Apx L-2 PSM SHARP Self-Eval

Approved Form

OMB Number: 1218-XXXX

Expiration Date: XX-XX-2026

Paperwork Reduction Act Notice

Persons are not required to respond to this collection of information unless it displays a valid OMB control number. The Occupational Safety and Health Administration (OSHA) requires that State On-Site Consultation program Consultants review the Process Safety Management of Highly Hazardous Chemicals (PSM) Interim Year Safety and Health Achievement Recognition Program (SHARP) Site Self-Evaluation Template completed and submitted by employers; and provide technical guidance as necessary to facilitate the effective implementation of PSM Program elements by small business employers participating in SHARP.

Employers participating in SHARP with processes covered by the PSM standard must conduct continuous assessment of the effectiveness of the implemented PSM Program elements in their workplace; complete the PSM Interim Year SHARP Site Self-Evaluation Template in the year following the last on-site evaluation by the Consultant to assess criteria for SHARP participation, and submit it to the Consultation program.

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.

OSHA estimates that it will take an employer 4 hours to assess the PSM Program elements implemented in the workplace and complete the PSM Interim Year SHARP Site Self-Evaluation. OSHA estimates that it will take the Consultant 2 hours to review an employer’s self-evaluation and provide any technical assistance needed.

The assessment of the PSM Program elements by small business employers, as well as the technical assistance provided by Consultants will facilitate effective program implementation.

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.

Appendix L-2: Process Safety Management of Highly Hazardous Chemicals (PSM) Interim Year Safety and Health Achievement Recognition Program (SHARP) Site Self-Evaluation Template

Name of Establishment: Date:

1. Explain how all the findings from the previous Compliance Audit were resolved and if documented corrective actions (29 CFR 1910.119(o)(4)) were all implemented and functioning adequately.

2. Explain how all Process Hazard Analyses (PHA) findings (29 CFR 1910.119(e)(3) through (e)(3)(vii)) were addressed (29 CFR 1910.119(e)(5)).

3. Was a PHA revalidation due? If yes, was it completed as specified in 29 CFR 1910.119(e)(4)&(6)? Please, provide a copy of the revalidated PHA, if applicable.

4. Was refresher training required for any operators this year (29 CFR 1910.119(g)(2))? If yes, was it completed as required? Please, provide operators training record(s), if applicable.

5. Were any new operators and/or maintenance personnel hired? Were newly hired operators provided initial training before being assigned tasks (29 CFR 1910.119(g)(1)(i))? Were newly hired maintenance personnel trained as required before being assigned tasks (29 CFR 1910.119(j)(3))? Please provide training records, if applicable.

6. Have all previous incident investigation findings been resolved (29 CFR 1910.119(m)(5))? If no, please explain. Please, provide the investigation report(s) and an explanation of how findings were addressed.

7. Did any incident(s) occur involving the PSM covered process since the most recent SHARP evaluation (29 CFR 1910.119(m) through (m)(7))? If yes, describe the incident(s), attach the incident investigation report(s), include the measures taken to resolve findings (29 CFR 1910.119(m)(5)).

8. Was the schedule in the written plan for routine testing, inspection and maintenance of equipment (29 CFR 1910.119(j)(2); 29 CFR 1910.119(j)(4) through (j)(4)(iv)) implemented and followed as required? If not, please explain why. Please, submit equipment testing, inspection and maintenance records.

9. Are engineering and administrative controls (29 CFR 1910.119(e)(3)(iii)) functioning and maintained effectively to protect workers from exposure to hazards? Have there been any issues with engineering controls; administrative controls; and/or personal protective equipment, if applicable (29 CFR 1910.119(f)(1)(iii)(B); 29 CFR 1910.132))? Please, explain your response.

10. Were operating procedures reviewed and certified annually as current and accurate (29 CFR 1910.119(f)(3))? If not, please explain; otherwise, submit a copy of the certified review findings.

11. Have there been any changes that required applying the Management of Change (MOC) procedures? If yes, were MOC procedures properly applied, and were they adequate for safe operations (29 CFR 1910.119(l)(1) and (j)(5)? Please, describe the changes and MOC procedures used, if applicable.

12. Describe any additional relevant self-evaluation findings.

Instructions:

1. Please, review the requested information and provide accurate responses to assess the effectiveness of your PSM Program implementation.

2. Appropriate documentation may be submitted in lieu of explanations.

3. Please, implement corrective actions to address any findings and document them in this report.

4. Employers participating in SHARP, completing this PSM Interim Year SHARP Site Self-Evaluation Template, must also complete Appendix E, Interim Year SHARP Site Self-Evaluation Template.