PROGRAM CONTACT PERSON LIST

Asbestos Management....................................................Brittany Larson

AED.......................................................................................N/A
AWAIR.......................................................................Brittany Larson
Bleacher Safety........................................................... Brittany Larson
Bloodborne Pathogens................................................Paulette Huisman
Community Right-to-Know..............................................Brittany Larson
Compressed Gas Safety................................................................N/A
Confined Space Entry..................................................Gregorio Montejo
Emergency Action Planning.............................................Brittany Larson
Employee Right-to-Know/Hazard Communication..................Brittany Larson
Facilities Safety Management...........................................Brittany Larson
First Aid/CPR ...........................................................Paulette Huisman
Hazardous Waste Management.........................................Brittany Larson
Hearing Conservation...................................................................N/A
Indoor Air Quality.........................................................Brittany Larson
Integrated Pest Management...........................................Brittany Larson
Laboratory Standard/Chemical Hygiene Plan.......................................N/A
Lead Management........................................................Brittany Larson
Lockout/Tagout ...................................Brittany Larson/ Gregorio Montejo
Machine Guarding ......................................................................N/A
Personal Protective Equipment.........................Brittany Larson/Don Junker
Playground Safety..................................Brittany Larson/ Gregorio Montejo
Radon Gas Safety.........................................................Brittany Larson
Respiratory Protection.................................................................N/A
USTs/ASTs................................................................................N/A
Welding Cutting Brazing...............................................................N/A
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: _ Brittany Larson

Is the Asbestos Management Plan in place? Yes No N/A

Is the Plan current for all buildings? Yes No N/A

Has the Plan (or Plans) been reviewed this school year? Yes No N/A

The Plan is located at affected building Yes .

Training for Asbestos Awareness was conducted Aug 29, 2007 .

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; .

(date)
Notification appeared in the following publication(s):

Name of publication Date

Student/Parent Handbook Aug. 2008

Three-year re-inspection Surveillance was conducted: 7-19-2010.

6-month Periodic Surveillance was conducted: 10-1-09

(first date)

4-10-09
(second date)

All caution labels have been posted.

Label locations: Boiler room door

Note: New labels need to be installed

Are supplies of repair materials adequate to meet the requirements of

maintenance and repair of ACM? Yes No N/A
 Asbestos Maintenance Supplies on Hand

Is documentation of Operations and Maintenance available?

Location: Yes, it is located in the closet in Brittany Larson’s office.

Status of the Asbestos repair and maintenance Work Order System: N/A
Established,

Pending
Comments: Repairs are out sourced. The overall condition of the ACBM
remains good so few repairs are anticipated.

Damage was noted in the music room. I will locate protective wrap to apply to
the damaged TSI. LC 9-30-09
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Brittany Larson

Is the AWAIR Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is the Safety Committee organized? Yes No N/A

How often are meetings held? N/A

Are minutes of the meeting maintained?

Location:

Posted:

How is the program communicated to employees? N/A

Who is the Contact Person for OSHA 300? Paulette Huisman

Is the OSHA 300A Log completed for the previous calendar year? No

Have the Logs been maintained for five (5) years? No

Location:

Is the Log posted from February 1 until April 30?

The location/s of the posted log: Teachers lounge

Is information on injuries recorded on the Log with five (5) working days? Yes
No N/A
 Safety Committee – Meeting Schedule

Date Location Time

.
.

District Safety Committee Members

Member Position Building

Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Paulette Huisman

Is the Bloodborne Pathogens Written Plan in place? Yes No

Has the Plan been reviewed this school year? Yes No

List job categories that may be at risk to exposure: All staff are considered “at-
risk’ at this school.
Note: Because of the size of the school and limited access to custodial services
all staff are considered at risk of exposure.

What is this school’s policy regarding Hepatitis B vaccinations for employees

considered at risk versus employees considered not at risk in the Exposure
Control Plan? All Staff are offered HBV vaccinations at no cost to them.

