1 Stanford University Injury and Illness Prevention Program Revision - December 2008
2 Stanford University INJURY AND ILLNESS PREVENTION PROGRAM (IIPP) CONTENTS PAGE 1.0 INTRODUCTION RESPONSIBILITIES Program Administrator Managers Supervisors Employees Department of Environmental Health and Safety COMPLIANCE COMMUNICATION Training Health and Safety Publications Health and Safety Meetings University Safety Partners Research Compliance Panels Anonymous Hazard Reporting Anti-Reprisal Policy VIOLENCE IN THE WORKPLACE POLICY SCHEDULED AND PERIODIC INSPECTIONS Work Area Inspection Schedule for Supervisors EH&S and Internal Audit Outside Agencies Recordkeeping of Scheduled and Periodic Inspections INJURY/ ILLNESS REPORTING AND INVESTIGATION Reporting Procedures Serious Illness/Injuries or Fatalities Standardized Forms Investigation Procedures EH&S Review of Incidents HAZARD CORRECTION Schedules for Correcting Hazards Recordkeeping Resources TRAINING AND INSTRUCTION Training Content Tri-tier Training Program Schedule Resources from EH&S Recordkeeping 10
3 INJURY AND ILLNESS PREVENTION PROGRAM 1.0 INTRODUCTION Stanford University makes all reasonable efforts to: - protect the health and safety of Stanford University faculty, staff, and students; - provide safe workplaces - academic, research, and administrative - for faculty, staff and students; - provide information to faculty, staff, and students about health and safety hazards; - identify and correct health and safety hazards and encourage faculty, staff and students to report hazards; - provide information and safeguards for those on campus and in the surrounding community regarding environmental hazards arising from operations at Stanford University. 1 Per California Code of Regulations, Title 8, Section 3203 ( Stanford has adopted an Injury and Illness Prevention Program (IIPP) which describes specific requirements for program responsibility, compliance, communication, hazard assessment, accident/exposure investigations, hazard correction, training, and recordkeeping. Requirements outlined in this manual are mandated by regulation where the word shall is used and are advisory in nature where the word should is used. 2.0 RESPONSIBILITIES 2.1 Program Administrator The ultimate responsibility for Stanford s IIPP rests with the President of Stanford University, John Hennessy. The program administrator is: Name: Lawrence M.Gibbs, MPH, CIH Title: Associate Vice Provost - Environmental Health and Safety Address: Stanford University, ESF Oak Road, Stanford CA Telephone: (650) Responsibilities include: Advising senior management on safety and health issues. Working with senior management to develop safety and health guidelines and policies. Preparing and distributing the University's guidelines, policies and procedures on safety and health issues. 1 Health and Safety at Stanford University - Principles, Responsibilities, and Practices (Adopted by Stanford University Cabinet, April 1991). Note that other policies described in this program are found in Administrative Guide Memos , IIPP.Doc Revised December 2008 Page 1 of 10
4 Maintaining current information on local, state and federal safety and health regulations. Serving as liaison with governmental agencies. Planning, organizing and coordinating safety trainings. Developing a code of safe practices and inspection guidelines. Arranging for safety and health inspections and follow up to insure necessary corrective action is completed. Establishing, conducting and maintaining an injury/illness/accident report and investigation procedure. Coordinating with the University's Department of Risk Management on maintaining injury and illness records (OSHA log 300). Reviewing injury and illness trends. Establishing a system for maintaining the records of inspection, hazard abatement and training. 2.2 Managers Managers are responsible for ensuring that: Individuals under their management have the authority to implement appropriate health and safety policies, practices, and programs. Areas under their management have adequate funding for health and safety programs, practices, and equipment. Areas under their management are in compliance with Stanford University health and safety practices, policies, and programs. 2.3 Supervisors Supervisors are responsible for implementing Stanford University IIPP. This includes: Ensuring that workplaces and equipment are safe, well maintained, and in compliance with external agency regulations and Stanford policies, programs, and practices. Ensuring that workplace safety and health practices and procedures are clearly communicated and understood by employees through training programs. Enforcing health and safety rules fairly and uniformly relating to job performance. Evaluating employees on compliance with safe work practices. Acknowledging employees who make a significant contribution to maintenance of a safe workplace and disciplining employees who fail to follow safe work practices. Encouraging employees to report workplace hazards without fear of reprisals. Ensuring that periodic, scheduled workplace inspections are conducted and that identified health and safety deficiencies are corrected in a timely fashion. Ensuring that workplace incidents (injuries, exposures, or illnesses) are reported, investigated, and that corrective actions are taken promptly. See Sections 7.1 and 7.2 regarding procedures for reporting serious and non-serious incidents. Ensuring that inspections/investigations and employee health and safety records are kept for the designated period(s) of time. IIPP.Doc Revised December 2008 Page 2 of 10
