SRB Safety Program
SRB Safety Program
You are now working for a Company, which is sincere in its desire to conduct all of its operations in the safest
manner possible.
We make every effort to safeguard all operations by providing safe tools and proper guarding, not only for job
efficiency, but primarily for you and your fellow employees' protection.
More can be accomplished in preventing accidents if you apply and use these instructions a minimum guide to
working safely.
Your performance with this organization will be judged by your ability to work safely and efficiently. Working
Safely is part of your job, and every member of this company is a member of our Safety Program.
Violation of a Safety Instruction or Rule may be followed by disciplinary action, even though a resulting accident
does not cause serious injury. Ignorance of a minimum standard for safety will not be accepted as an excuse
for its violation.
Entry into or presence on company premises, facility or work place by any person is conditioned upon the
company's right to search the person, personal effects, vehicles, lockers, baggage and quarters of any
employee or other entrant for any substances named in the paragraph above. By entering into or being present
on company premises, facility or work place any person is deemed to have consented to such searches which
may include periodic and unannounced searches or any one while on, entering or leaving company premises,
facility or work place. These searches may include the use of electronic detection devices, scent trained dogs,
or the taking of blood, urine, or saliva samples for testing to determined the presence of substances named in
the above paragraph. The company also reserves the right, at all times, to have authorized personnel conduct
periodic examinations of its employees and employees of its subcontractors and suppliers for the purpose of
determining if any such person present on a company job site are using marijuana, illegal drugs or alcohol.
The taking of blood, urine, or saliva samples for testing may be also required from any person on company
premise or work place who is suspected of being under the influence of drugs or alcohol, or who is involved in
vehicle accident, or who is injured in the course of employment.
Any person who refuses to submit to a search, screening, or testing as described in the policy or who is found
using, possessing or distributing any of the substances named in the first paragraph in this policy, or who is
found under the influence of any such substances, is subject to disciplinary action including immediate
discharge of employee, or removal in future prohibition from the premises, if not our employee.
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Any person who is found leaving company premises or work place in possession of company property,
(including food, supplies, or tools) which is not authorized for removal from company premises or work place is
subject to disciplinary action including immediate discharge of employee, or removal in future prohibition from
the premises if not our employee.
Legally prescribed drugs may be permitted on company premises or work location provided the drugs are
contained in the original prescription container and are prescribed by an authorized medical practitioner for the
current use of the person in possession of. Any person in possession of a valid prescription drug when on/or
entering company premises or work place locations may be required to complete a (prescription drug) form and
the company may, as it deems appropriate, determine if the drug produces hazardous effects.
The company has a right, in its discretion, to report use, possession or distribution of any substance named in
the first paragraph of this policy or the removal of company property to law enforcement officials and to turn
over to the custody of law enforcement officials any such substances of company property.
4. Fire protection equipment should not be obstructed, and is to be used for fire fighting purposes only.
5. Only authorized personnel are permitted to make electrical repairs.
6. Good housekeeping should be maintained in all work areas.
7. The use of gasoline as a cleaning solvent is strictly forbidden. An approved cleaning solvent must be
used to clean tools, machinery, and similar equipment.
8. A OSHA Hazardous Communications Program has been set up for all employees to have access to
the MSDS sheets on all chemicals that our company will be using, as well as a designated person who
will keep those files updated, and who will secure MSDS forms from others that our employees will
come in contact with in the course of their work.
9. Electrical equipment, machinery, steam, air or water lines should never be turned on or set in motion
without first checking carefully to see that no one may be injured by the action, and ONLY by
employees authorized to do so.
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Material Handling
1. To lift safely:
a. Size up the load first. Get help if load is bulky, heavy, or of unwieldy length.
b. Be sure of your footing.
c. Lift with your legs, while keeping your back straight.
d. Keep your balance; don't twist under strain or jerk the load.
e. Keep the load close to your body.
2. When two or more men are carrying long material together, all men should carry the material on the
same shoulder and should lift and lower the material in unison.
3. Do not throw material, tools, or other objects from buildings or structures until proper precautions are
taken to protect others from the hazard of falling objects.
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Guylines, Loadlines, Slings
1. Guylines should be flagged where they cross any path or roadway. They should never be tied to a
railroad track.
