40v-1. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the HonorableFollowing the initial visit, a Safety Program Officer will return within 30 days to verify at the Court County ofemployer’s compliance located atregulations. At that time, the Safety Program Officer will the with the in room , on the , and/or, programs.o'clock in the by the Chairman, recessed at noon, and at any review existing safety andday of committees 20 health As directed or adjournedwill perform a walkgive evidence as a witness in this action on the part of the SPO’s date, to testify and through of the employer’s facility. To ensure that employers are prepared for these meetings, please have the following information available: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a • Completed inspection form (included in this information packet) result of your failure to comply. • A copy of safety committee meeting minutes from one committee meeting Witness, Honorable , one of the Justices • A copy of the posted roster containing committee member names and departments of the Court in County, day of , 20 (Attorney you may have, type name below) To answer any of your questions or address any concernsmust sign above andthe staff of the Commission’s Safety and Health Services can be contacted at the Office of the Chairman, in Hartford, at (860) 493-1500. Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : INSPECTION FORM : Plaintiff(s) DATE: -against- COMPANY NAME: COMPANY ADDRESS: Index No. Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... COMPANY CONTACT: TELEPHONE # THE PEOPLE OF THE STATE OF NEW YORK BUSINESS TYPE: PPO: YES NO TO TOTAL EMPLOYEES: _____________ COMPANY SAFETY COMMITTEE: GREETINGS: TOTAL SAFETY COMMITTEE MEMBERS YES NO _____________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before TOTAL _____________ , the Honorable EMPLOYER MEMBERS at the Court located at County of in room , on the day of , 20 , at_____________ the o'clock in noon, and at any recessed TOTAL EMPLOYEE MEMBERS or adjourned date, to testify and give evidence as a witness in this action on the part of the SAFETY COMMITTEE CHAIRPERSON _____________ DATE SELECTED _____________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a _____________ result DATE OF LAST SAFETY MEETING of your failure to comply. DOES THEHonorable Witness, COMPANY HAVE A MASTER LIST OF Court SAFETY COMMITTEE MEMBERS? in County, day of , 20 YES , one of the Justices of the NO IF YES, DOES THIS MASTER LIST CONSIST OF MEMBER NAMES AND THEIR DEPARTMENTS? YES NO (Attorney must sign above and type name below) IS THIS LIST POSTED WHERE ALL EMPLOYEES HAVE ACCESS? YES NO Attorney(s) for ARE SAFETY MEETING MINUTES KEPT? YES NO IF YES, DO THESE MEETING MINUTES LIST THE ATTENDEES? Office and P.O. Address YES NO ARE ALL MEMBERS OF THE SAFETY COMMITTEE PAID FOR ALL TIME Telephone No.: SPENT ON COMMITTEE ACTIVITIES? YES NO Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : DO SAFETY COMMITTEE MEETINGS INCLUDE: : ACCIDENT INVESTIGATIONS YES SAFETY INSPECTIONS Defendant(s) YES : ...................................................... SAFETY TRAINING PROGRAMS YES HAZARD IDENTIFICATION AND/OR WORKPLACE EXPOSURE PROGRAMS THE PEOPLE OF THE STATE OF NEW YORK YES FOLLOW-UP PROCEDURES FOR TO OPEN SAFETY ITEMS YES A WRITTEN AGENDA YES A RECORD OF ALL SUGGESTIONS AND RECOMMENDATIONS YES GREETINGS: NO NO NO NO NO NO NO FREQUENCY OF SAFETY all business and excuses being laid aside, you and each of you attend before _______________ WE COMMAND YOU, that MEETINGS , the Honorable at the Court DURATION OF SAFETY MEETINGS _______________ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the ARE RESPONSIBILITIES ASSIGNED TO CORRECT SAFETY ISSUES? YES NO HAVE ALL SAFETY COMMITTEE MEMBERS BEEN TRAINED IN and will make you liable to Your failure to comply with this subpoena is punishable as a contempt of court THEIR RIGHTS AND RESPONSIBILITIES AS for a maximum penalty of $50 and all damages sustained as a the party on whose behalf this subpoena was issued COMMITTEE MEMBERS? YES NO result of your failure to comply. IF YES, HOW? _______________________________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. STATE OF CONNECTICUT : REGULATIONCalendar No. Page 1 of _2_ pages OF : JUDICIAL Plaintiff(s) WORKERS’ COMPENSATION COMMISSION SUBPOENA -against- Concerning : Establishment and Administration of Safety and Health Committees at Work Sites : Effective May 22, 1995 : Section 31-40v-1 Purpose and Scope Defendant(s) : Section. 31-40v. of. the . general .statutes .“Establishment . . .safety . . . .health .committees by certain employers” requires that every . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of . . . . and . . . . . . . covered employer administer a safety and health committee to promote health and safety in places of employment in this state. The purpose of this regulation is to specify rules for establishing and administering committees which will bring employers and employees together in a non-adversarial, cooperative, and effective effort to promote safety and health at each work site. THE PEOPLE OF THE STATE OF NEW YORK Section 31-40v-2 Definitions TO For the purpose of sections 31-40v-1 through 31-40v-11, inclusive: (a) "Average incidence rate” means the average incidence rate of work-related injury and illness for all industries in this state as determined by the Department of Labor. GREETINGS: (b) "Chairman" means the chairman of the Connecticut Workers’ Compensation Commission or his designated agent. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before (c) “Employee” means a person engaged in service to an employer thea business of his employer. the Honorable at in Court , located at County of (d) “Employer” means a person engaged in day of who has employees, ,including the State of Connecticut and any political recessed business in room , on the , 20 at o'clock in the noon, and at any subdivision thereof. or adjourned date, to testify and give evidence as a witness in this action on the part of the (e) “Managerial member” means any individual who has the authority to use his judgment in the interest of the employer to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward or discipline other employees, or responsibility to direct them, or to adjust their grievances or effectively to recommend such actions. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf Committees was issued for a maximum penalty of $50 and all damages sustained as a Section 31-40v-3 Establishment of this subpoena result of your failure to comply. (a) Except as provided in subsection (e) of section 31-40v-4 and section 31-40v-10 of these regulations, each employer who has twenty-five or Witness, Honorable single work site in this state, as well as each employer who has twenty-four or less more employees at any , one of the Justices of the employees in this state whose rate of work-related injury and illness exceeds the average incidence rate, shall establish and Court in County, day of , 20 administer a safety and health committee for that work site. (b) In determining employment levels under sections 31-40v-1 to 31-40v-11, inclusive, of these regulations, the employer shall count all regular employees excluding temporary and seasonal workers under the employer’sabove and type name below) (Attorney must sign direction and control. Section 31-40v-4 Committee Membership and Composition Attorney(s) for (a) The committee shall be composed of at least as many employee members as employer members. The number of employee members on the committee may be greater than the number of employer members. (b) The employer’s non-managerial employees shall select employee safety and health members. Office and P.O. employee (c) Each committee shall have a chairperson elected by the committee members. Employer and Address members may have rotating responsibilities for chairing committee meetings. (d) Reasonable efforts shall be made to ensure that committee members are representative of the major work activities at the work Telephone No.: site. Facsimile No.: E-Mail do not primarily report to or work at a fixed (e) An employer need not provide a safety and health committee where the employees Address: location and at work sites where less than 25 employees are employed. In Mobile Tel. No.: such situations, a single centralized committee may represent the safety and health concerns of covered employees. American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 2 : Section 31-40v-5 Frequency of Meetings Calendar No. The committee shall meet at least once every three months, but may meet more often should they so choose. : JUDICIAL SUBPOENA Plaintiff(s) Section 31-40v-6 Recordkeeping -against- : (a) The employer shall keep a roster containing the names and departments of all: committee members. The names of current committee members shall be posted to ensure that all employees can readily contact committee members. (b) The employer shall keep a record of attendance and minutes of meetings. : Defendant(s) : (c) All .records regarding .safety . . . . . . . . committees. shall.be. provided.to .the . . . . . . . . . . . . . . . . . . and health . . . . . . . . . . . . . . . . . . . . . chairman or his designee. (d) The retention time for such records is three (3) years, after which said records may be purged. SectionTHE PEOPLE OF THE STATE OF NEW YORK 31-40v-7 Compensation Any employee who participates in committee activities in his/her role as a committee member, including, but not limited to, TO attending meetings, training activities, and inspections, shall be paid at his/her regular rate of pay for all time spent on such activities. Section 31-40v-8 Duties and Functions GREETINGS: The committee’s duties and responsibilities shall include, but not be limited to, establishing procedures for sharing ideas with the employer concerning: COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE (a) Safety inspections; , the Honorable at the Court (b) Investigating safety incidents, accidents, illnesses and deaths; located at County of (c) Evaluating accident and illness prevention programs; in room , on the day of , 20 , at o'clock in the noon, and at any recessed (d) Establishing training programs for the identification and reduction of hazards in the workplace which damage the reproductive or adjourned date, to testify and give evidence as a witness in this action on the part of the system of employees; and (e) Establishing training programs to assist committee members in understanding and identifying the effects of employee substance abuse on workplace accidents and safety. Section 31-40v-9 Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Training the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure shall be trained as committee members at no cost to the employees. All members of the committee to comply. Section 31-40v-10Witness, Honorable Pre-existing Committees Court in County, , one of the Justices of the day of , 20 Any employer who can establish that, prior to July 1, 1993, it had an existing safety and health program or other program determined by the chairman to be effective in the promotion of health and safety in the workplace may not be required to establish a safety and health committee pursuant to section 31-40v-3 of these regulations if such existing safety and health committee or program is in substantial compliance with the provisions of sections 31-40v-1 (Attorney must sign above and thesename below) to 31-40v-11, inclusive, of type regulations. Section 31-40v-11 Construction Attorney(s) for A safety and health committee established under and operating in conformity with the provisions of sections 31-40v-1 to 31-40v11, inclusive, of these regulations is intended to respect all rights of all employees, including those rights arising under the National Labor Relations Act and the Railway Labor Act, and a committee operating pursuant to the provisions of sections 31-40v-1 to 3140-11, inclusive, shall not be construed to constitute a labor organization within the meaning of section 2(5) of the National Labor Relations Act or a representative within the meaning of section 1, sixth, of the Railway Labor Act. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com