PROGRAM CONTACT PERSON LIST

Asbestos Management......................................................Cleve Downey

AED.......................................................................................N/A
AWAIR.....................................................................Leslie Honebrink
Bleacher Safety............................................................. Cleve Downey
Bloodborne Pathogens..................................................Leslie Honebrink
Community Right-to-Know................................................Cleve Downey
Compressed Gas Safety...................................................Cleve Downey
Confined Space Entry......................................................Cleve Downey
Emergency Action Planning................................................Cleve Downey
Employee Right-to-Know/Hazard Communication....................Cleve Downey
Facilities Safety Management.......................Leslie Honebrink/Cleve Downey
First Aid/CPR .................................................................................
Hazardous Waste Management...........................................Cleve Downey
Hearing Conservation......................................................Cleve Downey
Indoor Air Quality...........................................................Cleve Downey
Integrated Pest Management.............................................Cleve Downey
Laboratory Standard/Chemical Hygiene Plan.......................................N/A
Lead Management..........................................................Cleve Downey
Lockout/Tagout ............................................................Cleve Downey
Machine Guarding ..........................................................Cleve Downey
Personal Protective Equipment..........................................Cleve Downey
Playground Safety..........................................................Cleve Downey
Radon Gas Safety...........................................................Cleve Downey
Respiratory Protection....................................................Cleve Downey
USTs/ASTs...............................................................................N/A
Welding Cutting Brazing...............................................................N/A
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Cleve Downey

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: Custodial Office .

Training for Asbestos Awareness was conducted N/A .

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: 1-21-2008 .

6-month Periodic Surveillance was conducted: 9-27-09

(first date)

(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
 Asbestos Maintenance Supplies on Hand

Is documentation of Operations and Maintenance available?

Location: At the Custodial Office

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

Pending
Comments:

**For information regarding the medical review and questionnaire, see the
Respiratory Protection Program.**
Note: ACBM is now limited to floor tile and a very small amount of elbows and
lagging. It remains a possibility that ACBM may be buried in walls
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Leslie Honebrink

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?

Are minutes of the meeting maintained?

Location:

Posted:

How is the program communicated to employees?

Who is the Contact Person for OSHA 300? Matthew Devick

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

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

Location: Parish office

Is the Log posted from February 1 until April 30? Will be 2007

The location/s of the posted log: Main church office and Main School office

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

Date Location Time

.
.

District Safety Committee Members

Member Position Building

Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Leslie Honebrink

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:

Custodians Phy Ed.
Secretaries Special Ed
Playground Supervisors

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? Affected staff are offered vaccinations free of charge.

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

exposure incidents? The School Nurse or hired consultant provides training
annually for affected staff.

New Employees: _____10-4-07

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): the kits are located at the instructors desk or custodial office

Status of Declination forms: The declination forms are maintained by the

school nurse (Christy Elias)

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

Policy regarding cleanup: Custodians are expected to provide cleanup

responsibilities. Staff may be required when custodial staff is unavailable

Location of biohazard bags at school: Nurses office

Checklist of E/OHS Activities for Compressed Gas Safety

Program Contact Person(s) Cleve Downey

Department Contacts:

Maintenance: Cleve Downey

Is the Compressed Gas Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the facility been surveyed for compressed gas inventories? Yes No

Has training been conducted for affected personnel? Yes No

Are records established/maintained for gas inventory? Yes No

COMPRESSED GAS FIELD REVIEW

Compressed Gas Inventory

Date: 05-16-2008
Program Contact Person: Cleve Downey

Department: Custodial Department Responsible Person: Cleve Downey

Location: Metals Shop

Cylinders:
 O2 ____________  CO2 ____________
 Acetyl ____________  Argon ____________
 NH4 ____________  Argon/CO2____________
 Helium __1__________

Compliance Check List

Yes
No
1. Are cylinders in well-ventilated area? X
2. Are cylinders stored separate from flammables by at least 20 feet? X
3. During storage are oxygen cylinders separated from fuel gas X
cylinders, unless on welding cart?
4. Are cylinders kept away from sources of heat (below 130 F)? X
5. Are safety chains used at all times on both full and empty X
cylinders? (2/3rds from top of cylinder)
6. Are empty cylinders maintained separate from full cylinders? X
7. Are cylinders kept away from sources of ignition such as electricity, X
excessive heat or oily rags?
8. Are carts designed specifically for gas cylinders available? X
9. Are damaged cylinders, valves/hoses removed from service? X
10. Are all cylinders properly labeled with the contents? X
Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Cleve Downey

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: Activity 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

 Confined Space Inventory

Building: All Buildings

Building Contact: Cleve Downey Program Contact: Cleve Downey

Date: May 15, 2008

Room Opening Dimension Potential Permit/ Labeled Photo

Identification Dimension Of Hazards Non- ID #
Name Given Confined Permit/Alternat
Space Space e

Boiler Room 15”X12” 5’X5’ O2, LE Permit required

Chimney
Elevator Shaft 7’X3’ 7X7’X4.5’ Entrapment, Permit required
Elevator pit energy
Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Leslie Honebrink

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

Have the program and goals been approved by the School Board for the current
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? Maps are located in each classroom.