2. Loadlines should be carefully inspected each time they are rigged and each time they are taken down.
Defective or damaged rope or cable should be cut immediately to prevent further use.
3. Cable slings shall be inspected regularly and destroyed if defective. Slings should be hung up when
not in use.
4. Slings should be protected on sharp corners of loads, and should not be jerked when moving a load
(jerking may triple the load on a sling).
General Scaffolding
Scaffolding accidents, in most cases, are caused by careless maintenance and improper use. Help keep your
scaffold safe for your safety by observing these simple requirements:
1. Scaffolds, platforms, or temporary floors shall be provided for employees engaged in work that cannot
be performed safely from the ground.
2. All equipment should be inspected prior to use. Never use damaged or deteriorated equipment.
3. The footing or anchorage for scaffolds should be sound, rigid and capable of carrying the maximum
intended load, without settling or displacement. Unstable objects such as barrels, boxes, loose brick,
or concrete blocks should not be used to support scaffolds or planks.
4. Any scaffold including accessories such as braces, brackets, trusses, screw legs, ladders, etc.,
damaged or weakened from any cause shall be immediately repaired or replaced.
5. All planking shall be scaffold grades or the equivalent.
6. Don't stockpile materials on scaffolds; remove all materials and tools at the end of the day.
7. Never overload scaffolds. Pile materials being worked over ledger and bearer points to minimize
platform loadings.
8. Don't work on scaffolds during storms or high winds, and clear platforms of all ice and snow before
using. Sand wet planking to prevent slipping.
9. Protect scaffolds; don't bump or strike against scaffolds with vehicles or materials; control hoisted
material from ground with taglines.
10. Keep platforms and area around scaffold cleared of debris, unneeded equipment, material, and other
possible tripping hazards.
11. The use of shore or lean-to scaffolds is prohibited.
12. Ladders or makeshift devices shall not be used to increase height of scaffolding.
13. Scaffolding working surfaces shall be essentially level, with poles, legs, and uprights plumb and
securely braced to prevent swaying and displacement.
14. Scaffolds and their components, except for wire or fiber rope suspension, shall be capable of
supporting at least four times the maximum intended load.
15. Wire or fiber rope used for scaffold suspension shall be capable of supporting at least six times the
maximum intended load.
16. Access to scaffolding can be by separate or integral ladders or stairways meeting the requirements of
the section covering ladders and stairways. Do not use the braces or scaffold end supports for access.
17. Employees working on suspended or movable scaffolding or scaffolding without standard guardrails
shall be protected by nets, lifelines, lanyards and belts.
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Scaffolding Planks
General:
1. The width of all scaffolds, ramps, runways and platforms shall be sufficient to prevent congestion of
persons, materials, or equipment, and in no case shall they be less than 18 inches wide.
2. Planking shall overlap each member a minimum of 12 inches.
3. Scaffold planks shall extend over their bearers not less than 6 inches nor more than 12 inches.
4. When installed flush, the butt joints shall be at the centerline of a pole and the plank ends shall be
supported by and secured to separate bearers.
5. When necessary to prevent dislodgement or excessive deflection, intermediate support shall be
provided.
6. When a scaffold materially changes direction diagonally installed bearers shall be used to support the
intended loading and to prevent tipping.
7. When moving platforms or planking to another adjacent level, the old planking shall be left in place
until the new bearers have been installed.
Requirements:
1. Planking used as a working surface on scaffolds, platforms, runways, or ramps shall not be less than 2
inches nominal in thickness and scaffold grade or equivalent lumber according to American Lumber
Standards grading rules for species of wood used.
2. Plank edges will be laid flush and planking will be secured in place to prevent displacement.
3. The maximum permissible spans for 2-by 12-inch or wider planking is as follows:
Standard Guardrails
General:
1. Guardrails and toeboards shall be installed on all open sides and ends of platforms more than 10 feet
above the ground or floor.
2. Guardrails shall be 2-by 4-inches, or the equivalent, approximately 42 inches high, with a midrail, when
required. Supports shall be at intervals not to exceed 8 feet. Toeboards shall be a minimum of 4
inches in height.
3. Regardless of the material used, other than wire, the guardrail shall be capable of withstanding a
minimum loading of 200 pounds supplied in any direction at any point on the top rail with a minimum of
deflection.
