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Self-Insured Employers Initial Report Of Accident Prevention Program LIBC-221I - Pennsylvania

Self-Insured Employers Initial Report Of Accident Prevention Program 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 SELF-INSURED EMPLOYER'S INITIAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM This report must be submitted electronically to the Pennsylvania Bureau of Workers' Compensation Self-Insurance Division, in conjunction with the Employer's Initial Application for Self-Insurance. (Please print or type all information. Before completing, please refer to the accompanying instructions regarding Items #I through #VI.) Date Self-Insurance Initial Application was submitted to the Self-Insurance Division: _____________, 20___. Please Enter your Federal Employer Identification Number FEIN: I. Employer name: (Please see instructions on page 3) II. Mailing address: Street, P. O. Box, City, State, ZIP IIIa. Number of physical locations within the Commonwealth of Pennsylvania: IIIb. Total number of employees at all Pennsylvania physical locations: IV. State the elements contained within your Accident & Illness Prevention Program (A&IP) [check (3) all that apply]: (NOTE: Items (1) through (15) are considered to be basic to any Accident & Illness Prevention Program. A&IP Programs shall include program elements 1-15 and must be in place as a pre-requisite for self-insurance. Items (16) i through xi are required when applicable to the workplace and worksite environments. Check all that are in place at the time the Self-Insurance Application is submitted. (A&IP = Accident and Illness Prevention) ( ) 1. Safety Policy Statement ( ) 2. Designated A&IP Program Coordinator ( ) 3. Assignment of responsibilities for developing, implementing, and evaluating the A&IP Program. ( ) 4. A&IP Program goals and objectives ( ) 5. Methods for identifying and evaluating hazards and developing corrective actions for their mitigation. ( ) 6. Industrial Hygiene Surveys (see instructions) ( ) 7. Industrial Health Services (see instructions) ( ) 8. A&IP orientation and training ( ) 9. Regularly reviewed and updated emergency action plan ( ) 10. Employee A&IP suggestion and communications programs ( ) 11. A&IP Program Employee Involvement ( ) 12. Established safety rules and methods for their enforcement ( ) 13. Methods for accident investigation, reporting and recordkeeping. ( ) 14. Prompt availability of first aid, CPR and other emergency treatments. ( ) 15. Methods for determining and evaluating program 16. Protocol or Standard Operating Procedures, when applicable to the workplace and workplace environments for: ( ( ( ( ( ( ( ( ( ( ( ) ) ) ) ) i. ii. iii. iv. v. Electrical and Machine Safeguarding Personal Protective Equipment Hearing and Sight Conservation Lockout/Tag out Procedure Hazardous Material Handling, Storage and Disposal Procedures Confined Space Entry Fire Prevention and Control Substance Abuse Awareness and Prevention Policies and Programs Control of Exposure to Bloodborne Pathogens Preoperational Process Review Other protocols as may be appropriate for the individual self-insured employer's operations [Explain ­ Identify as Item #IV (16, xi) on additional sheet. ) vi. ) vii. ) viii. ) ) ) ix. x. xi. LIBC-221I REV 09-13 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com V. Number of Qualified Accident & Illness Prevention Personnel involved with the Program: (See Instructions) a. Staff Personnel c. In-Service Status b. Contracted Personnel d. Request for In-Service Status (Complete page 3) VI. Which of the following method(s) are to be used to determine the effectiveness of the Accident & Illness Prevention Program [check (3) method(s) to be used]: For the method(s) indicated, (if available) please supply the requested information. ( ) i. OSHA/BLS Incidence Rate Comparison by the North American Industry Classification (NAICS) number Please State Incidence Rate: a. Prior fiscal year b. One year prior to last fiscal year c. Two years prior to last fiscal year ( ) ii. Comparison of Statistics Derived from "First Reports" Please State your Injury and Illness Rate Using the FORMULA in the Instructions: a. Prior fiscal year b. One year prior to last fiscal year c. Two years prior to last fiscal year ( ) iii. Experience Modification Factor or Loss Ratio a. Prior fiscal year b. One year prior to last fiscal year c. Two years prior to last fiscal year ( ) iv. Other [any other methods used by the organization to determine the effectiveness of the Accident & Illness Prevention Program] E-MOD FACTOR LOSS RATIO I, the undersigned, verify that the facts set forth in this report and any attachments are true and correct. This verification is made subject to the penalties of Section 4904 of the Crimes Code, 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Name/contact (typed/printed) Title Email address Telephone Signature Date William A. Keefer, Manager Pennsylvania Bureau of Workers' Compensation Health and Safety Division 1171 South Cameron Street, Room 324 Harrisburg, PA 17104-2501 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-221I REV 09-13 (Page 2) *221I* American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR INDIVIDUAL SERVICE PROVIDER IN-SERVICE STATUS (Please print or type the following information for all employees and/or contracted personnel that you are requesting In-Service for who do not possess a current approved designation and that have not previously been granted "In-Service" status). (Mr., Mrs., Ms.) First Name M.I. Last Name Is service provider an employee? or contracted? What is the date the above service provider began providing Accident & Illness Prevention Services? MM DD YYYY Accident & Illness Prevention Service provider(s) information with regard to In-Service status: Name of recognized provider directing the above-mentioned in-service provider: (Mr., Mrs., Ms.) First Name M.I. Last Name Recognized Provider designation Credential Code Experience Provider # E Employee Contracted LIBC-221I REV 09-13 (Page 3) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-221I SELF-INSURED EMPLOYER'S INITIAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM This Self-Insured Employer's Initial Report of Accident & Illness Prevention Program Form must be submitted electronically with the Pennsylvania Department of Labor & Industry, Bureau of Workers' Compensation, Application for Self-Insurance Status. As part of its application for individual self-insurance status submitted to the
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