Health and Safety Policy (Sample)

Company Name:

Company Health and Safety Policy

This company is committed to a health and safety program that protects our workers, others (i.e. contractors)
who enter onto our property, and the general public.

The employer, supervisors and workers at every level are responsible and accountable for the company’s
health and safety performance. Active participation by everyone, every day, in every job is necessary for
the health and safety excellence that this company expects. Health and safety excellence includes the
promotion and maintenance of the highest degree of physical, psychological, and social well-being of all
employees. Our goal is a healthy, injury-free workplace for all workers. By working together we can achieve
this goal.

The employer will:

 Ensure
o the health, safety, and welfare of workers at the work site,
o the health, safety and welfare of other persons at or near the work site who may be affected by
hazards originating from the work site,
o that workers are aware of their OHS rights and duties,
o that workers are not subjected to or participate in harassment or violence at the work site,
o that workers are supervised by a person who is competent and familiar with the OHS Act,
Regulations, and Code,
o they consult and cooperate with the HSC,
o that health and safety concerns are resolved in a timely manner,
o where a prime contractor is required, the prime contractor is advised of all the supervisors and
workers names, and
o that supervisors and workers are adequately trained for the protection of health and safety at the
work site.

Supervisors will:
 Ensure
o they are competent to supervise the workers under their supervision,
o the workers under their supervision work in accordance with procedures and measures required
by the OHS Act, Regulations, and Code,
o the workers under their supervision use all hazard controls and properly uses or wears the
personal protective equipment required by the employer or under the OHS Act, Regulation or
Code, and
o that workers are not subjected to or participate in harassment or violence at the work site.
 Take all precautions necessary to protect the health and safety of every worker under their supervision.
 Advise every worker under their supervision of all known or reasonably foreseeable hazards to health and
safety in the area where the worker is performing work.
 Report concerns about an unsafe or harmful work site act or condition that occurs/exists or has
occurred/existed to the employer.
 Workers will:
 Protect the health and safety of themselves and other people at or near the worksite.
 Cooperate with their supervisors and employers to protect the health and safety of themselves and
others.
 Use and wear devices and personal protective equipment required by the employer or the OHS Act,
Regulation or Code.
 Refrain from causing or participating in harassment or violence.
 Report concerns about an unsafe or harmful work site act or condition that occurs/exists or has
occurred/existed to the employer or supervisor.

In addition, employers, supervisors and workers will:

 Cooperate with any person exercising a duty imposed by the OHS Act, Regulations, or Code, and
 Comply with the OHS Act, Regulation, and Code and any site policies, procedures, and codes of
practice.

Other workers (e.g. contractors, suppliers, or service providers) will comply with the OHS Act, Regulation and
Code and site policies.

Workers at every level must be familiar with the requirements of the Alberta Occupational Health and Safety
legislation as it relates to their work.

Signed Date

This form is for example purposes only. Completing this form alone will not necessarily put you in compliance with the legislation. It is important
and necessary that you customize this document to meet the unique circumstances of your worksite. Further, it is essential that this document is
not only completed, but is used, communicated, and implemented in accordance with the legislation. The Crown, its agents, employees or
contractors will not be liable to you for any damages, direct or indirect, arising out of your use of this form.
Emergency Response Plan – Template (Sample)

Company:

Address or Location:

Completed by:

Date:

Potential Emergencies The following are identified as potential emergencies:

(Refer to your hazard assessment
to determine which hazards could
require rescue or evacuation)

Emergency Procedures If an emergency (identified above) occurs, these steps need to be taken by
the assigned personnel:
(Detail procedures to be followed
for each identified emergency)

Locations of Emergency Emergency equipment is located at:

Equipment Fire Alarm:
Fire Extinguisher:
Fire Hose:
Panic Button:
Other:
Emergency Response Name: Training Received: Frequency:
Equipment Training &
Requirements
(List the names of workers trained
to use each type of emergency
equipment)
Location and Use of The nearest emergency services are located at:
Emergency Facilities Fire Station:
Ambulance:
Police:
Hospital:
Other:
Fire Protection Fire protection equipment listed below can be accessed by trained personnel
Requirements at the following locations:

Alarm and Emergency

Communication
Requirements

First Aid First Aid Kit Type:

Location:
Other Supplies:
First Aiders are:
Work Station & Shift:
Transportation Arrangements:
Procedures for Rescue and
Evacuation

Designated Rescue and The following workers are trained in rescue and evacuation: (Name and area
Evacuation Workers of expertise)