4. Railings required to withstand greater stress do to the nature of use shall be designed with a minimum
safety factor of four.
Wooden Guardrail:
1. Wooden posts and top rails shall be a minimum of 2-by 4-inch, construction grade or equivalent
lumber.
2. Post spacing shall not exceed 8 feet on centers.
3. Intermediate rails shall be a minimum of 1-by 6-inches.
4. Toeboards shall be a minimum height of 4 inches stalled flush with the planking or floor.
Pipe Guardrails:
1. Posts, toprails, and intermediate rails shall be a minimum 1.5-inch-nominal diameter steel pipe.
2. Posts shall be spaced not to exceed 8 feet on centers.
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Metal Guardrails:
1. Posts, toprails and intermediate rails shall be 2-by 3/8-inch angle iron, or equivalent.
2. Posts shall be spaced not to exceed 8 feet on centers.
Rope Guardrails:
1. Synthetic to natural fiber ropes shall not be used as guardrails.
2. Wire rope having equivalent strength of pipe guardrails may be used for top and intermediate rails
provided deflection is less than 12 inches under a 200-pound loading at center span.
Erection:
1. All scaffolds shall be erected in accordance with manufacturer's specifications and the load limits as
recommended by the manufacturer shall not be exceeded.
2. All metal scaffolds and towers shall be plumb and level.
3. The sections of metal scaffolds shall be securely connected.
4. All braces shall be securely fastened.
5. To prevent movement, the scaffold shall be secured to the building or structure at intervals not to
exceed 30 feet horizontally and 26 feet vertically.
6. A licensed professional engineer shall prepare drawings and specifications for metal frame scaffolds
exceeding 125 feet in height.
Working Surface:
1. Work platforms and planking shall be firmly secured at both ends to the bearers.
2. Planks shall extend over their end supports not less than 6 inches nor more than 12 inches.
3. Metal scaffolds and towers shall be enclosed on open side and ends with standard guardrails and
toeboards.
Member Dimensions
Uprights 2 x 4 inch
Guardrails 2 x 4 inch
Guardrail Height Approx. 42 inch
Intermediate Guardrails 1 x 6 inch
Toeboards 4 inch (minimum)
Planking 2 x 9 inch
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Suspension Scaffolds
Design:
1. All parts and components of suspension scaffold systems, except the suspension rope, shall be
designed and constructed with a minimum safety factor of four.
Suspension:
1. Suspension scaffolds shall be supported by wire, synthetic, or fiber ropes with a minimum safety factor
of six and secured to outrigger beams.
2. Suspension ropes shall have the fixed ends equipped with a proper size thimble secured by splicing or
other equivalent means and attached to the supports by closed-type shackles.
3. Running ends of the suspension ropes shall be securely attached to the hoisting drums, and at least
four turns of the rope shall remain on the drum at all times.
4. The suspension ropes shall be attached at the vertical centerline of the outrigger, and the attachment
shall be directly over the hoisting drum.
Outrigger Beams:
1. Outrigger beams shall be structural steel, equivalent in strength to at least a standard 7-inch, 15.3-
pound per foot steel I-beam, and shall be at least 15 feet long.
2. Unless designed by a professional engineer for a specific use, they shall not extend more than 6.5 feet
beyond the fulcrum or bearing point.
3. The outrigger beams shall be set with their webs in the vertical position and anchored to the structure
by the equivalent of U-bolts and anchor plates, washers, and nuts.
4. The beams shall rest on wood bearing blocks: a stop bolt shall be installed on each end of every
beam.
Hoisting Devices:
1. All suspension scaffolds shall be equipped with either manual or powered hoisting machines.
2. The machines shall be either worm geared or powered both up and down, and designed to stop
independently of manual braking and not move when the power is not being applied.
3. Power units and manually operated winches shall be of a type tested and listed by Underwriters
Laboratories, Inc., or Factory Mutual Engineering.
Scaffold Brackets:
1. Scaffold brackets shall be wrought iron or mild steel.
2. Reinforcing steel shall not be used as part of the support system.
Stability Control:
1. Suspension scaffolds shall be controlled by wire rope guides or equivalent means such as taglines to
prevent sway.