Is training provided at this school on methods and techniques to reduce

exposure incidents? All staff is provided training during the fall staff
development days.

New Employees: Provided at time of employment

Have the employees identified as first aid responders been given at a minimum
Red Cross First Aid Training? Yes No N/A

Are Exposure Control Kits available to staff? Yes No N/A

Location(s): Custodial closets and the main school office

Status of Declination forms: These are still subject to updating and organizing

How is blood or bodily-fluid-containing materials handled at this facility?

Policy regarding cleanup: Custodial staff are first choice however staff are
required to clean up fluid spills if custodial support is unavailable.
 Location of biohazard bags at school: Main School Office

Approved disposal location for biohazard waste: Worthington

Medical Center

Note: Training for all-staff was conducted Aug. 27, 2009. A roster of
participants is located in the Activities Manual.
Staff Attending:

Ken Karwoski
Craig Schafer
Gregorio Montejo
Hector Cervera
Glenis Marsh
Debora Sandhurst
Jody Reum
Brittany Larson
Sr. Cheryl Marie Wagner
Barb Stirn
Karen Shaughnessy
Nancy Johnson
Maritza Gibbs
Brittany Larson
Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Don Junker

Is the Confined Space Entry Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Have confined space areas been identified? Yes No N/A

Have measurements to include CCI/ft been completed? Yes No N/A

Are permit entry forms in place? Yes No N/A

Location: Activities Manual

Are confined space labels in the proper locations? Yes No N/A

Is a list of employees eligible to enter confined spaces complete? Yes No N/A

Has training for affected employees completed? Yes No N/A

Date of completion:
 Confined Space Inventory

St. Mary’s Catholic School

Building Contact: Don Junker

Completed By: _Brian Parrie Date: 8-23-2010

Room Identification Opening Dimension Potential Permit/ Labeled Photo

Name Given Space Dimension Of Confined Hazards Non- ID #
Space Permit

1st floor Pipe Chase 6’hX 2’w 20’X3’X12’ None Non- yes
permit
2nd floor Pipe Chase 6’hX 2’w 20’X3’X12’ None Non yes
permit
Boiler room 18” diameter 18”X4’ deep Engulfment Non no
Sump hole permit

Note: No permit required confined space could be identified.

Checklist of E/OHS Activities for Community Right-to-Know

Program Contact Person: N/A

Is the Community Right-to-Know Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Are quantities of stored and used designated hazardous materials documented

and verified? Yes No N/A
Where are the documents stored?

Have the State Emergency Response Commission and local fire department
been notified of hazardous materials on school grounds? Yes No N/A

When were they notified?

(date)

Has training been provided? Yes No N/A

Date:

Presenter:

Note: no reportable quantities of hazardous chemicals could be located on

campus. Therefore the Teir II is not required to be filed with the ERC or local
fire department.
Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Brittany Larson

Is the Emergency Action Planning program in place and as outlined in the

Minnesota Executive Order 93-27 and Model Crisis Management Plan? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Are information maps posted to indicate travel routes in the event of fire,
tornado shelter locations, and procedures during lockdown? Yes No

Located where? Maps are located in each classroom.

Are all drills timed and recorded? Yes No

Responsible person: Brittany Larson_________________________________

Location of records: Principal’s Office_______________________________

Forms provided: Yes No

Does this school coordinate drills with local government authorities to assure
sheltering in school, evacuating to their homes or use of congregate care
centers? Yes No N/A

Has this school completed the Fire Marshall required Fire Safety and Emergency
Evacuation Plan? Yes No N/A

Training provided for affected staff? Yes No N/A

Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Brittany Larson/Paulette Huisman

Is the Employee Right-to-Know/Hazard Communication Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the chemical inventory been completed for the following functional areas?

