IIPP/EAP Questionnaire

General Company Information
Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
Website
Main Phone
Office Hours - Main Office
Start Time*

Hours :

Minutes
End Time*

Hours :

Minutes
Business Days*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
IIPP Program Administrator
Name*
First Last
Email*
Direct Phone*
Mobile Phone
IIPP Coordinator
Name
First Last
Email
Direct Phone
Mobile Phone

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What is the company commitment statement and/or mission statement pertaining to safety polices, procedures, safety of the employees, subcontractors and clients?*
What is the safety culture the company is committed to instill?*
Does the company provide illness and injury training on the following? Please check all that apply.*
- IIPP Plan
- Safety Orientation
- Safe Code of Work Practices
- Emergency Action Plan
- Site Specific Safety Actions
- Job Specific Safety Actions
- New Job Assignment/Equipment Orientation
- New Substances, Processes, Procedures, or Hazard
- Serious Accidents
- NONE OF THE ABOVE
How often is the above training REVIEWED & Edited?*
How often is training refreshed or recertified?*
Describe types of health and safety training, purpose and frequency?
E.g. Evacuation | Disaster Preparedness | Annually
Training Type Purpose Frequency
Is the building/facility leased or owned?*
- Leased
- Owned
Is the building/facility free standing?*
- Yes
- No
Number of Floors Occupied*

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Who/What Position/Title at the company leads the Safety Orientation Meetings?*
Multiple rows may be added.
Position/Title First Name Last Name

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Occupational Health/Medical Clinic
Please name the Occupational Health/Medical Clinic employees are to report to if they have a non-life threatening accident or injury.
Clinic Name*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Phone
Emergency Room Hospital
Please list the nearest Emergency Room Hospital to each jobsite company is working on.
ER/Hospital Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*

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What is the procedure to call Emergency Responders for a Medical Emergency at the worksite?*
For each worksite, what is the direct dial telephone # to reach 911 when calling on a cell phone?*

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Does the company conduct drug testing as:*
- condition of employment?
- time of hire?
- random?
- following an incident?
- DRUG TESTING NOT PERFORMED UNDER ANY CIRCUMSTANCES
Is there a system for Employees to anonymously notify or inform the company of workplace hazards without identifying themselves:
- before an incident?
- immediately after an incident?
- following a near miss?
- NO SYSTEM AVAILABLE
IIPP Hard Copy
Where will a hard copy of the IIPP be kept?
Address*
Street Address Address Line 2 City State ZIP Code
Additional Details
IIPP Electronic Copy
This may be stored on a website, cloud storage, network storage location, etc.
Website
Details
Additional
If capable of providing an eBook version of information, please describe:
If capable of providing electronic, fillable versions of checklists, please describe:
For Safety Meeting, Training Rosters, Safety Checklists, Job Safety Analysis and other forms in hardcopy format, is there a method to a Scanner App to be on each Supervisors form to be emailed and filed in the Company Network folder? If so, please describe:

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Does the company have hazardous chemicals or substances on site?*
- Yes
- No
Please list hazardous chemicals or substances.
Do the chemicals have Safety Data Sheets (SDS) easily accessible to employees?
- Yes
- No
Please describe the location of the Safety Data Sheets.
What method can Employees retain the SDS on their Smart Phones. What Smart Phone Apps are you using?

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Fall Hazards
Are any employees working on ladders or exposed to fall hazards in excess of 7 1/2 feet?*
- Yes
- No
Please describe work conducted over 7 feet:
Please describe your Fall Protection Plan:
Please describe your Fall Protection Training:
What is the frequency of the Fall Protection Training?
Evacuation
What is the Evacuation Assembly Area at the main company location?*
Upload Image/Map of Assembly Area
Drop files here or

Max. file size: 512 MB.
Upload Floor Plans
Drop files here or

Max. file size: 512 MB.
Electrical
If conducting electrical work, please describe:
Voltage/Details
Forklift Usage
Do employees use forklifts at any company locations?*
- Yes
- No
List make(s) and model(s) of forklift(s) used.
Make Model
What types of training are provided or required?
- Annual
- Refresher
- Obstacle Course
Additional Details
Vehicle Usage
Do employees drive company vehicles or fleet vehicles?*
- Yes
- No
What is the frequency your company requests Random DMV Reports?
Additional Details