This form is for example purposes only. Completing this form alone will not necessarily put you in compliance with the legislation. It is important and
necessary that you customize this document to meet the unique circumstances of your worksite. Further, it is essential that this document is not only
completed, but is used, communicated, and implemented in accordance with the legislation. The Crown, its agents, employees or contractors will not
be liable to you for any damages, direct or indirect, arising out of your use of this form.
Multiple employers or self-employed persons at the work site –
Additional Considerations
Coordinating health and safety for multiple work site parties:
Examples of OHS program components that may require a coordinated, site-specific approach include:
□ Hazard assessments
□ Emergency response plans
□ Inspection procedure and schedule
□ Health and safety orientation and training for workers and supervisors
□ Procedures for investigating incidents, injuries and refusals to work
□ Others, depending on the work being performed at the work site and the work site parties involved

Criteria for evaluation and selection of other employers and self-employed persons:
When hiring other employers or self-employed persons, the employer must consider health and safety criteria in
the selection process.
Evaluation and selection procedures with pass/fail criteria may be developed in consultation with the HSC or HS
representative. Alternatively, a third party health and safety evaluation service or audit tool may be utilized.
The employer may request documentation such as:
□ Health and safety program handbook or manual
□ Health and safety policy
□ Safe work policies and procedures
□ WCB information (premium rate statement, clearance letter, employer report card)
□ Certificate of Recognition (COR)
□ Health and safety program audit results
□ Hazard assessments
□ HSC meeting minutes
□ Safety meeting minutes, toolbox talks, or pre-job tailgate meeting records
□ Worker and supervisor training and certification records
□ Other, depending on the work being performed at the work site and the work site parties involved

This documentation may form part of a contractor pre-qualification process that the employer uses to ensure that
other employers and self-employed persons equipped to address the health and safety requirements of the job.

Regular Monitoring
The procedures for monitoring other employers and self-employed persons at the work site could include:
□ Defining regular intervals, depending on the type and nature of the work being done at the work site.
o Note: If there is an HSC at the work site, the HSC must inspect the work site at least once before
each quarterly meeting. This is the minimum requirement for inspections by the HSC; an
employer can exceed that minimum.
□ Scheduled formal inspections and occasional visual checks (scheduled and unscheduled).
□ Assess the employer’s performance against their own written procedures, work site specific health and
safety policies, as well as the OHS Act, Regulations and Code
□ Processes for dealing with non-compliances
Please note: These are suggested processes and should be modified to suit individual employer’s needs
depending on the type and duration of the work being done.
This form is for example purposes only. Completing this form alone will not necessarily put you in compliance with the legislation. It is important and
necessary that you customize this document to meet the unique circumstances of your worksite. Further, it is essential that this document is not only
completed, but is used, communicated, and implemented in accordance with the legislation. The Crown, its agents, employees or contractors will not
be liable to you for any damages, direct or indirect, arising out of your use of this form.

Worker Orientation Record – Template (Sample)

This is an example of a checklist you may wish to use when training new workers on health and safety in your
workplace.
Worker’s Name:

Date of Hire:
Date of Orientation:
Supervisor’s Name:

Orientation Topics
Yes No
Covered? Written work procedures (list them here):
Rights of workers: ________________________________________
 Right to know □ □ ________________________________________
 Right to participate □ □ ________________________________________
________________________________________
 Right to refuse □ □
________________________________________
Company’s health and safety
policy ________________________________________

Health and safety

responsibilities for each work □ □ Other topics covered (list them here):
site party
________________________________________
Health and safety rules □ □ ________________________________________
Site orientation □ □ ________________________________________
Review of hazards □ □ ________________________________________
How to report unsafe conditions ________________________________________
and other health and safety □ □ ________________________________________
concerns

How to report incidents □ □

Comments:
Workplace violence prevention
plan □ □ ________________________________________
________________________________________
Harassment prevention plan □ □
________________________________________
Emergency procedures
 Review the ERP
□ □ ________________________________________
________________________________________
 Location of fire exit(s) □ □ ________________________________________
 and fire extinguisher(s)

How to get first aid treatment □ □

Location of first aid kit(s) □ □
WHMIS training (if applicable) □ □
Location of Safety Data Sheets
(SDSs) □ □
Use of personal protective
equipment □ □
Completion of this form does not indicate competency of workers. It may be used as a record that
training has occurred.
This form is for example purposes only. Completing this form alone will not necessarily put you in compliance with the legislation. It is important
and necessary that you customize this document to meet the unique circumstances of your worksite. Further, it is essential that this document is
not only completed, but is used, communicated, and implemented in accordance with the legislation. The Crown, its agents, employees or
contractors will not be liable to you for any damages, direct or indirect, arising out of your use of this form.