Location of Chemical Inventory

Form

Art Instruction Yes No N/A

Custodians Yes No N/A Kitchen

Food Service Yes No N/A Activities Manual

Science Rooms Yes No N/A

Shop (metals, wood, auto) Yes No N/A

Are MSDS available and located with the chemical inventory? Yes No

Do the MSDS concur with the chemical inventory? Yes No

Has training been provided for the following staff?

Art Instructors Yes No N/A Science Yes No N/A

Custodians Yes No N/A Shop Yes No N/A

Food Service Yes No N/A Transportation Yes No N/A

Checklist of E/OHS Activities for Facilities Safety Management
and Fire Safety in Schools

Program Contact Person: Brittany Larson___________________________

Is the Facilities Safety Management program in place? Yes No

Does this school use contracted services for the Management Assistant
Program? Yes No N/A

If no, who is the designated person or persons?

Fire and Life Safety in Schools

Program Contact Person: Brittany Larson___________________________

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
building? Yes No

Most recent date of sprinkler electronics inspection_________ N/A

Most recent date of alarm inspection_________ N/A

Most recent inspection of fire extinguishers: summer, 2007 N/A

Most recent inspection of fume hoods with fire suppressant________ N/A

Are emergency lights tested at least biannually? Yes No N/A

Science safety Checklist completed? Yes No N/A

If no, who is the designated person or persons?

 Facilities Safety Review

Building:

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art

Dark Room

Wood Shop

Kitchen

Metal Shop

Halls, Gym, etc.

Graphic Arts

Maintenance/Custodia
l

Transportation

Grounds/Garage

Chemistry/Life
Science

Fire and Life Safety Checklist

ART
X Emergency phone numbers posted and MSDS available
X Flammable liquids and combustibles stored properly

COMPRESSED GAS
X Cylinders chained in place so they cannot fall over
X Valve covers in place when cylinder not in use
SPRAY BOOTH
X Fire control sprinkler heads kept clean
X Mechanical ventilation provided when spraying is done in enclosed area
X ‘NO SMOKING’ signs posted in spray areas, paint rooms, booths, and storage
X Spray area at least 20’ from flames, sparks, operating electrical motors

BOILER ROOM
X Fire extinguisher mounted and accessible
X No combustibles stored in boiler room
X Two exits

CORRIDORS, ENTRANCES, STAIRS

X All decorations, artwork in corridors limited to 25% of wall surface
X All EXIT corridors and hallways free of obstructions
X All EXIT doors open in the direction of exit without effort
X All EXIT doors posted as exits with letters 5” high and ½” wide
X All EXIT signs visible and with working lights, if lighted
X Appropriate fire extinguishers are mounted within 75’ of outside areas
containing flammable liquids and within 10’ of any inside storage area for
such materials
X Buildings over two levels have doors that close automatically in stair tower
X Fire extinguishers free from obstruction or blockage
X Fire extinguishers provided for the types of materials in the area where
used
Class A Ordinary combustible material fires
Class B Flammable liquid, gas, or grease fires
Class C Energized-electrical equipment fires

X Fire extinguishers serviced, maintained, and tagged every year

X No dead-end corridor >20’
X Non-exit doors, passages, and stairways labeled, “NOT AN EXIT”
X Panic hardware on all exit doors and rooms with occupancy of 50 or more
X Sprinkler heads protected by metal guards, when exposed to physical
damage

ELECTRICAL
X Extension cords used for permanent wiring
X 36” clear access to all electrical control panels for emergency shutdown

EXTERIOR
X Dumpsters stored at least 5’ from any combustible buildings, doors, and
windows

GYM
X Stage curtain must be flame retardant

HOME EC
X Outlets within 6’ of a water source must be GFC

KITCHEN
X Exhaust hood, ducts, and filters clear of any grease accumulation

X Fire extinguisher within 30’ of cooking equipment (min. 40BC)

X Hood with auto fire extinguishing system inspected every 6 months
X Means to shut off gas supply to the cooking equipment for emergency
X MSDS available
X Outlets within 6’ of a water source must be GFC

