INSTRUCTIONS FOR COMPLETING THE PROGRAM REVIEW REPORT DWC101 - FOR REJECTED RISK EMPLOYERS PLEASE PRINT CLEARLY OR TYPE INFORMATION ON THIS FORM PART I: NOTIFICATION INFORMATION 1. 2. 3. 4. Date Notification Letter Received - Date notification of Rejected Risk Requiring Accident Prevention Service status was received by employer. TMIC Policy Number - Rejected Risk Program policy number for employer identified by Texas Mutual Insurance Company (TMIC) Federal Employer's Identification Number, (FEIN) - Obtain from the insurance policy for Rejected Risk Requiring Accident Prevention Services. Verify with the employer's records. North American Industry Classification System (NAICS) - Obtain from the insurance policy for Rejected Risk Requiring Accident Prevention Services. Verify with the employer's records. PART II: EMPLOYER INFORMATION 1. 2. 3. 4. 5. 6. 7. 8. Employer's Name - Name of the specific company identified as a Rejected Risk Requiring Accident Prevention Services. Employer's Mailing Address - The exact mailing address, for the employer, to which this form will be sent or delivered. City, State, Zip, and Telephone Numbers - For the address in item #2. Employer's Contact Name - Full name and title of authorized employer contact. Texas Business Name - The actual name of the operation in Texas (if different). Physical Address for Texas Location - Street address or physical location information for primary Texas work site. (NO P. O. BOX). City, State, Zip, and Telephone Numbers - For the address in item #6. Texas Contact Name - Full name, title, and e-mail address of authorized Texas contact. PART III: CONSULTANT'S INFORMATION 1. 2. 3. 4. 5. Name - Full name of consultant Telephone Number - Best contact phone number for the consultant. DWC Number – Approved Professional Source Consultant’s Number assigned by DWC or previously assigned by Texas Workers' Compensation Commission. Mailing Address - Current mailing address (contact Workers' Health and Safety if address changes) City, State, Zip - For the address in item #4. PART IV: OPERATION SAFETY ANALYSIS Each item must be answered by circling the response or filling in the blank. Additional pages may be attached to provide more information or details. Reference additional comments by item number. PART V: HAZARDOUS WORKPLACE CONDITION Each item must be answered by circling the response or filling in the blank. Additional pages may be attached to provide more information or details. Reference additional comments by item number. PART VI: SUMMARY OF OPERATIONS, FINDINGS, AND RECOMMENDATIONS The seven mandatory safety program components form the foundation of the Accident Prevention Plan. If the employer has these components in place, indicate by checking the YES column. If the component is in place and effectively implemented, write YES in the appropriate column. If the component is not effective, check YES in the "in-place" column, write NO in the "is it effective" column, and identify, by name and title, the person responsible for correcting the identified problem(s). If the employer does NOT have one of the components in place, check the No column and write in the name and title of the individual responsible for its inclusion in the submitted Accident Prevention Plan. PART VI: SIGNATURE BLOCK Consultant's Signature - Signature, DWC#, and date signed. Employer's Signature - Signature, title of person signing the form and date signed. The person signing the form must be on the payroll of the employer and have company authorization to sign legal documents. American LegalNet, Inc. www.FormsWorkflow.com DWC101 - FOR REJECTED RISK EMPLOYERS Texas Department of Insurance Division of Workers’ Compensation Workplace Safety, MS-27 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 512-804-4686 512-804-4619 fax PROGRAM REVIEW REPORT PART I: NOTIFICATION INFORMATION 2. TMIC Policy Number: 1. Date Of Notification Letter: 3. Federal ID Number (FEIN): 4. NAICS Code: PART II: EMPLOYER INFORMATION 1. Employer Name: TEXAS INFORMATION 5. Texas Business Name: 2. Employer Mailing Address: 6. Physical Address for Texas Location: 3. City: 7. City: Telephone No.: ( State: ZIP: ) Fax Number: ( ) 4. Employer Contact Name And Title: Telephone No.: ( State: ZIP: ) Fax Number: ( ) 8. Texas Contact, Name, Title, and E-mail