Form 33 On Site Consultation Progam Safety and Health Assessment

O n-Site Consultation Program 4-28-2022

Safety and Health Program Assessment Worksheet (OSHA Form 33)

The Occupational Safety and Health Administration (OSHA) developed OSHA Form 33, the Safety and Health Program Assessment Worksheet, for use by trained On-Site Consultation Program consultants. Consultants use this tool to conduct no-cost safety and health assessments of small- and medium-sized businesses and assist employers with establishing or improving workplace safety and health management programs (see www.osha.gov/consultation). This assessment worksheet applies the seven core elements in the Recommended Practices for Safety and Health Programs, released by OSHA in October 2016. This assessment is meant to assist employers with efforts to reduce the risks of workplace injuries, illnesses, and catastrophic events by identifying shortcomings and providing recommendations for continuous improvement. The assessment worksheet is also used to evaluate the implementation of safety and health programs for businesses seeking Safety and Health Achievement Recognition Program (SHARP) status. The consultant assigns ratings to the attributes evaluated using the criteria described in the table below.

Descriptions of Ratings for Attributes of the Safety and Health Program Elements
Assessment Ratings	Descriptions
Missing 0	All observations or cues in the workplace to assess an attribute are negative (Zero). No safety and health policy and procedures are present to implement the attribute (No activity). Effective development and implementation of policy and procedures are needed.
Developing 1	The weight of observations or cues in the workplace to assess an attribute are predominantly negative, inadequate and/or incomplete (Sometimes). Some safety and health policies and procedures are present to implement the attribute but they are inadequate (Little Activity). Major improvement is needed.
Well Developed 2	The weight of observations or cues in the workplace to assess an attribute are predominantly positive, adequate, and/or mostly complete (Often). Considerable safety and health policies and procedures are present to implement the attribute and they are adequate (Most Activities Completed). Minor improvement is needed.
Advanced 3	The weight of observations or cues in the workplace to assess an attribute are entirely positive and exceptional; and innovative means are applied to assure continuous improvement (Always). Exceptional safety and health policies and procedures are present to implement the attribute (All Activities Completed). Development, implementation, monitoring, and advancement of policy and procedures are effective. Continuous review and improvement are necessary.
Not Evaluated (NE)	NE is a default value when insufficient or no observations are collected in the workplace to assess a particular attribute; when this is the case no rating is required.
Special Notes	Personnel includes the entire workforce, management, supervisors, and workers independent of the type (salaried, hourly, contract) or duration (temporary, seasonal) of employment. All personnel refers to the personnel for the host employer, contractor, staffing agency, seasonal workers, etc., in the workplace, as applicable (not the total number of personnel in the workplace). All workers refers to the host employer’s workers, contractors, temporary workers, seasonal workers, etc., in the workplace, as applicable (not the total number of workers in the workplace). Total workplace approach – When making observations for each attribute, consultants must assess the attribute as being applicable to all personnel and all tasks occurring in the workplace. Complete safety and health program review – This requires assessing all attributes in #1-48 and multiemployer communication and coordination (C+C) attributes #49-52, when applicable (see additional information below). All observations collected are relevant to rating an attribute. Even in instances where it may appear that an attribute is not needed in the workplace, the consultant still needs to evaluate how the employer made such a determination, assess if the consultant’s findings fully support the determination, and if established processes in the workplace would be able to detect changes that would trigger implementing the attribute.

Consultants must determine the applicability of multiemployer C+C requirements to the workplace before starting an assessment:

1. Does the employer retain temporary workers and/or seasonal workers, at the workplace at any time? Yes No

2. Does the employer retain contractors at the workplace at any time? Yes No

Notes:

1. C+C requirements apply if the employer responds “Yes” to either one or both questions.

2. When applicable, the implementation of C+C requirements is determined by assessing attributes #49-52.

3. When conducting a complete/comprehensive safety and health program review, the consultant must inquire about the procedures followed by a host employer to address C+C requirements and evaluate them even when only the host employer’s personnel are at a workplace, but other types of workers such as temporary workers or contractors are “sometimes” retained.

Request Number	Visit Number	Visit Date
Establishment Name
Address

Ratings Distribution Table

Safety and Health Program Elements	Distribution of Ratings for Assessed Attributes
	Missing 0	Developing 1	Well Developed 2	Advanced 3	NE	Number of Attributes Evaluated	Average Attribute Rating	Element Scale Score
Management Leadership						? of 14
Worker Participation						? of 6
Hazard Identification and Assessment						? of 10
Hazard Prevention and Control						? of 10
Education and Training						? of 4
Program Evaluation and Improvement						? of 4
Communication and Coordination for Host Employers, Contractors, and Staffing Agencies						? of 4
Totals							Overall Average Attribute Rating:	Overall Average Element Scale Score:
Notes: Number of Attributes Evaluated: This is the total number of attributes assessed by the consultant in each element. Average Attribute Rating: This is the average rating for all attributes assessed in an element. This value can range from 0 to 3. For example, it will be 0 if all attributes assessed in the element were rated as 0. It will be 3 if all attributes assessed in the element were rated as 3. Element Scale Score: The Average Attribute Rating for each element multiplied by 33.333 yields an Element Scale Score between 0 and 100. A zero indicates all attributes were rated as 0 and a 100 indicates all attributes were rated as 3. The Element Scale Score simply recasts the Average Attribute Rating on a scale of 0 to 100 regardless of the number of attributes assessed by the consultant for an element. Overall Average Attribute Rating: This is an unweighted mean derived from the average of the seven Average Attribute Ratings and has an identical range (i.e., 0 to 3). Overall Average Element Scale Score: This is an unweighted mean derived from the average of the seven Element Scale Scores and has an identical range (i.e., 0 to 100).