SCIENCE LABS
CHEMICALS
X Chemicals stored in open lab work area kept to a minimum
X Neutralizing chemicals and spill kits readily available

FIRE SAFETY
X Aisles serving work areas on 2 sides at least 42” wide; those serving work
areas on one side only must be 36”
X Flammable liquids stored in refrigerated equipment in closed containers
X Flammable/combustible liquids and chemicals must not be stored in fume
hoods or on the floor, except in original container
X Refrigerators, freezers, or coolers that store or cool flammable liquids must
be of explosion-proof construction and properly labeled
X 2A-20BC or larger rated fire extinguisher for each 3,000 feet of lab; travel
distance must not exceed 50’ from anywhere in room

STORAGE
X Acids stored in approved cabinets
X Chemical storage area must have inventory
X Chemical storage area properly ventilated
X Chemicals properly labeled
X Chemicals stored in approved containers (original shipping package)
X Flammable liquids stored in approved cabinets
X Shelves used for chemical storage should have lip or guard to prevent
chemicals from falling off
X Storage cabinets and rooms locked against unauthorized entry

VENTILATION
X Hood tested every year
X Lab hoods achieve 100 lfm
X Means provided for manually shutting down ventilation equipment

STORAGE ROOMS
X Room used for storage of combustibles must have 1-hour fire-rated walls
(sheet rock or plaster) and fire-rated doors (or solid core 1.75” thick wood
doors) with self-closer (or automatic fire sprinklers in them)

TECHNICAL LAB AREAS

X Compressed gas cylinders (oxygen, acetylene, propane, etc.) secured so
they cannot fall over
X Emergency stop buttons colored red
X Fire extinguishers located within 30’ of hazardous processes (painting,
welding, and woodworking)—mounted and inspected
X Flammable liquids stored in approved cabinets
X Oil-soaked, greasy, or paint-soaked rags stored in metal containers with lids
X Solvent wastes and flammable liquids are kept in fire-resistant, covered
containers until they are removed from the worksite
X Worksite clean and orderly with clear paths to exit

Completed by ___________________________Date
Facilities Safety Management Checklist

ART
X Dark room requires eyewash station
X Emergency phone numbers posted and MSDS available
X Flammable liquids and combustibles stored properly

ASBESTOS
X Caution labels and signs used to warn of asbestos

AUTO/METAL SHOP
BAND SAW
X Lower blade fully guarded
X Upper blade guarded with adjustable guard

COMPRESSED GAS
X Cylinders chained in place so they cannot fall over
X Valve covers in place when cylinder not in use

DRILL PRESS
X Drill press permanently mounted
X Guards in place over belts, pulleys, chains, and sprockets

GARAGE DOORS
X Annual inspection
X Automatic reverse mechanism installed and warning sign posted if not
installed

GRINDER
X Adjustable tongue adjusted within ¼” of wheel
X Work rest adjusted to ⅛” of wheel

HAND AND PORTABLE TOOLS

X Extension cords being used are grounded
X Multiple plug adaptors are prohibited
X Portable electrical tools are grounded or double insulated type
X Safety glasses provided if necessary
X Tools and cords in good condition; no broken handles

HOISTS
X Annual inspection
X Controls plainly marked to indicate the direction of travel or motion
X Hook equipped with safety clip
HOISTS (cont’d)
X Overhead electric hoist equipped with a limit device to stop the hook travel
at its highest and lowest point of safe travel
X Rated load of each hoist legibly marked and visible to the operator

METAL LATHE
X Guarding on chuck end

SPRAY BOOTH
X Approved respiratory equipment provided when appropriate
X Area within 3’ around spray booth is clear
X Fire control sprinkler heads kept clean
X Mechanical ventilation provided when spraying is done in enclosed area
X ‘NO SMOKING’ signs posted in spray areas, paint rooms, booths, and storage
X Spray area at least 20’ from flames, sparks, operating electrical motors