2. Tiebacks of 3/4-inch manila rope, or equivalent, shall be installed on suspension scaffolds for use as a
secondary means of anchorage.
Platforms:
1. Platforms of two-point suspension scaffolds shall be either ladder type, plank type, beam type, or metal
type, constructed in conformance with section 1926.451 of the 1990 OSHA safety standards for the
Construction Industry.
2. The platforms shall not be less than 20 inches not greater than 36 inches wide overall.
3. The platform shall be securely fastened to the hangers with U-bolts or other equivalent means.
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Fleet Equipment Safety
The safe operation and proper maintenance of the Company Fleet Vehicles and Equipment is vital to
preventing accident and assuring use of safe equipment. These guideline are established to protect everyone.
1. Only authorized personnel are allowed to drive company vehicles or operate company equipment.
2. All equipment should be checked for proper safety equipment and deficiencies resolved prior to use.
3. Time sheets with "noted" safety-related problems should be passed on to the Maintenance Department
immediately.
4. No one should be allowed to operate a vehicle or a piece of equipment who cannot perform safely
because of an illness, emotional distress, medication, etc.
5. All equipment is to be kept in a reasonably clean condition. This is to aid in noticing any deficiencies
with equipment.
6. Every foreman is to have accident reporting forms with him at all time.
7. No fleet vehicles are to be allowed to be operated on public highways unless vehicle and operator are
properly licensed.
8. Supervision is not to assume that a person is properly licensed or has been trained in the safe
operation of the Fleet/Equipment.
9. Equipment should at no time be used for horseplay.
10. Equipment is to be used only for the purpose for which it was designed and within its safe working
limits.
11. Safety devices are not to be by-passed, removed, or rendered inoperative.
12. Guards, covers, warning devices, and other safety equipment are not to be removed except for
maintenance or testing. Such devices are to be reinstalled before equipment is put back into service.
13. Anyone working on or around a piece of equipment is to be made aware of any problem with the
equipment until repairs are made or it is removed from service.
14. No person is to be allowed to ride on a piece of equipment unless it is specifically designed for such
purpose.
15. Equipment found to be unsafe is to be removed from service and tagged. The maintenance
department is to be notified of the unsafe condition at that time.
16. Tags are to be secured at the location where machine is started. Information on this tag will include
date, nature of problem, and name of the installer.
17. If machine is "tagged", no one is allowed to remove the tag except mechanic making repairs or the
person that installed the tag.
18. Do not move winch trucks unless loads suspended from the winch lines are secured to prevent
swinging.
19. No riders are allowed on the ball or hook of any crane or derrick, nor on equipment, rigging or loads
being moved by crane or derrick.
20. Cranes, derricks and winch trucks must not be operated nearer than 12 feet to a voltage line of 220
volts or higher (or applicable state code). Lines which could accidentally come into contact with
equipment must be de-energized or otherwise made safe before any work is done.
21. Use a tag line on loads that are liable to shift or sway while being hoisted or lowered.
22. Keep out from under loads, and keep clear of moving loads.
23. The driver must not remain in the cab of a truck when it is being loaded with heavy materials by a
shovel, crane or similar mechanical equipment.
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Procedures for a Jobsite Accident / Emergency
1. See that the injured are cared for. Contact the appropriate Emergency Medical Service System. The
list of emergency numbers is posted on the jobsite.
3. Have someone call the SRB Acoustics Office and contact Steve Burt
6. Obtain the identity of all people who might have information about the accident.
C. Have someone call the SRB Acoustics office and contact Steve Burt.
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D. Preserve the scene as it was after the accident
Cordon off or barricade the area to keep curious bystanders from destroying evidence.
F. Obtain the identity of all people who might have information about the accident
Record their names, crafts, and company worked for. If members of the public, obtain their
addresses and telephone numbers.
As a final summary, the results of the steps should be placed in a detailed accident report form and transmitted
to the company Safety Representative as soon as practical with all backup information attached.
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Environmental Incident Management
Non-Emergency Spill:
A non-emergency spill is a spill that does not create immediate danger to personnel and/or the environment,
the contractor has the ability to immediately control and clean up , and is less than 25 gallons.
This could include, but would not be limited to, any of the following:
*Gas or diesel fuels
*Latex paint products
*Plaster materials
*Motor oils
2. All work in the area of the spill will be suspended until the spill is contained.
3. Contaminated materials will be removed from the work area, and stored on plastic for later disposal.
4. All handling and disposal of contaminated material will be in strict compliance with present EPA
regulations.
SRB Acoustics
Equal Employment Opportunity
Affirmative Action Plan
Preface
This Affirmative Action Plan is prepared in accordance with the regulations and requirements contained in
Executive Order 11246 and Chapter 60 of Title 41, code of Federal Regulations. It is intended to be specific and
result-oriented and the company has committed itself to applying all good faith efforts to effectuating the provisions
of this plan, Equal Employment Opportunity, and has set specific goals and time tables for the correction of these
deficiencies.
Internal:
In order to insure that our policy is known and understood internally, the company will do the following:
1. A statement of the policy will be included in any personnel manual distributed to management and
supervisory personnel, particularly those engage in recruiting and hiring.
2. A statement of the policy will be issued in memorandum form to all employees and reaffirmed on an
annual basis.
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3. A statement of the policy will be included at least semiannually in the newsletter distributed to all
employees.
4. The company's Equal Employment Opportunity Officer will meet with executive, management and
supervisory personnel to explain, interpret, and clarify if needed the policy and individual responsibility for
effective implementation.
5. The policy will be explained in employee orientation and management training programs.
6. The policy will be explained to appropriate union officials and their continued cooperation will be
requested.
7. At all places of employment, the company will post in conspicuous locations easily accessible and visible
to employees and applicants for employment legible notices which include the company's affirmative
action policy.
8. The company will include non-discrimination clauses in all union agreements and will review all such
contractual agreements to insure they are non-discriminatory.
9. When employees are pictured in employee handbooks or similar publications, both minority and non-
minority men and women will be pictured.
10. The company will make available such elements of this program as will enable its employees to know of
and avail themselves of its benefits.
External:
In order to insure that our policy is known and understood in the community, the company will do the following:
1. We will inform our recruiting sources of our policy and stipulate that these sources actively recruit and
refer minorities and women for all available vacancies.
2. We will notify appropriate minority and women's organizations of the company's policy.
3. We will not use pictures in "Help Wanted" advertising.
4. We will send written notification of our policy to subcontractors, vendors, and suppliers.
5. We will include the Equal Opportunity clause in purchase orders, contracts, etc., covered by the executive
Order 11246, as amended, and as otherwise provided by law.
6. We will communicate to prospective employees the existence of our Affirmative Action Program and make
available such elements or that program as will enable such prospective employees to know of and avail
themselves or its benefits.
7. When employees are pictured in product, service, or consumer advertising, both minority and non-
minority, men and women will be pictured.
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Responsibility for Implementation:
Effective July 15, 2005, Steve Burt is designated as Equal Employment Opportunity Officer for this company. In
this capacity, he/she has the authority to implement and execute the policy as stated and as outlined in this plan.
The Equal Employment Opportunity Officer has the following responsibilities for implementing the company's policy
and Affirmative Action Program:
12. Reviewing progress relative to this program on a semiannual basis, and updating and revising this
program on an annual basis.
13. Communicate responsibilities of line personnel with respect to the company EEO policy and this program.
Line personnel responsibilities for implementation shall include, but not be limited to, the following:
1. Assistance in the identification of problem areas and establishment of goals and objectives.
2. Involvement with local minority organizations, women's organizations and community service programs.
3. Periodic audit of training programs, hiring, and promotion patterns to remove impediments to the
attainment of goals and objectives.
4. Regular discussion with managers and supervisors to be certain the company's policies are being
followed.
5. Review of the qualifications of all employees to insure that all employees are given full and equal
opportunities for transfers and promotions.
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6. Instructing supervisors that their work performance is being evaluated on the basis of their Equal
Employment Opportunity efforts and results, as well as other criteria.
7. Instructing supervisors of their responsibility to take action to prevent harassment of employees placed
through Affirmative Action effort and to maintain an atmosphere of constructive EEO/AAP employee
relations and development.
Sexual Harassment
It is the policy of the company that all of our employees should be able to enjoy a work atmosphere free from all
forms of illegal discrimination including sexual harassment.
Sexual Harassment infringes on an employee's right to a comfortable work environment and is a form of illegal
misconduct which undermines the integrity of the employment relationship. No employee, male or female should
be subjected to unsolicited and unwelcome sexual overtures or conduct, either verbal or physical.
Sexual harassment does not mean occasional compliments of a socially acceptable nature. Sexual harassment
refers to conduct which is offensive to the individual, which harms morale and which creates a hostile and unsafe
environment for the employee.
This includes repeated offensive sexual flirtations, advances, or propositions; continued or repeated verbal abuse
of a sexual nature; the display of sexually suggestive pictures or objects or any offensive or abusive physical
conduct. No employee should so much as imply that any individual's "sexual cooperation" will have an effect on
the individual's employment, assignment, compensation, advancement, career development, or any other condition
of employment.
An employee who feels sexually harassed is encouraged to use the company complaint procedure. The normal
complaint procedure may be bypassed and the complaint may be taken by the Company EEO Officer.
SRB Acoustics
It is the policy of SRB Acoustics, to afford equal employment opportunity to all qualified persons regardless of
race, color, religion, age, sex national origin or disability. We will provide that employment opportunity in full
compliance with the Civil Rights of 1964, the Age discrimination in Employment Act of 1967, the Equal Pay Act,
the Rehabilitation Act of 1973, the Vietnam Era Veterans Readjustment Assistance Act of 1974, the Americans
with Disabilities Act of 1992, and all other applicable laws and regulations, including all contract provision.
We will recruit, hire, and promote in accord with that policy. We will base decisions on employment so as to
further the principle of equal employment opportunity. We will insure that promotional decisions are in accord with
the principles of equal employment opportunity by imposing only valid requirements for promotional opportunity.
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We will insure that all other personnel actions such as compensation, benefits, transfers, layoffs, return from layoff,
company sponsored training, education, tuition assistance, social, and recreational programs will be administered
consistent with this policy of equal employment opportunity.
Further, we will take appropriate affirmative action to employ and advance in employment qualified minority group
members, women, disabled or handicapped individuals, disabled veterans, and veterans of the Vietnam era.
We will periodically, and at least semiannually, conduct analysis of all personnel actions to assure equal
opportunity.
It is the established policy of the company to offer available employment to qualified job applicants regardless of
race, color, religion, age, sex, national origin or disability. Managers and supervisors, at all levels throughout the
entire organization, are instructed to insure that employment, upgrading, promotion, raises, employment benefits,
training and selection for training, and all other actions concerning personnel shall be taken solely on the basis of
merit, fitness, and company's commitment to affirmative action.
1. The employee should report a complaint or discrimination to his/her immediate supervisor. The
supervisor shall review and document all pertinent facts relevant to the complaint and attempt to resolve
the problem at the project level.
2. If no resolution is reached, the employee should contract the company EEO Officer who shall attempt to
resolve the complaint by conferring with the employee and with the employee's superintendent.
3. If the complaint has not been resolved by the efforts of the EEO Officer, the employee shall request
through the EEO Officer a conference with the company President, to discuss the complaint and all facts
that relate thereto.
4. If the complaint has not been resolved between the employee and SRB Acoustics management, the
employee shall be referred by the Company EEO Officer to the EEOC or CCRC for further consideration.
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duty is to provide a progression of job duties that will return the injured worker to their regular job.
Steve Burt, office 303-935-5031, will be the designated coordinator, responsible for coordinating the return-
to-work program.
The attached return-to-work program should be followed when a worker sustains a work-related injury or
illness.
1. All injuries will be reported immediately to the worker's direct supervisor who will notify the designated
coordinator. Injuries will be filed via the Internet, phone or fax to Pinnacol Assurance within 24 hours.
2. The injured worker will seek medical attention from the designated medical provider (name of
designated provider)_Concentra.
In case of an emergency, the injured worker is to seek medical attention from the nearest medical
facility. Follow-up care must be coordinated through the designated medical provider. Pinnacol Assurance
may not pay for medical expenses incurred by the injured worker if he or she seeks unauthorized treatment
from a non-designated medical provider. When possible, follow-up medical appointments are to be made
before or after work hours. Time off for medical appointments will be treated consistently with other personnel
policies.
