Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Urban Jirik

Is the Asbestos Management Plan in place? Yes No N/A

Is the Plan current for all buildings? Yes No N/A

Has the Plan (or Plans) been reviewed this school year? Yes No N/A

The Plan is located at affected building: School Office

Training for Asbestos Awareness was conducted 10-4-07 .

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; .

(date)
Notification appeared in the following publication(s):

Name of publication Date

Three-year re-inspection Surveillance was conducted: 5-13-08 .

6-month Periodic Surveillance was conducted: 1-13-06 10-04-07

(first date)

9-26-06
(second date)

All caution labels have been posted.

Label locations: N/A

Are supplies of repair materials adequate to meet the requirements of

maintenance and repair of ACM? Yes No N/A

Note: Repairs or removals are done by outside contractors.

 Asbestos Maintenance Supplies on Hand

Is documentation of Operations and Maintenance available? No

Status of the Asbestos repair and maintenance Work Order System: N/A
Established,

Pending
Comments:
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Sr. Yvonne

Is the AWAIR Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is the Safety Committee organized? Yes No N/A

How often are meetings held? 3rd Tuesday of the monthly

Are minutes of the meeting maintained?

Location: Sr. Yvonne’s office

Posted: No

How is the program communicated to employees?

Who is the Contact Person for OSHA 300? Church book: Beverly Schoenborn

Is the OSHA 300A Log completed for the previous calendar year?

Have the Logs been maintained for five (5) years?

Location:

Is the Log posted from February 1 until April 30?

The location/s of the posted log: basement of school, work room

Is information on injuries recorded on the Log with five (5) working days? Yes
No N/A
 Safety Committee – Meeting Schedule

Date Location Time

3rd Tuesday of month St. Michael’s School Library 5:30 PM

.
.

District Safety Committee Members

Member Position Building

Dan Schoenborn Chair person St. Michael’s School
Dena Lefebore St. Michael’s School
Barb Agnew Vice Chair St. Michael’s School
Michelle Gieseke St. Michael’s School
LuAnn Durant St. Michael’s School
Nicole Ore Secretary St. Michael’s School
Beth Eynick St. Michael’s School

Note: The teachers rotate each month as representatives to the board. The
focus of the committee is to insure maintenance and improvement and safety
of school facilities.
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Sr. Yvonne _

Is the Bloodborne Pathogens Written Plan in place? Yes No

Has the Plan been reviewed this school year? Yes No

List job categories that may be at risk to exposure: All staff are considered at
risk.

What is this school’s policy regarding Hepatitis B vaccinations for employees

considered at risk versus employees considered not at risk in the Exposure
Control Plan? Vaccinations are offered to affected staff

Is training provided at this school on methods and techniques to reduce

exposure incidents?__Annual all-staff training is provided by a hired consultant.

New Employees: ___within ten days of hiring__

Have the employees identified as first aid responders been given at a minimum
Red Cross First Aid Training? Yes No N/A

Are Exposure Control Kits available to staff? Yes No N/A

Location(s): Kits are located in classrooms and the main office

Status of Declination forms: not maintained at this time

How are blood or bodily-fluid-containing materials handled at this facility?

Policy regarding cleanup: Custodians provide primary cleanup. Staff may

need to clean spills on occasion

Location of biohazard bags at school: Main office

Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Urban Jirik

Is the Confined Space Entry Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Have confined space areas been identified? Yes No N/A

Have measurements to include CCI/ft been completed? Yes No N/A

Are permit entry forms in place? Yes No N/A

Location: Activities Manual

Are confined space labels in the proper locations? Yes No N/A

Is a list of employees eligible to enter confined spaces complete? Yes No N/A

Has training for affected employees completed? Yes No

Date of completion: 10-4-07

Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Sr. Yvonne

Is the Emergency Action Planning program in place and as outlined in the

Minnesota Executive Order 93-27 and Model Crisis Management Plan? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Are information maps posted to indicate travel routes in the event of fire,
tornado shelter locations, and procedures during lockdown? Yes No

Located where? Written instructions are located in each classroom.

Are all drills timed and recorded? Yes No

Responsible person: Sr. Yvonne

Location of records: Main Office

Forms provided: Yes No

Does this school coordinate drills with local government authorities to assure
sheltering in school, evacuating to their homes or use of congregate care
centers? Yes No N/A

Has this school completed the Fire Marshall required Fire Safety and Emergency
Evacuation Plan? Yes No N/A

Training provided for affected staff? Yes No N/A

Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Urban Jirik

Is the Employee Right-to-Know/Hazard Communication Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the chemical inventory been completed for the following functional areas?

Location of Chemical Inventory

Form

Art Instruction Yes No N/A

Custodians Yes No N/A

Food Service Yes No N/A

Science Rooms Yes No N/A

Shop (metals, wood, auto) Yes No N/A

Are MSDS available and located with the chemical inventory? Yes No

Do the MSDS concur with the chemical inventory? Yes No

Has training been provided for the following staff?

Art Instructors Yes No N/A Science Yes No N/A

Custodians Yes No N/A Shop Yes No N/A

Food Service Yes No N/A Transportation Yes No N/A

Checklist of E/OHS Activities for Facilities Safety Management
and Fire Safety in Schools

Program Contact Person: Urban Jirik

Is the Facilities Safety Management program in place? Yes No

Does this school use contracted services for the Management Assistant
Program? Yes No N/A

If no, who is the designated person or persons? Lee Carlson

Fire and Life Safety in Schools

Program Contact Person: Urban Jirik

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
district building? Yes No

Most recent date of sprinkler electronics inspection_________ N/A

Most recent date of alarm inspection_________ N/A

Most recent inspection of fire extinguishers: May, 2008__________ N/A

Most recent inspection of fume hoods with fire suppressant________ N/A

Are emergency lights tested at least biannually? Yes No N/A

 Facilities Safety Review

Building: St. Michael’s School

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art X

Dark Room X

Wood Shop X

Kitchen 3-27-07

Metal Shop X

Halls, Gym, etc. 3-27-07

Graphic Arts X

Maintenance/ 3-27-07
Custodial

Transportation X

Grounds/Garage 3-27-07

Chemistry/Life X
Science
Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): Sr. Yvonne

Is the First Aid/CPR program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

the District determined a provider in the event of a medical emergency? Yes

No

The local provider determined travel time was estimated to be within the 4-8
minute limit. Therefore Mahnomen Health Center
will be the designated emergency response provider.

The local provider determined travel time was estimated to be in excess of the
4-8 minute limit. Therefore N/A will be the
designated emergency response person located within the district.

Has training been provided for affected staff? Yes No

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Urban Jirik/ Sr. Yvonne

Is the IAQ Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has an IAQ Committee been established?.

Have the program and goals been approved by the School Board for the current
school year? Yes No

Has the annual cursory walk-through been conducted? Yes No

Have the districts key building systems been evaluated? Yes No

When was the evaluation completed?

Who conducted the evaluation?

Were occupied areas of the district evaluated using the EPA’s Tools For Schools
check list or equivalent?
• Teachers check list? An information fact sheet was provided all –staff.
# of forms distributed # of Forms returned:

• Building maintenance checklist?

• Building ventilation checklist?

Training conducted
(date)

Training has been scheduled for _______________.

(date)

Has the District determined the mechanical ventilation rate of each occupied
space? Yes No.

Supportive technical services were conducted on: _________________.

(date)

Results of technical services are located? __ ________

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Urban Jirik

Is the IPM Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the annual monitoring been conducted to determine location and degree of
infestation? Yes No

A map of the problem area/areas has been developed. Yes No

Has notice been given to parents regarding application activities? Yes No

Location or publication used to notify parents__________________________.

Checklist of E/OHS Activities for Lead-in-Water Management

Program Contact Person: Urban Jirik

Is the Lead-in-Water Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

This school completed testing of water supply taps __________.

(date)

Is a map of all potable water taps available for review? Yes No N/A

Checklist of E/OHS Activities for Lead-in-Paint Management

Program Contact Person: Urban Jirik

Is the Lead-in-Paint Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Testing for lead in paint on playground equipment: Note: All playground

equipment has been replace with lead free.

Date completed: N/A

Yet to be tested: N/A

Results of evaluation for paint condition in rooms K-1:

Building constructed post-1978; facility not applicable
Building constructed prior to 1978; paint determined to be in
______________ condition
Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Urban Jirik

Is the Lockout/Tagout Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is LO/TO equipment available? Yes No N/A

Is the equipment appropriate for application? Yes No N/A

If available, where is the equipment located? _________________________

Is the equipment maintained in an orderly and readily usable condition? Yes No

N/A

Have affected personnel been trained as to methods and technique of use? Yes
No N/A

Are written procedures available for affected staff? Yes No N/A

If available, the procedures are located where? _________________________

Has the annual audit of energy control procedures been completed? Yes No

Date or dates of completion:

Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Urban Jirik

Is the Playground Safety program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Surfacing:

The equipment has adequate protective surfacing under and around it

and the surfacing materials have not deteriorated

Loose-fill surfacing materials have no foreign objects or debris

Loose-fill surfacing materials are not compacted and do not have

reduced depth in heavy use areas such as under swings or at slide exits

General Hazards:

There are no sharp points, corners, or edges on the equipment

There are no missing or damaged protective caps or plugs

There are no hazardous protrusions and projections

There are no potential clothing entanglement hazards, such as open S-

hooks or protruding bolts

There are no pinch, crush, and shearing points or exposed moving parts

There are no trip hazards, such as exposed footings on anchoring

devices and rocks, roots, or any other environmental obstacles in the
play area

Deterioration of the Equipment:

The equipment has no rust, rot, cracks, or splinters, especially where

it comes in contact with the ground
 There are no broken or missing components on the equipment (e.g.,
handrails, guardrails, protective barriers, steps, or rungs on ladders)
and there are no damaged fences, benches, or signs on the playground

All equipment is securely anchored

Security of Hardware:

There are no loose fastening devices or worn connections, such as S-

hooks

Moving components, such as swing hangers or merry-go-round bearings,

are not worn

Drainage:

The entire play area has satisfactory drainage, especially in heavy use
areas such as under swings and at slide exits

Leaded Paint:

The leaded paint used on the playground equipment has not

deteriorated as noted by peeling, cracking, chipping, or chalking

There are no areas of visible leaded paint chips or accumulation of

lead dust

General Upkeep of Playgrounds:

The entire playground is free from miscellaneous debris or litter such

as tree branches, soda cans, bottles, glass, etc.

There are no missing or full trash receptacles

Note: The playground area has undergone significant upgrading and removal of
older equipment. The cushioning material consists of pea rock and is
reasonably well maintained. The new playground equipment was installed in
September of 2002.
Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Urban Jirik

Is the Personal Protective Equipment Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has a survey of potential workplace hazards been completed? Yes No N/A

Date(s) activity was conducted:__________________________

Have recommendations been completed for appropriate equipment? Yes No

Has training been completed for the following departments?

Art and Photo Yes No N/A

Custodial Yes No N/A
Grounds keeping/Garage Yes No N/A
Kitchen Yes No N/A
Maintenance Yes No N/A
Science Laboratories Yes No N/A
Technical Education Yes No N/A
Transportation Yes No N/A
Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: Urban Jirik

Does this school provide respirators for voluntary use? Yes No N/A
If the school allows employees to use respirators voluntarily the following is
mandatory.
1. Read and follow instructions provided by manufacturer.
2. Choose respirators certified for use against contaminants of concern.
3. Do not wear respirators in atmospheres containing contaminants not
designed to protect from those contaminants.
4. Keep track of respirators so that you do not mistakenly wear someone
else’s respirator.

Is the Respiratory Protection program in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Date of review: __5-13-08_____________

Are all employees in this program identified? Yes No N/A

Employee Intended Type of Medical Exam/ Date of Date of

Use Respirator Questionnaire Medical Fit Test
Urban Jirik Miscellanous N95, dust N/A N/A N/A
mask

Fit testing was completed on N/A.

(date)

Type of testing protocol; Irritant Smoke (Stannic Chloride) or

Bitrex (Denatonium Benzoate)
Condition and location of respirators:

Condition:______________________________________________________

Location(s):___________________________________________________

Are the appropriate adequate accessories on hand? Yes No N/A

Verified by