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Initial Report Of Accident And Illness Prevention Program Status LIBC-231G - Pennsylvania

Initial Report Of Accident And Illness Prevention Program Status Form. This is a Pennsylvania form and can be used in Workers Comp .
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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION COMMONWEALTH OF PENNSYLVANIA INITIAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM STATUS BY NEW GROUP SELF-INSURANCE FUNDS 1. Proposed fund name: 2. Mailing address: (Street, P.O. Box, City, State, ZIP) Address (line 1) Address (line 2) City State ZIP 3. TotalnumberofmemberstobeaffiliatedwiththeGroupSelf-InsuranceFund: 4. Whatmethodswillbeutilizedfordeterminingprogramservicescommitments[Checkallthatapply]: ( ( ( ) ) ) a. Member Contribution (%) b. Request c. RequestOnly d. LossHistory ( ( ( ( ) ) ) ) e. IncidenceRate f. FirstReportRate g. IncurredLosses h. PaidLosses ( ( ( ) i. ) j. FundAdministratorRequest AnnualInspection ( ) ) k. Other[Explain/Identifyas Item4(k)onadditionalsheets] 5. Accident&IllnessPreventionprogram[checkallthatapply]NOTE:Item(1)through(8)areconsidered tobebasictoanyAccident&IllnessPreventionProgram.TheA&IPProgrammustincludeProgramelements 1-8andmustbeinplaceasapre-requisiteforself-insurance.Items9(i)through(xi)arerequiredwhen applicabletoworkplaceandworksiteenvironments.[Checkallthatapply]: ( ) 1. SafetyProgramPolicyStatement 2. DesignatedA&IPprogramcoordinator 3. Assignment of responsibilities for developing,implementingandevaluating theA&IPProgram 4. A&IPProgramgoalsandobjectives 5. A&IPProgramemployeeinvolvement 6. EmployeeA&IPsuggestionand communicationprograms 7. Method(s)foraccidentinvestigation, reportingandrecordkeeping ( ( ( ( ) ) ) ) ) ) ( ( ( ( ( ) ) ) ) ) i. Electricalandmachinesafeguarding ii. Personalprotectiveequipment iii. Hearingandsightconservation iv. Lockout/tagoutprocedure v. Hazardousmaterialhandling,storage and disposal vi. Confinedspaceentry vii. Firepreventionandcontrol viii. Substanceabuseawarenessand preventionpoliciesandprograms ix. Control of exposure to blood borne pathogens x. Preoperationalprocessreview xi. Otherprotocolsasmaybeappropriatefor operations[Explain-Identifyasitem#5 (9,xi)onadditionalsheet.] ( ) ( ) ( ) ( ) ( ) ( ( ) ) 8. Method(s)fordeterminingandevaluating A&IPProgrameffectiveness(mustcomplete ( item8) ( 9. ProtocolorStandardOperatingProcedures, whenapplicabletotheworkplaceand worksiteenvironmentsfor: ( ) LIBC-231G REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com 6. Indicatethenumberofqualifiedpersonnelthea.EmployeeA&IPProviders b.ContractedA&IPProviders: fundplanstoutilizetoprovideAccident&Illness PreventionProgramservices: 7. StatethetypesofAccident&IllnessPreventionmaterialsthatthefundintendstoprovidetoitsmembers: [Checkalltheapply]: ( ( ( ( ) a. Audiovisualmaterials ) b. Posters/payrollstuffers ) c. Booklets,brochuresor pamphlets ) d. Regulations/standards ( ( ( ( ) e. Sample forms ) f. Sample programs ) g. Awards ) h. Other[Explain/identify asItem7(h)on additionalsheet] 8. Whichofthefollowingmethod(s)willbeusedtodeterminetheeffectivenessofthefund'sAccidentand IllnessPreventionProgram?