Customizable Safety Policies

just another example of


The following is a partial list of the customizable safety policies available to policyholders of Midwestern Insurance Alliance. It’s  just one of the many innovative ways Midwestern Insurance Alliance supports your business. These and many additional safety and HR resources can be accessed through our Risk Management Center.

To learn more about our Risk Management Center or to request login credentials, click here

The following safety policies are available in the Risk Management Center

Accident Prevention – English/Spanish

An accident prevention policy dedicated to promoting a safe workplace.

Aerial Lift Evaluation Form – English/Spanish

An outlined evaluation form on the operation of aerial lifts.

Aerial Lifts – English/Spanish

A written policy on the proper use of aerial lifts, scissor lifts, and other types of lifts.

Anti-Harassment Policy – English/Spanish

A policy on harassment in the workplace describing prohibited behaviors, employee rights and responsibilities, complaint procedures, confidentiality, prohibited retaliation, and supervisor responsibilities.

Back Injury Prevention and Ergonomic Evaluation – English/Spanish

A written policy for employees that details how to avoid back injuries while in the workplace.

Basic Accident Report – English

A basic accident reporting form to be filled out by employees and supervisors.

BBS Supervisor Evaluation – English

An evaluation guide for preparing employees for a new position.

Bicycle Safety Policy Indemnity and Release Form – English/Spanish

A policy for locations where bicycles are used.

Bloodborne Pathogens Exposure Control Plan – English/Spanish

The Bloodborne Pathogens ECP is designed to minimize or eliminate occupational exposure to bloodborne pathogens.

CDL- Notification of Traffic Violation – English/Spanish

An example notification of traffic violation form for CDL drivers.

Claim Status Log – English/Spanish

Log for tracking workers compensation claims and the return to work status.

Cold Stress Prevention Program – English

A program that establishes controls to protect employees from cold stress, including hazard assessments, engineering controls, administrative controls, personal protective equipment including proper clothing, and employee training.

Confined Space Entry – English

A written policy for employees entering or working around confined spaces.

Confined Space Entry Control Worksheet – English

A form used to evaluate hazards for developing a Job Hazard Analysis for a Confined Space.

Contractor Safety Program – English

This program provides guidelines for the review and approval of contractors and subcontractors and establishes necessary safety measures to follow onsite.

Crane Daily Inspections – English

A safety check to be done at the beginning of each shift.

Crane Operation – English

A written program to establish safe practices for the operation and maintenance of cranes to minimize the potential for personal injury and property damage.

Driver Qualification Policy – English/Spanish

In order to become a certified driver and maintain driving privileges, the following requirements must be met.

Driver Ride Along Evaluation Form – English

A checklist of items to review and document during a ride along test for an employee.

Driver Safety – Emergency Supplies Checklist – English/Spanish

A checklist to evaluate driving habits to determine additional practices and improvements for overall safety.

Driver Safety – Safe Driving Evaluation – English/Spanish

An evaluation of driving habits to determine changes and improvements for overall driver’s safety.

Driver Safety – Safe Driving Habits Evaluation – English/Spanish

A self-evaluation of driving habits to determine changes and improvements for overall driver’s safety.

Driving – Oversize Loads Checklist – English

A pre-trip checklist for loads that require additional permits and authorization.

Driving Safety Policy for Non-Commercial Drivers – English

This policy covers procedures for non-commercial drivers including sections on employee training, certificates of insurance, accident investigation, basic driver safety and procedures for traffic violations and vehicle inspections.

Electrical Safety – Hazard Checklist – English

This checklist covers electrical safety hazards to watch out for.

Electrical Safety Checklist – English/Spanish

A sample electrical checklist.

Emergency Action Plan – English

A template plan to complete and deploy in an organization in preparation for business closure and natural disasters.

Emergency Evacuation Plan – English

A policy for the identification and implementation of emergency evacuation procedures.

Energy Control Procedure – English

This procedure establishes the minimum requirements for lockout of energy sources that could cause injury to personnel.

Ergonomics Awareness – Caution Zone Checklist – English/Spanish

Use this checklist to determine if any typical job activities put employees at risk for ergonomic stress. These are movements or postures that are regularly required to complete a job and are performed more than once per week for more than one week per year. Use a separate checklist for each job position.

