Drug-Free Safety Program - Safety Action Plan Company name Policy number The purpose of an action plan is to help employers improve their safety and health processes. Review the results from the Safety Management Self-Assessment and identify and prioritize manageable action items that will generate the desired improvements. If you would like assistance completing this action plan or with developing or implementing any of the action plan activities, please call 1-800-644-6292 and request personal assistance from your assigned BWC representative. For each section determine: 1. What actions (if any) you will take and how they will be 3. When will each planned action item be completed? accomplished? 4. What is the expected improvement to your safety and 2. Who will be responsible for ensuring the completion of health process once the action item is completed? each action item? 1. Management commitment ­ The level of commitment that management demonstrates to the safety and health process Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 2. Accountability ­ The process used to assign safety and health management responsibilities and to evaluate, recognize and reward performance Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 3. Employee participation ­ The extent the employees participate in and are encouraged to be involved in the safety and health of the workplace Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process BWC-1588 (Rev. Oct. 2, 2014) DFSP-5 1 | Page American LegalNet, Inc. www.FormsWorkFlow.com 4. Safety culture ­ The organizational values, management style, environment and social norms related to safety and health Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 5. Hazard prevention and control ­ The process to identify and correct unsafe acts and conditions Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 6. Safety and health training and education ­ The process of ensuring safety education and training is provided to people at all levels, and that skills are assessed to ensure understanding Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 7. Accident analysis ­ The method of gathering and analyzing accident information; determining root causes and identifying safety improvements to prevent future accidents Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process BWC-1588 (Rev. Oct. 2, 2014) DFSP-5 2 | Page American LegalNet, Inc. www.FormsWorkFlow.com 8. Workers' compensation claims management ­The management process for ensuring timely filing of claims, care for injured workers, and minimizing the financial impact of claims on the organization Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 9. Return-to-work practices ­ The management process for ensuring a safe, efficient return to work by injured workers to help reduce financial burdens on the employee and employer Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process 10. Employee health promotion (wellness) ­ The organization's efforts to encourage personal health improvement and health maintenance among its employees Planned activity (attach separate sheet if needed) Person responsible Target date Describe how this completed activity will improve your safety and health process X Signature of company official responsible for this action plan Date submitted BWC-1588 (Rev. Oct. 2, 2014) DFSP-5 3 | Page American LegalNet, Inc. www.FormsWorkFlow.com