SAFETY AND HEALTH PROGRAM ASSESSMENT WORKSHEET, FORM 33

Attribute Descriptions

Assessment Ratings

Missing

Developing

Well Developed

Advanced

Not Evaluated

0

1

2

3

NE

Management Leadership: Top Management Leadership

How well does top management project the value of safety and health and initiate the foundation for a successful safety and health program?

Name of Top Management: _________________________________________________________

1. Top management communicates a policy that establishes safety and health as a core value.

Observations:

Recommendations:

2. Top management participates in planning and evaluating safety and health performance to drive continuous improvement.

Observations:

Recommendations:

3. Top management assures line managers and supervisors oversee safety and health performance and are provided with proficient staff support as needed.

Observations:

Recommendations:

Management Leadership: Foundation

How well does the management team initiate the basic requirements of a successful safety and health program?

4. Safety and health goals with supporting objectives that focus on specific actions to establish or improve the overall safety and health program exist.

Observations:

Recommendations:

5. An action plan designed to accomplish the organization’s safety and health goals and supporting objectives is in place.

Observations:

Recommendations:

Management Leadership: Safety and Health Program Implementation

How well does the management team execute all of the following steps, that are required for implementing every aspect of the safety and health program (each depending on the previous requirements)?

6. Managers and supervisors personally follow safety and health procedures to set a visible leadership example.

Observations:

Recommendations:

7. Managers support fair and effective policies that promote safety and health performance by all personnel.

Observations:

Recommendations:

8. Safety and health program tasks are assigned and clearly communicated to a specific person(s) [or position(s)] for performance or coordination.

Observations:

Recommendations:

9. An accountability mechanism is included with each assignment of safety and health tasks to monitor performance.

Observations:

Recommendations:

10. Personnel assigned safety and health responsibilities have the necessary knowledge, skills, and current information to effectively perform their duties.

Observations:

Recommendations:

11. Personnel have the authority necessary to effectively carry out their assigned safety and health tasks as delegated by management.

Observations:

Recommendations:

12. Managers ensure that appropriate resources are fully provided to personnel to support the safety and health program.

Observations:

Recommendations:

13. Incentive programs (or similar practices) effectively promote the performance of safety and health responsibilities by personnel.

Observations:

Recommendations:

14. Organizational policies result in correcting non-performance or poor performance of safety and health responsibilities by personnel.

Observations:

Recommendations:

Worker Participation

Is worker participation encouraged by the management team?

Do all workers fully participate in the safety and health program to assure its effectiveness?

15. All workers are encouraged to participate in all aspects of the safety and health program, and there are effective processes without barriers for workers to use.

Observations:

Recommendations:

16. All workers routinely participate in hazard identification activities and have access to the information they need to understand safety and health hazards.

Observations:

Recommendations:

17. All workers routinely participate in hazard prevention and control activities and have access to the information they need to understand control measures.

Observations:

Recommendations:

18. All workers routinely participate in receiving and delivering safety and health training.

Observations:

Recommendations:

19. All workers routinely participate in safety and health planning activities.

Observations:

Recommendations:

20. All workers routinely participate in evaluating and improving the organization’s safety and health performance.

Observations:

Recommendations:

Hazard Identification and Assessment

Are hazards routinely identified to reduce or eliminate fatalities, injuries, and illnesses for routine, nonroutine, and emergency operations?

21. The comprehensive baseline hazard assessment for the workplace is periodically updated.

Observations:

Recommendations:

22. The workplace hazard assessment is performed by individuals with the proper expertise.

Observations:

Recommendations:

23. Effective job hazard analysis is routinely performed.

Observations:

Recommendations:

24. Changes in the workplace are always effectively analyzed for their impact on occupational safety and health before implementation.

Observations:

Recommendations:

25. Safety Data Sheets and labels are used to assess potential hazards associated with chemical products in the workplace.

Observations:

Recommendations:

26. Effective safety and health self-inspections are performed regularly to identify new or recurring hazards, associated with routine, nonroutine, and emergency situations.

Observations:

Recommendations:

27. An effective hazard reporting system exists for early identification of hazards.

Observations:

Recommendations:

28. All incidents that result in any form of OSHA recordable injuries or illnesses are investigated for root causes to prevent recurrence.

Observations:

Recommendations:

29. Near misses are investigated for root causes to prevent an injury or illness.

Observations:

Recommendations:

30. Hazard identification activities involve evaluating identified hazards to determine risk, prioritizing hazards for correction, and identifying interim controls.