5 2.4 Employees Employees are responsible for following the requirements of the IIPP. This involves: Keeping themselves informed of conditions affecting their health and safety. Participating in training programs as required. Adhering to healthy and safe practices in their workplace. Promptly reporting to their supervisors of potential hazards in the workplace and workplace incidents (injuries, exposures, or illnesses). 2.5 Department of Environmental Health and Safety (EH&S) EH&S is responsible for the development and administration of the IIPP. This involves: Providing training and technical assistance to managers and supervisors on implementation of the IIPP. Assisting supervisors in conducting workplace hazard assessments to identify, evaluate, and correct hazards. Reviewing, updating and evaluating the overall effectiveness of the IIPP. Evaluating the adequacy and consistency of training designed by schools, departments, etc. (i.e., Tier 2 Training - See Section 9.2). 3.0 COMPLIANCE Stanford University shall ensure that employees comply with safe and healthy work practices. Managers and supervisors are responsible for establishing and maintaining good health and safety practices. To ensure compliance: Employees are recognized for following safe and healthful work practices (e.g., oral acknowledgments at receptions, small gifts such as plaques, etc.). Employees are trained and retrained, as necessary or as required. Health and safety practices are integrated into new employee job descriptions and performance appraisals. Disciplinary actions with employees for failure to follow safe and healthful work practices are taken, when appropriate. An anti-reprisal policy for employees reporting safety and health concerns is enforced. 4.0 COMMUNICATION Stanford University shall communicate with employees in a form readily understandable by all affected employees on matters related to occupational safety and health, including provisions designed to encourage employees to inform their supervisors of hazards at the worksite without fear of reprisal. The various communication systems Stanford uses to relay information to all employees on matters relating to occupational safety and health, include: IIPP.Doc Revised December 2008 Page 3 of 10
6 The tri-tier training program, Health and safety publications, Health and safety meetings, University Safety Partners, Research compliance panels, Anonymous and confidential hazard reporting, And an anti-reprisal policy. These systems are described below: 4.1 Training A tri-tier training program is an integral component of the communication system. The training program is described in Section Health and Safety Publications Health and safety publications are available from Environmental Health and Safety. Call the Training and Communications Office at (650) to request copies. Health and Safety at Stanford - Introduction and Overview EH&S s website Research Policy Handbook, Chapter 6 Campus Report, EH&S health and safety news section 4.3 Health and Safety Meetings Health and Safety meetings at the school, department or unit level are conducted to reinforce important concepts including, but not limited to the following: Clearly communicate health and safety programs and procedures to the employees and students. Encourage employees and students to report workplace hazards to management without fear of reprisal as described in Section 4.7. Encourage employees and students to report workplace incidents (injuries, exposures, and illnesses). 4.4 University Safety Partners Represent the deans of each school and several administrative areas (e.g., Residential Dining Enterprises, Facilities Operations). Communicate with respective departments about health and safety matters or to ensure the implementation of applicable EH&S programs. Meet regularly to discuss campus-wide safety issues and to share safety concerns with EH&S. 4.5 Research Compliance Panels Assure the institution's compliance with federal regulations regarding research activities by reviewing those research activities which involve the use of human IIPP.Doc Revised December 2008 Page 4 of 10
7 subjects, laboratory animals, biohazardous agents, recombinant DNA or radiological hazards. 4.6 Anonymous Hazard Reporting To report a hazard or share a health and safety concern, employees may call (650) or submit a concern via EH&S s web address - Hazard reporting may be done anonymously or confidentially. 4.7 Anti-Reprisal Policy Employees and students shall not be discharged or discriminated against in any manner for bona fide reporting of health and safety hazards to Stanford or to appropriate governmental agencies. Supervisors shall inform employees and students of this policy and encourage reporting of workplace hazards to the management. 