BOILER ROOM
X Caution label and signs used to warn of asbestos if needed
X Compressor and moving chains and belts guarded
X Eyewash station provided per pH
X Fire extinguisher mounted and accessible
X Lockout/tagout equipment provided when necessary
X No combustibles stored in boiler room
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals; goggles, face shields, safety glasses
provided when a danger of flying particles or corrosive materials
X Two exits

CONFINED SPACE
X Warning labels present

CORRIDORS, ENTRANCES, STAIRS

X All decorations, artwork in corridors limited to 20% of wall surface
X All EXIT corridors and hallways free of obstructions
X All EXIT doors open in the direction of exit without effort
X All EXIT doors posted as exits with letters 5” high and ½” wide
X All EXIT signs visible and with working lights, if lighted
X Appropriate fire extinguishers are mounted within 75’ of outside areas
containing flammable liquids and within 10’ of any inside storage area for
such materials
X Buildings over two levels have doors that close automatically in stair tower
X Fire extinguishers free from obstruction or blockage
X Fire extinguishers provided for the types of materials in the area where
used
Class A Ordinary combustible material fires
 Class B Flammable liquid, gas, or grease fires
Class C Energized-electrical equipment fires

X Fire extinguishers serviced, maintained, and tagged every year

X No dead-end corridor >20’
X Non-exit doors, passages, and stairways labeled, “NOT AN EXIT”
X Panic hardware on all exit doors and rooms with occupancy of 50 or more
X Sprinkler heads protected by metal guards, when exposed to physical
damage

ELECTRICAL
X Cover plates present on outlets and switches
X Disconnecting switches and circuit breakers labeled to indicate service area
X Exposed wiring and cords with frayed or deteriorated insulation are repaired
or replaced promptly
X Extension cords used for permanent wiring
X Flexible cords and cables are free of splices and taps
X Light fixtures below 7’ grounded and guarded
X 36” clear access to all electrical control panels for emergency shutdown
X Unused openings in electrical panels and fittings are closed with
appropriate covers, plugs, or plates

EMPLOYER POSTINGS
X OSHA workplace poster displayed in a prominent location
X Summary of OSHA 300/300A log posted in February

EXTERIOR
X Dumpsters stored at least 5’ from any combustible buildings, doors, and
windows

GYM
X Basketball hoops that raise and lower over a seating area have a 2nd safety
strap
X Bleachers must not have >9” gap between seat and footrest (may become
4”)
X Stage curtain must be flame retardant

HOME EC
X First Aid Kit and fire extinguisher available
X ‘Microwave in Use’ sign posted
X Outlets within 6’ of a water source must be GFC

KITCHEN
X Doors on cold storage rooms provided with an inside release mechanism
X Emergency phone numbers posted
X Exhaust hood, ducts, and filters clear of any grease accumulation
X Eyewash if exposed to injurious corrosive materials (oven cleaner)
X Fan should be 3-prong when used in wet area
X Fire blanket available
X Fire extinguisher within 30’ of cooking equipment (min. 40BC)
X First Aid Kit available
X Hood with auto fire extinguishing system inspected every 6 months
X Means to shut off gas supply to the cooking equipment for emergency
X ‘Microwave in Use’ sign posted
X MSDS available
X Outlets within 6’ of a water source must be GFC
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals

NOISE
X Approved hearing protection available to every employee working in the
area
X Employees in high noise area given periodic audiometric testing
X Noise levels at acceptable levels (<85 dBA) where continuous noise

SCIENCE LABS
CHEMICALS
X Chemicals stored in open lab work area kept to a minimum
X Neutralizing chemicals and spill kits readily available

ELECTRICAL
X Electrical outlets properly grounded
X 36” clear access to electrical panel