3. The injured worker should deliver a copy of the medical provider’s work status report to the
designated coordinator within 24 hours of the medical visit, if feasible.
4. The designated coordinator is responsible for maintaining regular contact with the injured worker and
the medical provider, and obtaining recovery status information and work restriction updates.
5. The designated coordinator will maintain a list of modified duty tasks. Once the employer is ready to
make a job offer to the injured worker, the coordinator sends the proposed tasks to the treating physician for
approval, in accordance with the formal job offer process.
6. During the modified duty period, the designated coordinator will provide to Pinnacol Assurance records
of wages paid to the injured worker. If the injured worker is receiving full wages during the modified duty
period, the designated coordinator will provide Pinnacol Assurance a statement to that effect; no ongoing
provision of pay records is then required.
7. Modified duty will be allowed as long as it is realistic for the job to continue, or until the injured
worker receives a release to full duty or reaches maximum medical improvement (MMI).
8. The designated coordinator will monitor and document the injured worker's performance while on
modified duty.
While on modified duty, the injured worker will be held to all existing personnel policies and will be
responsible for maintaining acceptable performance standards as a condition of continued employment.
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Modified duty assignments are designed to be temporary and transitional in nature. They will be reviewed
jointly by the supervisor, injured worker and relevant staff to address increasing work duties and overall
performance. This will be completed at least once a month.
______________________________________________ ____________________
Employer’s Signature Date
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Job Description & Functional Analysis
Training/Skills:
Heavy lifting, driving flatbeds or scrap trucks, operating forklifts, reading, and writing.
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Walking and Carrying for approximately 6 hours per day.
Sitting in truck and Driving for approximately 2 to 3 hours per day.
Climbing stairs while carrying materials weighing 40 to 60 pounds when the job
cannot be stocked any other way. Climbing in and out of truck back and cab.
Driving requirements:
Must conform to D.O.T. standards of physical and mental capabilities. This and
essential job requirement of all drivers of company vehicles.
I have read and understand the essential requirements of this job. I have no physical
problems or mental restrictions that would prevent me from safely and effectively
performing all the essential job functions and occupational activities.
_________________________________ ___________________
Employee Signature Date
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Job Description & Functional Analysis
Training/Skills:
Knowledge of simple math, ability to read a measuring tape, possess manual dexterity,
ability to use knife in cutting drywall, and the ability to use and understand various
tools used on jobsite.
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Lifting, Pushing, and Pulling 15 pounds on a regular and constant basis. 5 to 6
hours per day. (screw gun)
Lifting and Carrying 10 to 15 pound metal studs frequently. 3 to 4 hours per day.
Reaching above shoulder and at shoulder height with the weight of drywall, metal
studs, screw gun on a regular basis.
Full Use of fingers and both hands required for this manually dexterous position.
Along with mental and muscular coordination simultaneously.
Stooping and Bending to cut drywall and metal studs with knife and chop saw.
Standing and Walking for 8 hours except for lunch and 15 minute breaks.
Climbing scaffold as high as 3 to 4 stories, possibly higher, 4 to 8 timers per day
when jobs are above ground level.
I have read and understand the essential requirements of this job. I have no physical
problems or mental restrictions that would prevent me from safely and effectively
performing all the essential job functions and occupational activities.
_________________________________ ___________________
Employee Signature Date
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Job Description & Functional Analysis
Training/Skills:
Knowledge of simple math, ability to read a measuring tape and blueprints, knowledge
of how to lay out work, manual dexterity, ability to use tools for measuring and cutting,
ability to use and understand various tools on job site.
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Reaching above and at shoulder height with the weight of wood studs, metal studs,
various tools on a regular basis.
Full Use of fingers and both hands required for this manually dexterous position.
Manual dexterity along with simultaneous mental and muscular coordination is an
essential job requirement.
Standing and Walking for 8 hours except for lunch and 15 minute breaks.
Climbing scaffold as high as 3 to 4 stories, possibly higher, 4 to 8 timers per day
when jobs are above ground level.
I have read and understand the essential requirements of this job. I have no physical
problems or mental restrictions that would prevent me from safely and effectively
performing all the essential job functions and occupational activities.
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Employee Signature Date
23