Ergonomics Awareness – Computer Workstation Checklist – English/Spanish

A checklist to evaluate the ergonomic safety of employees working at computer workstations.

Ergonomics Awareness – Hazard Zone Checklist – English/Spanish

Use this checklist to determine if any typical job activities of caution zone jobs may put employees at risk of hazardous levels of ergonomic stress. These are movements or postures that are regularly required to complete a job and are performed more than once per week for more than one week per year. Use a separate checklist for each job position.

Fall Protection – Jobsite Worksheet – English/Spanish

Fall protection plan evaluation and audit tools, including prework planning worksheet.

Fall Protection Policy – English/Spanish

A written policy for facilities and field operations where personnel are exposed to elevated work hazards.

Fire Prevention Plan – English

A Fire Prevention Plan policy in accordance with the Occupational Safety and Health Administration’s (OSHA) fire prevention standard, 29 CFR 1910.39.

First Aid Responder Responsibilities and Agreement Form – English/Spanish

This agreement form highlights first aid responder responsibilities and is to be reviewed prior to acceptance of the position.

Fleet Accident Analysis – English/Spanish

Provides a template to compile investigative information after a vehicle incident.

Fleet Safety – Driver Emergency Pack Checklist – English

Suggested items that should be included in employee vehicles for emergency events.

Fleet Safety Policy – Regulated – English

A policy for employees who drive a commercial motor vehicle (CMV) as a function of their employment.

Fleet-Driver Evaluation – English/Spanish

A form to be completed for ride-along evaluations and spot checks of drivers.

Food Safety – Components – English/Spanish

Checklist for the components of a food safety program for each location.

Food Safety – Requirements – English

The food safety program should include a written plan for each individual site and be based on Hazard Analysis Critical Control Point (HACCP) principles.

Forklift Operation Program – English

Forklift operation requirements to implement by facility managers.

Forklift Operator Checklist – English

A vehicle inspection checklist that reviews visual and operational controls.

Forklift Safety – Skills Test Evaluation – English/Spanish

An evaluation to document a forklift operator’s driving skills and habits.

Forklift Safety Training – Practical Evaluation for Certification – English

This evaluation form is designed to be used by a trainer during the required on-site practical evaluation of a forklift operator. This portion of operator certification should be performed after the learner completes formal classroom instruction on forklift safety and the evaluation form should be filed as a record of the training to satisfy OSHA regulation 29 CFR 1910.178.

General Hold Harmless and Insurance Requirements – English

Provides example general hold harmless and insurance requirements language used in contracts.

Hand Tool Safety – English

A written policy for the proper use of hand tools in the workplace.

Hazard Assessment for PPE – English

A hazard assessment policy for employees using PPE (personal protective equipment).

Hazard Assessment Worksheet – English

A worksheet used for assessing and identifying hazards in the workplace and job-site.

Hazard Communication – Hazardous Chemical Training Template – English/Spanish

Describes the necessary elements needed to train employees on hazardous chemicals.

Hazard Communication – Hazardous Chemicals Inventory – English/Spanish

A form used to document hazardous chemicals found in the workplace as part of a successful Hazard Communication Program.

Hazard Communication – Program Audit – English/Spanish

An evaluation form for assessing the completeness of your Hazard Communication Program.

Hazard Communication Program – English

The Written Hazard Communication Program provides guidelines to educate employees and contractors on proper receipt, use, labeling, and storage of chemicals. Also covered is how to read and use SDSs and general training requirements. Included are a Hazardous Material Inventory and a Chemical Safety Training Document.

Heat Illness Prevention Plan – English

A policy on how to protect employees who work outdoors or in hot environments from heat illness.

Hot Work – English/Spanish

A written policy for employees working in or around hot-work environments.

Hot Work Permit – English/Spanish

A detailed hot work permit for any operation with sparks, open flames or heat producing tasks.

Housekeeping – English

A written policy on the importance of proper housekeeping in the office and on the job site.

Incident Investigation Form – English/Spanish

A form that is to be used in the case of an on the job accident.