FIRE SAFETY
X Aisles serving work areas on 2 sides at least 42” wide; those serving work
areas on one side only must be 36”
X Fire blanket available
X Flammable liquids stored in refrigerated equipment in closed containers
X Flammable/combustible liquids and chemicals must not be stored in fume
hoods or on the floor, except in original container
X Heat sources not left unattended
X Refrigerators, freezers, or coolers that store or cool flammable liquids must
be of explosion-proof construction and properly labeled
X 2A-20BC or larger rated fire extinguisher for each 3,000 feet of lab; travel
distance must not exceed 50’ from anywhere in room

GENERAL
X Emergency phone numbers posted and MSDS available
X Eyewash station and quick drench shower where employees are exposed;
station required if pH <2 or >11, and shower required if pH <1 or >12
X Eyewash station flushed weekly and shower monthly for 3 minutes
X First Aid Kit accessible with necessary supplies

STORAGE
X Acids stored in approved cabinets
X Chemical storage area must have inventory
X Chemical storage area properly ventilated

STORAGE (cont’d)
X Chemicals properly labeled
X Chemicals stored in approved containers (original shipping package)
X Flammable liquids stored in approved cabinets
X Shelves used for chemical storage should have lip or guard to prevent
chemicals from falling off
X Storage cabinets and rooms locked against unauthorized entry

VENTILATION
X Hood tested every year
X Lab hoods achieve 100 lfm
X Means provided for manually shutting down ventilation equipment

STAIRS
X Handrails on all stairways with 4 or more risers; 1.5” clearance between
handrail and wall; handrail capable of withstanding a load of 200 pounds
X Mid-rail on open stairway
X Slip-resistant step surfaces

STORAGE ROOMS
X Room used for storage of combustibles must have 1-hour fire-rated walls
(sheet rock or plaster) and fire-rated doors (or solid core 1.75” thick wood
doors) with self-closer (or automatic fire sprinklers in them)

TECHNICAL LAB AREAS

X Compressed gas cylinders (oxygen, acetylene, propane, etc.) secured so
they cannot fall over
X Electric power can be locked out for maintenance, repair, or security
X Emergency phone numbers posted and MSDS sheets available
X Emergency stop buttons colored red
X Eyewash station and quick drench shower provided if necessary per pH
X Fire extinguishers located within 30’ of hazardous processes (painting,
welding, woodworking)—mounted and inspected
X First Aid Kit accessible with necessary supplies
X Flammable liquids stored in approved cabinets
X Oil-soaked, greasy, or paint-soaked rags stored in metal containers with lids
X Power shut off switch within reach of operator’s position
X Protective eyewear provided when a danger of flying particles or corrosives
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals
X Pulleys and belts within 7’ of the floor properly guarded
X Radial arm saws arranged so that cutting head will gently return to the back
of the table when released
X Saws used for ripping are equipped with anti-kickback devices
X Solvent wastes and flammable liquids are kept in fire-resistant, covered
containers until they are removed from the worksite
X Worksite clean and orderly with clear paths to exits

WOOD SHOP
JOINTER
X Anti-magnetic shut off switch
X Guarding on both sides of blades

RADIAL ARM SAW

X Anti-kick fingers
X Cutting head will gently return to the back of the table when released
X Equipped with anti-magnetic shut off
X Guards on left side should fall when saw is pulled forward
X Saw will not extend beyond table edge

STORAGE
X Quantities or flammable and combustible liquids in excess of 10 gallons
stored in approved storage cabinet or storage room; less than 10 gallons
stored in approved safety cans

TABLE SAW
X Anti-kickback mechanism
X Anti-magnetic shut off switch

Completed by ___________________________Date
Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): Paulette Huisman___________________________

Is the First Aid/CPR program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Has the District determined a provider in the event of a medical emergency?

Yes No

The local provider determined travel time was estimated to be within the 4-8
minute limit. Therefore Worthington Area Hospital
will be the designated emergency response provider.

The local provider determined travel time was estimated to be in excess of the
4-8 minute limit. Therefore N/A will be the
designated emergency response person located within the district.