Are all drills timed and recorded? Yes No

Responsible person: Stasha, Sectary_________________________________

Location of records: School 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

Note: Contact persons for development of the Emergency Plan:

• Cathy Bjorklund, Librarian
• Linda Morris, Social Worker
Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Cleve Downey

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 program been approved by the School Board for the current 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 Custodial Office

Food Service Yes No N/A Food service desk

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: Leslie Honebrink

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: __Cleve Downey_________________________

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
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: June , 2008___________ N/A

Most recent inspection of fume hoods with fire suppressant: April, 2008 N/A

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

Science safety Checklist completed? Yes No N/A

Note: Link to Facility Safety Surveys

 Facilities Safety Review

Building: St. Joseph’s Elementary School

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art X

Dark Room X

Wood Shop X

Kitchen 1-23-08 See document dated Facility Safety Report

Metal Shop X

Halls, Gym, etc. 1-23-08 See document dated Facility Safety Report

Graphic Arts X

Maintenance/Custodia 1-23-08 See document dated Facility Safety Report

l

Transportation X

Grounds/Garage 1-23-08 See document dated Facility Safety Report

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

Program Contact Person(s): Leslie Honebrink

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

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

Has 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 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 will be the
designated emergency response person located within the district.

Has training been provided for affected staff? Yes No

Note: School nurse Christy Elias provides training for staff.

Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Cleve Downey

Is the Hearing Conservation Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the school been surveyed for noise hazards? Yes No

Have sound level measurements been collected? Yes No

Have the results been documented? Yes No

Location: Activities Manual

Has training been scheduled or completed for affected individuals this school
year?
Yes No N/A

Date:

Presenter:

Have regulatory changes occurred that may affect this program? No

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Leslie Honebrink

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? No

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: Cleve Downey

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: Cleve Downey

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 __1999-2000.

(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: Cleve Downey

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
__good____________ condition
Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Cleve Downey

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 Machine Guarding
Program Contact Person: Cleve Downey
Is the Machine Guarding Plan for each affected work area in place? Yes No

Is the plan/plans current? Yes No

Has the Plan been reviewed this school year? Yes No

Has a survey of all district fixed equipment been conducted?

Yes No

When was the evaluation completed? _______________________

Who conducted the evaluation? _______________________

How are corrections documented? _______________________________

Is all fixed equipment safeguarded to meet OSHA criteria? Yes No

Has the alternative MDE “best practices” criteria used to safeguard equipment?
Yes No

Has equipment determined not in compliance scheduled for repair or

replacement? Yes No

If replaced, was “best practices,” bid specification criteria used for

procurement? Yes No
 Identified Fixed Equipment Locations

Location Building/Buildings Staff Affected # of item

Automotive Shop N/A N/A N/A
Wood Shop N/A N/A N/A
Custodial/Maintenanc Custodial work 2 1
e room
Welding Shop N/A N/A N/A
Ag Shop N/A N/A N/A
Bus Garage N/A N/A N/A
Art N/A N/A N/A
Scene shop N/A N/A N/A
Science N/A N/A N/A

Contracted technical services to review and recommend? __________________.

Name of person or contractor conducting survey? ___________________.

(date)

Results of technical services located where? ________________________

Checklist for minimum requirements:

• Power outage protection provided for required equipment
• Emergency stops provided for required equipment
• Safe work practice placards at applicable fixed tool stations
• Proper guards provided and used
• Color coding as prescribed by OSHA standards
• Non-slip surfaces by each piece of equipment
• Fixed equipment secured to prevent “walking” or movement

Has a log of employee accidents and near misses been established and used?
Yes No
Annual training for affected staff is provided? Yes No

Training conducted ____________.

(date)
Training has been scheduled for ____________.
(date)
Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Cleve Downey

Is the Playground Safety 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

Note: The St. Joseph School is not responsible for playground equipmement.
The Town Site Park located to the south and west of the school is considered
the official playground. The playground is maintained by the city of
Moorhead.
Surfacing:
Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Cleve Downey

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:__May15, 2008_________________

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: Cleve Downey

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: _______________

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
Cleve Downey Misc AO ½ mask N/A N/A N/A

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:__Good functional condition____________________

Location(s): On shelf behind the custodial work room

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

Verified by Lee Carlson