Address: PART III: CONSULTANT'S INFORMATION 1. Name: 2. Telephone Number: ( ) DWC101 Rev. 08/06 4. Mailing Address: 3. DWC Number: 5. City: State: ZIP: TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART IV: OPERATION SAFETY ANALYSIS 1. MANAGEMENT 1a-1. HAS MANAGEMENT ADOPTED AND PUBLISHED A SAFETY POLICY STATEMENT YES NO 1a-2. HAS MANAGEMENT SIGNED THE SAFETY POLICY STATEMENT YES NO 1a-3. DOES MANAGEMENT SUPPORT THE SAFETY POLICY YES NO 1a-4. HAS MANAGEMENT ESTABLISHED CLEAR GOALS FOR THE SAFETY PROGRAM(S) YES NO 1a-5. HAS MANAGEMENT INFORMED THE EMPLOYEES OF THESE GOALS YES NO 1a-6. HAS MANAGEMENT INVOLVED ALL LEVELS OF EMPLOYEES IN THE DEVELOPMENT OF THE SAFETY PROGRAMS YES NO 1a-7. HAS MANAGEMENT EFFECTIVELY COMMUNICATED THE SAFETY PROGRAMS TO THEIR SUPERVISORS AND EMPLOYEES YES NO 1b-1. HAS MANAGEMENT ASSIGNED THE RESPONSIBILITY FOR IMPLEMENTATION OF THE ACCIDENT PREVENTION PLAN YES NO 1b-2. DOES MANAGEMENT ENFORCE ITS SAFETY RULES YES NO 1b-3. HAS MANAGEMENT MADE SAFETY THE RESPONSIBILITY OF ALL EMPLOYEES YES NO 1b-4. HAS SAFETY BECOME A DAILY PART OF ALL EMPLOYEES' JOBS AND ACTIONS YES NO 1b-5. DOES MANAGEMENT FOLLOW ALL OF ITS OWN SAFETY RULES YES NO 1b-6. LIST THE COMPONENTS AND RESPONSIBILITIES NOT ASSIGNED A.____________________________ B.____________________________ C.____________________________ 1a-8. DOES MANAGEMENT REQUIRE TRAINING OF THEIR SUPERVISORS AND EMPLOYEES IN THE USE OF THE ACCIDENT PREVENTION PLAN YES NO 2. ANALYSIS D.____________________________ NA 2-1. IS THERE A SAFETY ANALYSIS COMPONENT IN PLACE YES NO 2-2. IS DATA CENTRALLY COLLECTED YES NO 2-3. IS THE DATA ANALYZED YES NO 2-4. WHAT FREQUENCY IS ESTABLISHED FOR THE ANALYSES (MONTHLY, QUARTERLY, ETC.) 2-5. ARE TRENDS WIDELY COMMUNICATED YES NO 2-6. DOES MANAGEMENT FOLLOW UP ON ADVERSE TRENDS YES NO 2-7. ARE TRENDS USED TO ADJUST THE ELEMENTS OF THE PROGRAMS (INSPECTION, TRAINING, ACCIDENT INVESTIGATION, ETC) YES NO 2-8. IS AN OPERATION SAFETY ANALYSIS USED TO DETERMINE POTENTIAL NEEDS FOR COMPONENT CHANGES YES NO E.____________________________ F.____________________________ G.____________________________ 2-9. WHAT IS ANALYZED DOCUMENTATION A. ____________________________ B. ____________________________ C. ____________________________ OPERATIONS A. ___________________________ B. ___________________________ C. ___________________________ 2-10. WHAT ADDITIONAL ANALYSIS INPUTS ARE NEEDED NA A. ___________________________ B. ___________________________ C. ___________________________ DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 3 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART IV: OPERATION SAFETY ANALYSIS (CONTINUED) 3. RECORD KEEPING 4. TRAINING AND EDUCATION 3-1. HAS MANAGEMENT ESTABLISHED REQUIREMENTS FOR ITS RECORD KEEPING SYSTEM YES NO 3-2. IS THERE A DOCUMENTED PROGRAM YES NO 3-3. HAS MANAGEMENT TRAINED SUPERVISORS AND EMPLOYEES ON THE RECORD KEEPING SYSTEM YES NO 3-4. DOES THE RECORD KEEPING SYSTEM SUPPORT THE COMPONENTS YES NO 3-5. IS DATA USED IN TREND AND OPERATION ANALYSIS 4-1. IS THERE A TRAINING COMPONENT YES NO 5-1. IS THERE AN INSPECTION COMPONENT IN PLACE YES NO 4-2. IS THERE A DOCUMENTED TRAINING PROGRAM YES NO 5-2. IS THERE A DOCUMENTED INSPECTION PROGRAM IN PLACE WHICH MEETS THE NEEDS OF THE COMPANY YES NO IF YES, WHAT ARE THE PROGRAMS AND FREQUENCY: 5-3. ARE FREQUENCIES ASSIGNED FOR THE INSPECTIONS YES NO A. ____________________________ B. ____________________________ YES NO C. ____________________________ 3-6. WHAT DOCUMENTATION DID YOU REVIEW: 5. INSPECTION & AUDIT 5-4. ARE RESPONSIBILITIES ASSIGNED TO FOLLOW UP ON CORRECTIVE ACTIONS YES NO D. ____________________________ 5-5. ARE CORRECTIVE ACTIONS VERIFIED IN A TIMELY MANNER YES NO A. ____________________________ B. ____________________________ 4-2. DOES NEW HIRE ORIENTATION INCLUDE SAFETY TRAINING YES NO C. ____________________________ D. ____________________________ E. ____________________________ 4-4. DOES TRAINING COVER ALL OPERATIONS AND MEET ANALYZED NEEDS YES NO 5-6. ARE INSPECTION REPORTS USED IN TREND ANALYSES YES NO 5-7. ARE ALL OPERATIONS COVERED ON THE INSPECTION REPORT YES NO F. ____________________________ IF NO, WHAT OPERATIONS SHOULD BE ADDED TO TRAINING: IF NO, WHAT NEEDS TO BE ADDED: 3-7. WHAT ADDITIONAL DOCUMENTATION IS REQUIRED: NA. A. ____________________________ A. ____________________________ B. ____________________________ A. ____________________________ B. ____________________________ C. ____________________________ B. ____________________________ C. ____________________________ D. ____________________________ C. ____________________________ D. ____________________________ D. ____________________________ E. ____________________________ 5-8. IS THE INSPECTOR(S) TRAINED ON THE INSPECTION PROGRAM YES NO E. ____________________________ F. ____________________________ 4-5. HAS MANAGEMENT TRAINED ITS SUPERVISORS IN THE REQUIREMENTS OF THE ACCIDENT PREVENTION PLAN YES NO 5-9. ARE REQUIRED STATE POSTINGS AND EMPLOYEE NOTICES DISPLAYED YES NO 4-6. HAVE THE EMPLOYEES BEEN TRAINED IN THE REQUIREMENTS OF THE ACCIDENT PREVENTION PLAN YES NO DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 4 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART IV: OPERATION SAFETY ANALYSIS (CONTINUED) 6. ACCIDENT INVESTIGATION 7. REVIEW AND REVISION 6-1. IS THERE AN ACCIDENT INVESTIGATION COMPONENT YES NO 6-2. IS THERE A DOCUMENTED ACCIDENT INVESTIGATION PROGRAM IN PLACE MEETING THE NEEDS OF THE COMPANY YES NO 6-3. ARE ACCIDENT INVESTIGATIONS USED TO IDENTIFY CAUSES YES NO 6-4. ARE ACCIDENT INVESTIGATIONS USED TO ESTABLISH ACCOUNTABILITY YES NO 7a-1. IS THERE A SPECIFIED FREQUENCY FOR THE PERIODIC REVIEW YES NO 7a-2. ARE CHANGE(S) IN THE ESTABLISHED INDUSTRY PRACTICES INCLUDED IN THE REVIEW YES NO 7a-3. HAS MANAGEMENT ASSIGNED A PERSON(S) TO COMPLETE THE PERIODIC REVIEW YES NO 7a-4. IS THE REVIEW USED TO ADJUST THE FOLLOWING COMPONENTS OF THE ACCIDENT PREVENTION PLAN: 7b-2. HAS MANAGEMENT ASSIGNED A PERSON(S) TO COMPLETE THE TRIGGER REVIEW YES NO 7b-3. IS THE TRIGGERED REVIEW USED TO ADJUST THE FOLLOWING COMPONENT(S) OF THE ACCIDENT PREVENTION PLAN A. A. INSPECTION COMPONENT YES NO B. TRAINING COMPONENT 6-5. ARE CORRECTIVE ACTIONS VERIFIED IN A TIMELY MANNER YES NO YES NO INSPECTION COMPONENT YES NO 6-6. IS A NEAR MISS REPORTING SYSTEM IN PLACE YES NO C. ACCIDENT INVESTIGATION COMPONENT YES NO B. 6-7. IS THERE EVIDENCE OF A TREND(S) FROM THE REVIEW OF THE LAST 12 MONTHS OF ACCIDENTS NA YES NO 7b-1. IS A SPECIAL REVIEW TRIGGERED BY PLANNED CHANGES IN OPERATIONS, EQUIPMENT, OR THE WORK PLACE ENVIRONMENT YES NO TRAINING COMPONENT YES NO D. MANAGEMENT COMPONENT C. ACCIDENT INVESTIGATION COMPONENT YES NO YES NO E. RECORD KEEPING COMPONENT YES NO IF YES, DESCRIBE: D. MANAGEMENT COMPONENT YES NO E. RECORD KEEPING COMPONENT YES NO F. F. ANALYSIS COMPONENT YES NO ANALYSIS COMPONENT YES NO 6-8. WAS CORRECTIVE ACTION TAKEN FOR THE NOTED TREND YES NO 6-9. ARE SUPERVISORS TRAINED ON ACCIDENT INVESTIGATION PROCEDURES YES NO DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 5 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART V: WORKPLACE EXPOSURES Include a detailed description of each condition found; the possible result or occurrence from the condition; recommended changes to the Accident Prevention Plan components to prevent recurrence. Were condition(s) identified YES. NO. Item # Location: Operation: Condition: Potential effects: Affected component(s) of the plan: 1. 2. 3. 4. 5. 6. 7. Recommended changes to the Accident Prevention Plan component(s): Item # Location: Operation: Condition: Potential effects: Affected Component(s) of the Plan: 1. 2. 3. 4. 5. 6. 7. Recommended changes to the Accident Prevention Plan component(s): Item # Location: Operation: Condition: Potential effects: Affected component(s) of the Plan: 1. 2. 3. 4. 5. 6. 7. Recommended changes to the Accident Prevention Plan component(s): Item # Location: Operation: Condition: Potential effects: Affected component(s) of the Plan: 1. 2. 3. 4. 5. 6. 7. Recommended changes to the Accident Prevention Plan component(s): DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 6 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART VI: SUMMARY OF OPERATIONS, FINDINGS AND RECOMMENDATIONS IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 1. Management MANAGEMENT: A management component with a written safety policy statement and assignment, by position or title, of safety responsibilities and authority. Review of the Management Component reveals: Recommendation(s): IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 2. Analysis ANALYSIS: An analysis component includes a review of safety program documentation and employer operations to evaluate the effectiveness of existing programs and to detect existing or potential trends. The analysis component will contain a statement as to the interval between the accomplishment of the analyses. Review of the Analysis Component reveals: Recommendation(s): DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 7 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART VI: SUMMARY OF OPERATIONS, FINDINGS AND RECOMMENDATIONS IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 3. Record Keeping RECORD KEEPING: A safety program record keeping system shall state what records are maintained, where they are kept, the person(s) who maintains the records, and how long the records will be kept. These records should be retained as required by law and operational requirements. Review of the Record Keeping Component reveals: Recommendation(s): IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 4. Safety & Health Education and Training SAFETY & HEALTH EDUCATION AND TRAINING: This includes a safety and health education plan or schedule, stating the training topics, interval between training sessions, trainer (by position or title), and who will receive the training. This component also assigns the responsibility for training supervisors and employees in the use of the Accident Prevention Plan and its components. Review of the Safety & Health Education and Training Component reveals: Recommendation(s): DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 8 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART VI: SUMMARY OF OPERATIONS, FINDINGS AND RECOMMENDATIONS (CONTINUED) IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 5. Audit/Inspection AUDIT/INSPECTION: The safety audit/inspection component includes the identification, by title or position, of a qualified person(s) to conduct the audit/inspections. Clearly state what inspections are conducted, who performs the inspections, the training of inspector(s) for this component, and how often inspections are conducted. Are the inspections and corrective actions documented? Who is responsible for recommending corrective actions and follow up? Review of the Audit/Inspection Component reveals: Recommendation(s): IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible for Corrective Action. 6. Accident Investigation ACCIDENT INVESTIGATION: The accident investigation component is used to identify the cause factors of injuries. This component includes investigation procedures, identification of accident investigations and determination of corrective actions needed. The component should contain a clear guideline or procedure to follow to identify cause factors. What documentation supports the investigation and notes corrective actions taken? Review of the Accident Investigation Component reveals: Recommendation(s): DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 9 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART VI: SUMMARY OF OPERATIONS, FINDINGS AND RECOMMENDATIONS (CONTINUED) IN PLACE COMPONENT NO YES If Yes, is it effective? (yes or no) List Name and Title of Person Responsible For Corrective Action. 7. Review and Revision PERIODIC REVIEW AND REVISION: This component ensures review and revision of the safety program when changes in operations, equipment, or employee activities are determined or anticipated to insure continued effectiveness of the program requirements. The component also includes the periodic review and revisions of the safety program, including a statement as to the interval (minimum of annually) between reviews. Review of the Program Review and Revision Component reveals: Recommendation(s): PART VI: SIGNATURE BLOCK SIGNATURE/STATEMENT: The consultant's signature indicates that he/she personally audited the safety programs for the aboveidentified employer and completed the Program Review Report. The employer's signature attests that the contracted consultant ascribed below performed the Review. Note: Signature and dates are required. CONSULTANT'S SIGNATURE DWC# DATE EMPLOYER'S SIGNATURE TITLE DATE REMEMBER, REMOVE DOUBT & ESTABLISH ACCOUNTABILITY. DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION PAGE 10 American LegalNet, Inc. www.FormsWorkflow.com