Has training been provided for affected staff? Yes No

Checklist of E/OHS Activities for Hazardous Waste Management

Program Contact Person(s)

Primary Contact Person:_Don Junker__________________________

Secondary Contact Person: Brittany Larson___________________________

Is the Hazardous Waste Management program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Did this school generate ten gallons of waste per year? Yes No

Note: In Greater Minnesota, schools generating ten gallons of waste per year or
less they do not need a license.

Did this school generate 220 pounds or less per month hazardous waste (about
½ drum or less liquid)? Yes No

Note: Wastes that does not count includes antifreeze, cathode ray tubes,
fluorescent lamps, lead acid batteries, pcb ballasts, photo fixer reclaimed on
site, used oil and oil filters.

Training for VSQG’s do not have training requirements however MPCA strongly
recommends persons handling wastes be given training on best handling and
safety risks associated.

Has training been provided for affected persons? Yes No N/A

Date Conducted:
Date Scheduled:

Has annual report and license application sent in? Yes No N/A
Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Brittany Larson/Don

Junker___________________________

Is the Hearing Conservation Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the school been surveyed for noise hazards? Yes No

Have sound level measurements been collected? Yes No

Have the results been documented? Yes No

Location: Activities Manual

Has training been scheduled or completed for affected individuals this school
year? Yes No N/A

Date:

Presenter:

Have regulatory changes occurred that may affect this program? No

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Don Junker___________________________

Is the IAQ Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has an IAQ Committee been established? No

Has the annual cursory walk-through been conducted? Yes No

Have the districts key building systems been evaluated? Yes No

When was the evaluation completed? N/A

Who conducted the evaluation? N/A

Were occupied areas of the district evaluated using the EPA’s Tools For Schools
check list or equivalent?
• Teachers check list? An information fact sheet was provided all –staff.
# of forms distributed # of Forms returned:

• Building maintenance checklist?

• Building ventilation checklist?

Training conducted
(date)

Training has been scheduled for _______________.

(date)

Has the District determined the mechanical ventilation rate of each occupied
space? Yes No.

Supportive technical services were conducted on: __N/A_______________.

(date)

Results of technical services are located? __N/A ________

 IAQ Survey Review Form

St. Mary’s Catholic School Worthington

Building: Elementary School

Building Contact: Don Junker/Brittany Larson Program Contact: L Carlson

Room Identification Water Ventilation Building failures Cleanliness/ O&M

Contact individual Intrusion proble i.e. foundation Proper Carpets
ms or roof problems storage

Recommendations: No official complaints during school year. Issues exist for

ventilation. Unit vents provide some fresh air to the second and third floor
classrooms. The basement classrooms receive fresh air only by opening
windows. The building exhibits no sign of moisture intrusion or indications the
roof may be leaking that could lead to mold issues.

Walk-through conducted by: Lee Carlson Date: 2/14/2008

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Don Junker___________________________

Is the IPM Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the annual monitoring been conducted to determine location and degree of
infestation? Yes No

A map of the problem area/areas has been developed. Yes No

Has notice been given to parents regarding application activities? Yes No

Location or publication used to notify parents:_Student/ Parent Handbook_.

Checklist of E/OHS Activities for Lead-in-Water Management

Program Contact Person: _Don Junker__________________________

Is the Lead-in-Water Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

This school completed testing of water supply taps _10/2/1995_________.

(date)

Is a map of all potable water taps available for review? Yes No N/A

Checklist of E/OHS Activities for Lead-in-Paint Management

Program Contact Person: Don Junker___________________________

Is the Lead-in-Paint Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Testing for lead in paint on playground equipment: Note: All playground

equipment has been replaced with lead free.

