Program Review Report w-Instructions {DWC-101}

INSTRUCTIONS FOR COMPLETING THE PROGRAM REVIEW REPORT DWC101 - FOR REJECTED RISK EMPLOYERS PLEASE PRINT CLEARLY OR TYPE INFORMATION ON THIS FORM PART I: NOTIFICATION INFORMATION 1. 2. 3. 4. Date Notification Letter Received - Date notification of Rejected Risk Requiring Accident Prevention Service status was received by employer. TMIC Policy Number - Rejected Risk Program policy number for employer identified by Texas Mutual Insurance Company (TMIC) Federal Employer's Identification Number, (FEIN) - Obtain from the insurance policy for Rejected Risk Requiring Accident Prevention Services. Verify with the employer's records. North American Industry Classification System (NAICS) - Obtain from the insurance policy for Rejected Risk Requiring Accident Prevention Services. Verify with the employer's records. PART II: EMPLOYER INFORMATION 1. 2. 3. 4. 5. 6. 7. 8. Employer's Name - Name of the specific company identified as a Rejected Risk Requiring Accident Prevention Services. Employer's Mailing Address - The exact mailing address, for the employer, to which this form will be sent or delivered. City, State, Zip, and Telephone Numbers - For the address in item #2. Employer's Contact Name - Full name and title of authorized employer contact. Texas Business Name - The actual name of the operation in Texas (if different). Physical Address for Texas Location - Street address or physical location information for primary Texas work site. (NO P. O. BOX). City, State, Zip, and Telephone Numbers - For the address in item #6. Texas Contact Name - Full name, title, and e-mail address of authorized Texas contact. PART III: CONSULTANT'S INFORMATION 1. 2. 3. 4. 5. Name - Full name of consultant Telephone Number - Best contact phone number for the consultant. DWC Number ­ Approved Professional Source Consultant's Number assigned by DWC or previously assigned by Texas Workers' Compensation Commission. Mailing Address - Current mailing address (contact Workers' Health and Safety if address changes) City, State, Zip - For the address in item #4. PART IV: OPERATION SAFETY ANALYSIS Each item must be answered by circling the response or filling in the blank. Additional pages may be attached to provide more information or details. Reference additional comments by item number. PART V: HAZARDOUS WORKPLACE CONDITION Each item must be answered by circling the response or filling in the blank. Additional pages may be attached to provide more information or details. Reference additional comments by item number. PART VI: SUMMARY OF OPERATIONS, FINDINGS, AND RECOMMENDATIONS The seven mandatory safety program components form the foundation of the Accident Prevention Plan. If the employer has these components in place, indicate by checking the YES column. If the component is in place and effectively implemented, write YES in the appropriate column. If the component is not effective, check YES in the "in-place" column, write NO in the "is it effective" column, and identify, by name and title, the person responsible for correcting the identified problem(s). If the employer does NOT have one of the components in place, check the No column and write in the name and title of the individual responsible for its inclusion in the submitted Accident Prevention Plan. PART VI: SIGNATURE BLOCK Consultant's Signature - Signature, DWC#, and date signed. Employer's Signature - Signature, title of person signing the form and date signed. The person signing the form must be on the payroll of the employer and have company authorization to sign legal documents. American LegalNet, Inc. www.FormsWorkflow.com DWC101 - FOR REJECTED RISK EMPLOYERS Texas Department of Insurance Division of Workers' Compensation Workplace Safety, MS-26 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 512-804-4000 512-804-4001 fax PROGRAM REVIEW REPORT PART I: NOTIFICATION INFORMATION 1. Date Of Notification Letter: 4. NAICS Code: 2. TMIC Policy Number: 3. Federal ID Number (FEIN): PART II: EMPLOYER INFORMATION 1. Employer Name: 2. Employer Mailing Address: 3. City: Telephone No.: ( ) State: ZIP: Fax Number: ( ) TEXAS INFORMATION 5. Texas Business Name: 6. Physical Address for Texas Location: 7. City: Telephone No.: ( ) State: ZIP: Fax Number: ( ) 4. Employer Contact Name And Title: 8. Texas Contact, Name, Title, and E-mail Address: PART III: CONSULTANT'S INFORMATION 1. Name: 2. Telephone Number: ( ) 3. DWC Number: 4. Mailing Address: 5. City: State: ZIP: DWC101 Rev. 08/06 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com PROGRAM REVIEW REPORT PART IV: OPERATION SAFETY ANALYSIS 1. MANAGEMENT 1a-1. HAS MANAGEMENT ADOPTED AND PUBLISHED A SAFETY POLICY STATEMENT YES NO 1a-2. HAS MANAGEMENT SIGNED THE SAFETY POLICY STATEMENT YES NO 1a-3. DOES MANAGEMENT SUPPORT THE SAFETY POLICY YES NO 1a-4. HAS MANAGEMENT ESTABLISHED CLEAR GOALS FOR THE SAFETY PROGRAM(S) YES NO 1a-5. HAS MANAGEMENT INFORMED THE EMPLOYEES OF THESE GOALS YES NO 1a-6. HAS MANAGEMENT INVOLVED ALL LEVELS OF EMPLOYEES IN THE DEVELOPMENT OF THE SAFETY PROGRAMS YES NO 1a-7. HAS MANAGEMENT EFFECTIVELY COMMUNICATED THE SAFETY PROGRAMS TO THEIR SUPERVISORS AND EMPLOYEES YES NO 1a-8. DOES MANAGEMENT REQUIRE TRAINING OF THEIR SUPERVISORS AND EMPLOYEES IN THE USE OF THE ACCIDENT PREVENTION PLAN YES NO 1b-1. HAS MANAGEMENT ASSIGNED THE RESPONSIBILITY FOR IMPLEMENTATION OF THE ACCIDENT PREVENTION PLAN YES NO 1b-2. DOES MANAGEMENT ENFORCE ITS SAFETY RULES YES NO 1b-3. HAS MANAGEMENT MADE SAFETY THE RESPONSIBILITY OF ALL EMPLOYEES YES NO 1b-4. HAS SAFETY BECOME A DAILY PART OF ALL EMPLOYEES' JOBS AND ACTIONS YES NO 1b-5. DOES MANAGEMENT FOLLOW ALL OF ITS OWN SAFETY RULES YES NO 1b-6. LIST THE COMPONENTS AND RESPONSIBILITIES NOT ASSIGNED A.____________________________ B.____________________________ C.____________________________ D.____________________________ E.____________________________ F.____________________________ G.____________________________ 2-9. WHAT IS ANALYZED DOCUMENTATION A. ____________________________ B. ____________________________ C. ____________________________ OPERATIONS A. ___________________________ B. ___________________________ C. ___________________________ 2-10. WHAT ADDITIONAL ANALYSIS INPUTS ARE NEEDED NA A. ___________________________ B. ___________________________ C. ___________________________ 2. ANALYSIS 2-1. IS THERE A SAFETY ANALYSIS COMPONENT IN PLACE YES NO 2-2. IS DATA CENTRALLY COLLECTED YES NO 2-3