Incident Investigation Plan – English

A policy on the topic of conducting incident investigations including the process of investigating incidents, gathering information about the incident, identifying root causes, and determining corrective actions to prevent the incident from recurring.

Incident Management Gap Analysis – English

A simple checklist for an Incident Management Gap Analysis.

Indemnity and Release Form – English/Spanish

An example indemnity and release form.

Injury and Illness Prevention Program (IIPP) – English

This document outlines key elements of a comprehensive Injury and Illness Prevention Program. It includes best practices including hazard identification and assessment, incident investigation, controlling and correcting hazards, training and recordkeeping.

Insurance – Hold Harmless and Related Guidelines – English

Example contract language for insurance, hold harmless, bond, and related guidelines for contracts for construction.

Insurance – Requirements for General Service – English

Example insurance requirements for general service agreements including consultants.

JHA Process Evaluation – English

Step-by-step evaluation to prepare employee for new position (i.e., responsibilities, safety measures, job requirements, etc.).

Job Hazard/Safety Analysis Development Worksheet – English

A worksheet that allows you to list the safety requirements for each task.

Job Safety Analysis (JSA) Process – English

JSAs are designed to enhance employees’ awareness and adherence to safety controls. JSAs outline by position the various steps, respective hazards, and job requirements that need to be in place to prevent incidents from occurring.

Job Site Safety Audit – English

Evaluation form to be used in auditing departments to ensure the Job Safety Analysis (JSA) process is fully in place.

Joint Hold Harmless Agreement – English

Example language for joint hold harmless agreements.

Kitchen Safety – Checklist – English

Daily checklist to determine areas in your kitchen operations requiring corrective action.

Kitchen Safety – Cooking and Reheating Temperature Log – English

A form to record product name, time, the two temperatures/times, and any corrective action taken.

Kitchen Safety – Cooling Temperature Log – English English/Spanish

Form to record temperatures during the cooling cycle of foods in your kitchen.

Kitchen Safety – Damaged or Discarded Product Log – English

A form to record product name, quantity, action taken, reason, initials, and date each time a food product is damaged or discarded in your kitchen.

Kitchen Safety – Surface Cleaning and Sanitizing Log – English

A log to record time, temperatures, sanitizer concentration, and any corrective action taken for food service kitchens.

Ladder Inspection Checklist – English/Spanish

Specific risk factors identified for inspecting ladders before use.

Lead Exposure – English

A written substance data sheet on the dangers of lead exposure from the OSHA standard 1910.1025 App. A

Lead in Construction – English/Spanish

Policy detailing the dangers of lead in the construction industry and ways to minimize the risk of harmful exposure.

Lockout and Tagout – Information Placard – English

A form to be filled out when lockout/tagout procedures need to be performed on equipment.

Lockout and Tagout – Information Placard 2 – English

A form to be filled out when lockout/tagout procedures need to be performed on equipment. Includes space for adding photos.

Lockout and Tagout – Program Audit – English

This document serves as an audit report checklist to identify areas of improvement in a lockout and tagout program.

Lockout and Tagout – Warning Form – English

A form that helps employees identify which equipment must be locked out prior to maintenance or service.

Lockout and Tagout – Warning Form 2 – English

A form that helps employees identify which equipment must be locked out prior to maintenance or service. Includes space for adding photos.

Lockout and Tagout Policy – English

A policy on Lockout and Tagout aimed to prevent the unexpected startup or release of hazardous energy from machines and equipment during servicing or maintenance.

Noise and Hearing Conservation – English/Spanish

The purpose of this procedure is to protect employees from hazardous noise exposure to prevent hearing loss.

Noise and Hearing Conservation Program Audit – English/Spanish

An evaluation form to assist in reviewing your hearing conservation program.

Orientation Checklist – English

A sample checklist for use with new employees to help explain and hold them accountable for proper safety practices.

OSHA 300 Logs

Excel Spreadsheet with OSHA 300, OSHA 300A and OSHA 301

Outdoor Home Playground Safety Handbook – English

This handbook is intended as guidance for homes and residential child care facilities.

Patient and Resident Handling Checklist – English

A safety checklist for moving residents and patients.

Personal Protective Equipment Inspection – English

A safety checklist that reviews safe working behaviors when using personal protective equipment (PPE).

Personal Protective Equipment Policy – English

Outlines the personal protective equipment that must be worn at all facilities.

Personal Vehicles – Usage Guidelines – English

An example form is to be read and signed by all individuals who drive their personal vehicles. By signing this form, the undersigned agrees to all terms and conditions as outlined.

Portable Ladders – English

The purpose of this procedure is to require the safe use and proper construction, inspection, and maintenance of ladders at work sites.

Reduce Motor Vehicle Crashes – Guidelines – English

Guidelines for employers on how they can help reduce motor vehicle crashes.

Release of Liability and Assumption of Risk for High Risk Athletic Activity – English/Spanish

Example release form of liability and assumption of risk for high risk athletic activity.

Respiratory Program Questionnaire

The essential parts of a respiratory program include having a respirator questionnaire reviewed by a physician.

Respiratory Protection Program – English

This program defines the responsibilities of organizations that require the use of respiratory protection. It also addresses the voluntary use of respirators.

Retail Safety Checklist – English

A safety checklist for use in the retail environment.

Return to Work Flowchart – English

A flowchart procedure for employees who sustain a compensable injury with temporary modified/transitional duties.

Return to Work Program – English

A program designed for employees who sustain a compensated injury with temporary modified/transitional duties.

Return to Work Program Checklist – English

A simple checklist to fill out during the return to work process.

Ride Behind Evaluation – English/Spanish

A short form to evaluate the safety of a fleet driver.

Safe Driving Pledge – English/Spanish

An agreement between the employee and organization acknowledging the organizations driver safety policies.

Safety and Health Program – English

A program that incorporates the use of JSAs to create a comprehensive safety and health program. This details how JSAs can be used for every position and on the job hazard.

Safety Commitment – English

A form for employees to sign acknowledging their commitment to safe working practices.

Safety Committee Program – English

This program is designed to promote and assure a safe and healthful work environment and to foster a commitment and involvement of employees and management in this cooperative effort.

Safety Inspection Checklist – English

A checklist for use during safety inspections and observations.

Safety Interview Questions – English

Sample interview questions geared for the construction and manufacturing industries.

Safety Suggestion Form – English/Spanish

A form employees can use to recommend safety improvements.

Safety Work Order – English

A work order form for identifying hazards and scheduling repairs.

Sewing Station Design – English

This section explains potential hazards encountered at the sewing workstation and a general description of a proper workstation design.

Sharps Injury Log – English

A blank sharps injury log.

Slip, Trip, and Fall Prevention – Inspection Form – English/Spanish

An inspection form to evaluate your workplace for slip, trip, or fall hazards.

Spill Prevention and Response Plan – English

A plan designed to prevent spills and to allow for the proper responses to chemical spills and other emergency releases involving hazardous materials.

Substance Abuse Policy – English

The purpose of this testing policy is to protect the physical and psychological well being of all the staff at this organization’s facilities and job sites and protect the safety of the public.

Temporary Agency Quarterly Audit – English

Use this form to track the performance of temporary agencies.

Temporary Placement Audit – English

A quarterly audit for temp agencies used by your organization.

Training Sign In Sheet – English/Spanish

A simple sheet to help document training

Trenching and Shoring – Site Assessment – English/Spanish

A procedural assessment of safety conditions and inspections of your excavation work site.

Water Safety Plan – English

This document describes the development, implementation, and maintenance of a water safety plan.

Work Zone Traffic Control Plan – English

A written policy on the proper operations involving work performed on roads, highways, and similar areas where motor vehicles may be a hazard.

Workers Compensation – Gap Analysis and Opportunity Assessment – English

A tool for assessing the workers compensation and safety and health programs and finding opportunities for improvement.

Workers Compensation Calculation Sheet – English

Calculates the indirect (hidden) costs of incidents.

Working Alone Policy – English

A policy for situations where it may be necessary for employees to work alone.

Workplace Violence Prevention Program – English

An example workplace violence prevention program.

Workstation Purchasing Specification – English

A detailed checklist of what to look for when purchasing new workstation materials such as computers, desks and monitors.