Date completed: N/A

Yet to be tested: N/A

Results of evaluation for paint condition in rooms K-1:

Building constructed post-1978; facility not applicable
Building constructed prior to 1978; paint determined to be in
__good____________ condition
Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Don Junker_____________________________

Is the Lockout/Tagout Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is LO/TO equipment available? Yes No N/A

Is the equipment appropriate for application? Yes No N/A

If available, where is the equipment located? _________________________

Is the equipment maintained in an orderly and readily usable condition? Yes No

N/A

Have affected personnel been trained as to methods and technique of use? Yes
No N/A

Are written procedures available for affected staff? Yes No N/A

If available, the procedures are located where? Activities Manual

Has the annual audit of energy control procedures been completed? Yes No

Date or dates of completion: 1-29-03

Checklist of E/OHS Activities for Machine Guarding
Program Contact Person: ____N/A_____________________________

Note: No fixed machines where located during the survey of the facility. This
program is not required at this time.
Checklist of E/OHS Activities for Playground Safety

Program Contact Person: __ Gregorio Montejo _________________________

Is the Playground Safety program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Surfacing:

Needs Improvement The equipment has adequate protective

surfacing under and around it and the surfacing materials have not
deteriorated

X Loose-fill surfacing materials have no foreign objects or debris

X Loose-fill surfacing materials are not compacted and do not have

reduced depth in heavy use areas such as under swings or at slide exits

General Hazards:

X There are no sharp points, corners, or edges on the equipment

X There are no missing or damaged protective caps or plugs

X There are no hazardous protrusions and projections

X There are no potential clothing entanglement hazards, such as open S-

hooks or protruding bolts

X There are no pinch, crush, and shearing points or exposed moving parts

X There are no trip hazards, such as exposed footings on anchoring

devices and rocks, roots, or any other environmental obstacles in the
play area

Deterioration of the Equipment:

X The equipment has no rust, rot, cracks, or splinters, especially where

it comes in contact with the ground
 X There are no broken or missing components on the equipment (e.g.,
handrails, guardrails, protective barriers, steps, or rungs on ladders)
and there are no damaged fences, benches, or signs on the playground

X All equipment is securely anchored

Security of Hardware:

X There are no loose fastening devices or worn connections, such as S-

hooks

X Moving components, such as swing hangers or merry-go-round bearings,

are not worn

Drainage:

X The entire play area has satisfactory drainage, especially in heavy use
areas such as under swings and at slide exits

Leaded Paint:

N/A The leaded paint used on the playground equipment has not
deteriorated as noted by peeling, cracking, chipping, or chalking

N/A There are no areas of visible leaded paint chips or accumulation of lead
dust

General Upkeep of Playgrounds:

X The entire playground is free from miscellaneous debris or litter such

as tree branches, soda cans, bottles, glass, etc.

X There are no missing or full trash receptacles

Note: The cushion barriers are loose and are not effectively containing pea
rock. The pea rock is very thin and should be added to.LC 11-17-2009
Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: _Don Junker_______________________

Is the Personal Protective Equipment Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has a survey of potential workplace hazards been completed? Yes No N/A

Date(s) activity was conducted:__2-14-08________________________

Have recommendations been completed for appropriate equipment? Yes No

Has training been completed for the following departments?

Art and Photo Yes No N/A

Custodial Yes No N/A
Grounds keeping/Garage Yes No N/A
Kitchen Yes No N/A
Maintenance Yes No N/A
Science Laboratories Yes No N/A
Technical Education Yes No N/A
Transportation Yes No N/A
 Personal Protective Equipment Assessment

Location: Location: Location: Location:

Maintenance Custodial/Maintenance Kitchen Office
Building
Employee: Employee: Employee: Employee:
Don Junker Don Junker Pat, Marcia Paulette H.,
Brittany Larson
Nitrile
Latex X
Hand Vinyl X X X
Leather X X
Neoprene X
Impact X X
Face Splash X
Shield
Muffs X X
Ear
Plugs X X
Neo Apron X X
Body
Denim
Steel Toes
Foot
Metatarsal
Head Hard Hat

Sound, heat, Heat, chemical,

Heat,
Hazard(s) impact, impact, vapor, