Worker Safety Plan Review Form 3 (cont’d) (to be completed following the review of the original Worker Safety Plan on reverse of this page) Committee Members Reviewing Safety Plan: P/VP or Supervisor: Worker: JOHS Worker Rep: Review Date: Original Corrective Actions (OCA) Review: (see reverse of this page for OCA's) OCA OCA OCA Review Notes regarding status of OCA # Person Ongoing Responsible ( or X) ( or X) 1. 2. 3. 4. Person Implementation Additional Corrective Actions Required Responsible Date 1. 2. 3. 4. (add additional steps as needed) Additional Notes Relevant to Review: Committee Member Sign-off: Plan does not need further revision P/VP or Supervisor: ___________________ Plan requires ongoing monitoring Worker: ___________________________ Plan was revised, further Review Date scheduled for: JOHS Worker Rep: ____________________ Plan no longer required, as of date: Provide copies to: - Associate Superintendent (via email) - P/VP or Supervisor (to be shared with JOHS Committee) - - -HR (cmerner@sd61.bc.ca) District Behavioral Consultant (dmarchant@sd61.bc.ca) Worker (redacted) File this completed form, in a binder, in a secure location in the administrator’s office.
Form 3 (cont’d) Worker Safety Plan Review (to be completed following the review of the original Worker Safety Plan on reverse of this page) Committee Members Reviewing Safety Plan: P/VP or Supervisor: Worker: JOHS Worker Rep: Review Date: Original Corrective Actions (OCA) Review: (see reverse of this page for OCA's) OCA # OCA ( or X) OCA Ongoing ( or X) Review Notes regarding status of OCA Person Responsible 1. 2. 3. 4. Additional Corrective Actions Required Person Responsible Implementation Date 1. 2. 3. 4. (add additional steps as needed) Additional Notes Relevant to Review: Committee Member Sign-off: P/VP or Supervisor: ___________________ Worker: ___________________________ JOHS Worker Rep: ____________________ Plan does not need further revision Plan requires ongoing monitoring Plan was revised, further Review Date scheduled for: Plan no longer required, as of date: Provide copies to: - Associate Superintendent (via email) - P/VP or Supervisor (to be shared with JOHS Committee) -HR (cmerner@sd61.bc.ca) - District Behavioral Consultant (dmarchant@sd61.bc.ca) - Worker (redacted) File this completed form, in a binder, in a secure location in the administrator’s office.
VPP-Form-3-Jan.-2018-Fillalbe.docx