5.0 VIOLENCE IN THE WORKPLACE POLICY Stanford University has developed a policy which provides guidelines for responding to violence or threats of violence in the workplace - see Administrative Policy 23.9 entitled, Violence in the Workplace, which is available at - The general roles and responsibilities of employees, supervisors, Staff Affairs Officers, Employee Relations, Help Center, and Police/Security are dictated by the type of situation. There are specific procedures for responding to: Threats of violence. Acts of violence not involving injuries or weapons. Acts of violence involving injuries or weapons. 6.0 SCHEDULED AND PERIODIC INSPECTIONS Stanford University shall have procedures for identifying and evaluating work place hazards, including scheduled periodic inspections to identify unsafe conditions and work practices. Supervisors are responsible for seeing that periodic inspections are conducted. To assist supervisors, EH&S has developed self-inspection checklists ( that can be adapted for local use. IIPP.Doc Revised December 2008 Page 5 of 10
8 6.1 Work Area Inspection Schedule for Supervisors Work area inspections shall be conducted according to the following schedule: Upon initial establishment of IIPP. Recommended frequency: office areas: at least annually labs and shops: at least quarterly When new substances, processes, procedures or equipment which present potential new hazards are introduced. When new, previously unrecognized hazards are identified. When occupational injuries or illnesses occur. 6.2 EH&S and Internal Audit To assist supervisors in identifying and correcting potential hazards, EH&S conducts surveys (e.g., baseline occupational health and safety surveys of operating units, inspections of hazardous materials storage/disposal, fire safety). Stanford s Internal Audit Department includes a review of the unit s compliance with health and safety issues related to the implementation of this IIPP. 6.3 Outside Agencies Several outside agencies conduct regular, periodic inspections at Stanford, which assist the University in achieving some of its inspectional responsibilities. These include: County of Santa Clara Fire Marshal s Office City of Palo Alto Fire Department County of Santa Clara Environmental Health Department 6.4 Recordkeeping of Scheduled and Periodic Inspections Records of scheduled and periodic inspections to identify unsafe conditions and work practices shall be maintained by the supervisor for a minimum of one year (unless otherwise specified). The records shall include: The person(s) conducting the inspection, Any description of the unsafe conditions and work practices, The actions taken to correct the identified unsafe conditions and work practices. 7.0 INJURY AND ILLNESS REPORTING AND INVESTIGATION Stanford University shall investigate workplace incidents (injuries exposures, or illnesses). The following standardized procedures for reporting and investigating workplace injuries, illnesses, and incidents are reviewed below. IIPP.Doc Revised December 2008 Page 6 of 10
9 7.1 Reporting Procedures Employees are to report workplace incidents (injuries, exposures, or illnesses) to their supervisor as soon as possible Serious Injuries/Illnesses or Fatalities Supervisor immediately contacts EH&S at (650) to report work related death, serious injury, or illness. Cal/OSHA defines an injury or illness as serious if it: Requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation; or An employee suffers a loss of any member of the body; or An employee suffers any serious degree of permanent disfigurement. EH&S immediately reports any serious injury, illness, or fatality to Cal- OSHA. Other incidents may be reported on a case-by-case basis For more details, see document entitled, Serious Accident/Illness Reporting Procedures at mainrencon/occhealth/iipp/accidentflow.pdf Standardized forms for reporting and investigating workplace incidents (injuries, exposures, or illnesses) SU-17 Incident Investigation Report Form ( - Complete within 24 hours and fax to Risk Management at Investigation Procedures Note: To report incidents involving non-employees (students, visitors, and other third parties), complete the SU-17B Non-Employee Incident Report Form ( Within 24 hours of occurrence, supervisors must investigate any workplace incident (injury, exposure, or illness) involving their staff and follow-up with corrective measures via completion of an SU-17 form EH&S Review of Incidents: All serious accidents (described in Section 7.1) and overexposures 2 to chemical, biological, radiation, and physical stressors are investigated immediately by EH&S Occupational Health and Safety (OH&S) Program or other EH&S units as appropriate. For other incidents where additional follow-up is appropriate, EH&S - OH&S Program reviews submitted SU-17 information to help ensure adequate corrective actions have been identified and implemented. 8.0 HAZARD CORRECTION 2 As established by California Occupational Health and Safety Administration (Cal-OSHA) regulations. IIPP.Doc Revised December 2008 Page 7 of 10
10 Stanford University is committed to correct unsafe or unhealthy work conditions in a timely manner, based on the severity of the hazards. 8.1 Schedules for Correcting Hazards Hazards shall be corrected according the following procedures: When observed or discovered; When an imminent hazard exists which cannot be immediately abated without endangering employee(s) and/or property, all exposed personnel will be removed from the area, except those necessary to correct the existing condition. Employees necessary to correct the hazardous condition shall be provided with necessary safeguards. 8.2 Recordkeeping As corrective actions are implemented, supervisors shall document the effort and maintain such record for at least one year. 8.3 Resources Unsafe conditions that cannot be corrected with resources available to the supervisor or manager must be reported to the next higher level of management. Resources to correct hazards include the following: Facilities Operations - If the correction required is part of Facilities Operations maintenance responsibilities, Facilities Operations will address the repair without charge to the department. Departmental Funds - If the repair does not fall into the category of maintenance, departmental funds may be required. School/University Funds- If departmental funds are not available, departments must seek other resources from the school or University. 9.0 TRAINING AND INSTRUCTION 9.1 Training Content Stanford University policy requires that "faculty, staff and students shall be trained to protect themselves from hazards in their working environment. Supervisors shall train employees and students in: General health and safety practices; Job-specific health and safety practices and hazards; Recognition and assessment of health and safety risks; Minimization of risks through sound safety practices and use of protective equipment; Regulations and statutes applicable to their work; and, Stanford University health and safety policies." IIPP.Doc Revised December 2008 Page 8 of 10
11 9.2 Tri-Tier Training Program (Health and Safety at Stanford University Principles, Responsibilities, and Practices) Stanford has organized its training system into a tri-tier program, which is described below: 9.3 Training Schedule Tier 1: General Safety Training General University orientation provided by Human Resources to all new employees. Includes information on Stanford's health and safety policies and practices, employee health and safety rights and responsibilities, health and safety services at Stanford, what the employee should expect in terms of further training. Tier 2: Hazard-Specific Training Provided by the school, Department or building safety representatives in conjunction with EH&S to employees and students in labs, shops, or other workplaces where special hazards may be encountered. Training topics include ergonomics, hazard communication, departmental emergency response/evacuation procedures, forklift safety, EH&S reviews Tier 2 Trainings for adequacy and consistency. Tier 3: Job-Specific Training Provided by the supervisor for laboratory researchers and assistants, lab class students, shop and food service workers, or other employees and students as appropriate). Training consists of information specific to the hazards and equipment used by these individuals. Training is communicated by one or more of the following methods: safety meetings (formal or informal), material safety data sheets, videos, pamphlets, booklets, and postings. Training shall be provided to all employees/ students: When the IIPP is first established; When new employees are hired; When employees are given new job assignments for which training has not previously been received; Whenever new substances, processes, procedures or equipment are introduced to the workplace and represent a new hazard; Whenever the employer is made aware of a new or previously unrecognized hazard; When employees become supervisors (so that they can familiarize themselves with the safety and health hazards to which employees under their immediate direction and control may be exposed). 9.4 Training Resources From EH&S IIPP.Doc Revised December 2008 Page 9 of 10
12 EH&S assists schools and departments in providing health and safety training to employees on a variety of topics. These include IIPP training, laboratory safety training, respirator training, radiological safety, and many others. Training information can be accessed online through STARS ( EH&S has developed standardized forms for training recordkeeping. These are available from EH&S. EH&S has a safety video library, a collection of safety publications, and technical staff to assist supervisors and departments in implementing training programs. 9.5 Recordkeeping Documentation of health and safety training for each employee shall include: (1) employee name or other identifier, (2) training dates, (3) type(s) of training, and (4) training providers. This documentation shall be maintained for one year. Training records of employees who have worked less than one year for the employer need not be retained beyond the term of employment if they are provided to the employee upon termination of employment. The supervisor is responsible for maintaining these records. Stanford Training and Registration System (STARS) via the Stanford Axess portal is a computerized training database for registration and maintenance of training documentation. Call EH&S s Training and Communications Office at (650) if you have questions regarding this area. IIPP.Doc Revised December 2008 Page 10 of 10
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