[Checkallthatapply]: ( ( ( ( ( ) ) ) ) ) I. OSHA/BLSIncidenceRateComparisonbyNorthAmericanIndustrialClassificationSystem(NAICS)Code II. Comparisonofstatisticsderivedfrom"FirstReports" III. Experiencemodificationfactor IV. Lossratio V. OthermethodusedbytheGroupSelf-InsuranceFunddeemedappropriatebytheBureau [Explain/identifyasitem8(V)onadditionalsheet] I,theundersigned,verifythatthefactssetforthinthisreportandanyattachmentsaretrueandcorrect.This verificationismadesubjecttothepenaltiesofSection 4904 of the Crime Code, 18 Pa. C.S. Subsection 4904, relatingtounswornfalsificationtoauthorities. Name/Contact(please print)** Title Telephone Emailaddress Signature Bureaucontactinformation: Date PennsylvaniaBureauofWorkers'Compensation Health&SafetyDivision ReportProcessing&AuditSection 1171SouthCameronStreet,Room324 Harrisburg,PA17104-2501 717.772.1636 (**Contactpersonnameandtelephonenumberofpersonsigningthisformarenecessaryincaseadditionalinformationisneeded.) Auxiliary aids and services are available upon request to individuals with disabilities. Equal opportunity Employer/Program LIBC-231G REV 09-13 (Page 2) *231G* American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-231G GROUPFUND'SINITIALREPORTOFACCIDENT&ILLNESSPREVENTIONPROGRAM ThisformmustbesubmittedelectronicallywiththeBureauofWorkers'Compensation,Self-Insurance DivisionatthetimeApplicationismadeforgroupself-insurancestatus. NOTE: The term `accident & illness prevention program' as described in the Pennsylvania Workers' Compensation Act is synonymous with the terms `safety and health program and loss control program'. ITEM 1: ITEM 2: ITEM 3: ITEM 4: ITEM 5: StatethefullnameoftheGroupSelf-InsuranceFund,asitwillberegisteredwiththe Self-InsuranceDivision. EntertheaddressoftheGroupSelf-InsuranceFund,asitwillberegisteredwiththe Self-InsuranceDivision. Enterthetotalnumberofmembersaffiliatedwiththefundatthetimeapplicationismade totheSelf-InsuranceDivision. Describethemethod(s)thatwillbeusedindeterminingAccident&IllnessPrevention ProgramServicescommitmenttofundmembers. ChecktheelementsthatwillbecontainedwithintheAccident&IllnessPreventionProgram offeredbythefund.Items(1)through(8)areconsideredtobetheminimumacceptable elementsthatthefundisrequiredtohaveforthefundmembers.Elementslistedunder(9) arerequiredwhenapplicable,basedonworkplaceandworksiteenvironments.Thefollowing definitionsapplytospecificprogramelements. (1) (2) (3) (4) (5) (6) Safetypolicystatement:AwrittenstatementregardingtheAccident&IllnessPrevention PolicythatcontainstheSelf-InsuredGroupphilosophyregardingaccidentandillness prevention.TheSafetyProgramPolicyStatementservesasthefoundationforallprogram activities.Thestatementshouldbesignedbyachiefexecutiveofficer,andshouldbe communicatedtoallmembers. DesignatedA&IPprogramcoordinator:Anindividual(s)appointedbythegroupfund tocoordinatetheprovisionoftheAccident&IllnessPreventionProgrambymember locationoronafund-widebasis.Assignmentofthesafetyprogramcoordinatormust bedocumentedandmadepartofthedesignatedindividual'sdutiesandresponsibilities. Assignmentofresponsibilitiesfordeveloping,implementingandevaluatingtheA&IP Program:AssignmentofAccident&IllnessPreventionProgramresponsibilities,asthey pertaintomembers'employeesandstaff,(includescontractedprovidersretainedand responsibleforcertainprogramelements).Theindividual,positionand/ortitleofthe position,andtheassignmentofindividualorpositionresponsibilitiesmustbedocumented. A&IPProgramgoalsandobjectives:AdocumentedprocedureexplaininghowAccident& IllnessPreventionProgramgoal(s)andobjective(s)areset.Example:Agoalmaybea25% red
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