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Potential Injuries
Please select all that apply.
List any additional injuries not mentioned above.
Safety Supplies
Check all types of safety supplies/equipment that are available.*
- First Aid Kits
- AEDs
- Disaster Supplies
- Eyewash Stations
- Personal Protective Equipment
- Fire Extinguishers
- Other
Other Safety Equipment
List of locations where first aid kits may be found.
example: Copy Room, 2nd Floor | Monthly | ICE Safety Solutions
Location Inspection/Restocking Frequency Inspected/Restocked By
Please upload a list of the first aid kit items or an image of the inside of a cabinet with items clearly visible.
Accepted file types: jpg, gif, png, doc, docx, xls, xlsx, pdf, Max. file size: 512 MB.
If you do not have a list or image to upload, please enter the items so we can review how these match up with potential injuries.
Item/Product Description Quantity
Does the company have Automated External Defibrillators (AEDs) at any locations?*
- Yes
- No
List of locations where AEDs may be found.
example: Copy Room, 2nd Floor | Monthly | ICE Safety Solutions
Location Inspection Frequency Inspected/Maintained By
Are employees trained in the usage of AEDs?*
- Yes
- No
Please describe any training relevant to AED usage:
Does the company have fire extinguishers?*
- Yes
- No
List of locations where fire extinguishers may be found.
example: Copy Room, 2nd Floor | Monthly | ICE Safety Solutions
Location Inspection Frequency Inspected/Maintained By
Are employees trained in the usage of fire extinguishers?*
- Yes
- No
Please describe any training relevant to fire extinguisher usage:
Please select all types of disaster supplies available.
List locations of disaster supplies.
Example: Copy Room, 2nd Floor
Training
Please describe any additional required training that has not been mentioned thus far:

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Are any employees working in a confined space?*
Confined space means a space that: (1) Is large enough and so configured that an employee can bodily enter and perform assigned work; and (2) Has limited or restricted means for entry or exit (for example, tanks, vessels, silos, storage bins, hoppers, vaults, and pits are spaces that may have limited means of entry.); and (3) Is not designed for continuous employee occupancy.
- Yes
- No
If so, please describe.

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Ergonomics Specialist
Type*
Name
First Last
Email
Phone
Is training in Proper Lifting and Moving provided?
- Yes
- No

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How are employees recognized for safe workplace practices?*
Examples: Keeping a posted record of days worked without injury Informal recognition of safety practice; Formal recognition of individuals or groups for safety performance; Material recognition such as gifts, products, services and money, including raises and bonuses; Privileges such as time off, opportunity for promotion, new responsibility.
How are safety infractions reprimanded?*
Example: 1st | Warning | Written
Occurrence Action Type
What is the termination policy for safety infractions?*
Does your company hold regular safety meetings?*
- Yes
- No
How often are these meetings held?

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Please attach a copy of your most recent IIPP.
Accepted file types: pdf, doc, docx, Max. file size: 512 MB.
That's it! We'll get started on drafting your IIPP. In the meantime, do you need someone to contact you about any of these?
- CPR/First Aid/AED Training
- ERT/Floor Warden Training
- Bomb Threat, Fire Extinguisher, or Other Safety Training
- Online OSHA Training
- Safety Supplies
- First Aid Kit/AED Inspections and Maintenance
- AED Program Management

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Training Type	Purpose	Frequency

Position/Title	First Name	Last Name

Make	Model

Location	Inspection/Restocking Frequency	Inspected/Restocked By

Step 1 of 13

General Company Information

Office Hours - Main Office

IIPP Program Administrator

IIPP Coordinator

Occupational Health/Medical Clinic

Emergency Room Hospital

IIPP Hard Copy

IIPP Electronic Copy

Additional

Fall Hazards

Evacuation

Electrical

Forklift Usage

Vehicle Usage

Potential Injuries

Safety Supplies

Training

Ergonomics Specialist