Observations:

Recommendations:

Hazard Prevention and Control

After identification, are hazards eliminated or controlled? Are controls monitored to verify that they remain effective?

31. Feasible engineering solutions are effectively used to protect all workers from hazards.

Observations:

Recommendations:

32. Effective safe work practices and administrative controls are used to protect all workers from hazards.

Observations:

Recommendations:

33. Personal protective equipment is effectively used to protect all workers from hazards.

Observations:

Recommendations:

34. An effective plan for monitoring the timely correction of hazards is in place.

(c.19 An effective procedure for tracking hazard correction is in place.)

Observations:

Recommendations:

35. Effective monitoring of established hazard controls is conducted to verify that they continue to function properly.

Observations:

Recommendations:

36. Applicable OSHA mandated programs are effectively in place to promote safe and healthful working conditions.

Observations:

Recommendations:

37. Effective preventive maintenance is routinely performed to ensure that facilities and equipment are in good working condition.

Observations:

Recommendations:

38. Effective housekeeping is routinely practiced to control hazards.

Observations:

Recommendations:

39. The organization is properly prepared for emergency and nonroutine situations.

Observations:

Recommendations:

40. The organization has an effective plan for ensuring timely and appropriate emergency medical care for all personnel at the workplace.

Observations:

Recommendations:

Education and Training

Do all personnel have the required knowledge and skills to safely perform their duties?

41. All workers receive effective training in a language and literacy level they understand to do their work safely, before performing assigned tasks, changes in assigned tasks, and changes in the workplace.

Observations:

Recommendations:

42. The training provided to all personnel includes appropriate information about the workplace and its safety and health program.

Observations:

Recommendations:

43. Supervisors receive effective safety and health training to oversee all workers and demonstrate knowledge of the benefits of a safety and health program to the business.

Observations:

Recommendations:

44. Managers receive effective safety and health training to fulfill their roles and demonstrate knowledge of the benefits of a safety and health program to the business.

Observations:

Recommendations:

Program Evaluation and Improvement

Are there processes in place to monitor, assess, and update the safety and health program to assure continuous improvement of workplace conditions?

(Note: See attribute #2 for top management planning and evaluation of safety and health performance.)

45. Data from lagging indicators are effectively analyzed to monitor performance and progress.

Observations:

Recommendations:

46. Data from leading indicators are effectively analyzed to monitor performance and progress.

Observations:

Recommendations:

47. An evaluation of in-place OSHA mandated programs is conducted at least annually to correct shortcomings and identify additional opportunities to improve.

Observations:

Recommendations:

48. An evaluation of the overall safety and health program is conducted at least annually to correct shortcomings and identify additional opportunities to improve.

Observations:

Recommendations:

Communication and Coordination for Host Employers, Contractors, and Staffing Agencies (i.e., C+C)

At a multiemployer workplace, do the various employers effectively communicate and coordinate to provide and maintain a safe work environment for all personnel?

49. The host employer coordinates with staffing agencies and contractors prior to work to ensure they meet the safety and health related specifications outlined in bid documents and contracts.

Observations:

Recommendations:

The host employer, contractors, and staffing agencies coordinate on work planning, scheduling, and resolving important program differences.
Observations:
Recommendations:

The host employer implements effective procedures to exchange information with staffing agencies and contractors about potential hazards and controls in the workplace.
Observations:
Recommendations:

The host employer coordinates with staffing agencies and contractors prior to work to establish effective procedures for resolving safety and health conflicts that arise onsite.
Observations:
Recommendations:

Paperwork Reduction Act Notice –PENDING submission for approval --- this is only a place holder/example

OMB Number: pending

Expiration Date: pending

Persons are not required to respond to this collection of information unless it displays a valid OMB control number. OSHA requires that State On-Site Consultation program Consultants (Consultants) participating in the Pilot Study use the Draft Revised Form 33 if they collect information in the course of their consultation visit which would allow them to fill out the worksheet.

Consultants must complete all Draft Revised Form 33 information before the Consultation Program Manager who oversees a State On-Site Consultation program recommends an applicant for the OSHA Safety and Health Achievement Recognition Program (SHARP), that exempts the employer from OSHA or State Plan programmed enforcement inspections.

In accordance with 29 CFR 1908.6(h)(1) and (2), Consultants must preserve the confidentiality of information obtained as a result of a consultative visit, including information that contains or might reveal a trade of secret of the employer.

It is estimated that Consultants average 45 minutes to complete 12-18 entries of the Form 33 for a limited-service consultation visit; and average 5 hours to complete all 58 entries of the Form 33 for a comprehensive consultation visit or SHARP evaluation. This includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the Form 33. The same time estimates are predicted for the completion of the Draft Revised Form 33.

The Form 33 serves as a comprehensive evaluation tool. The information obtained from the Form 33 is used to evaluate an employer’s safety and health management system. Similarly, the Draft Revised Form 33 is designed to serve as a comprehensive tool for evaluating employers’ safety and health management systems.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Office of Small Business Assistance, Occupational Safety and Health Administration, Room N-3660, 200 Constitution Avenue, NW, Washington, DC 20210.

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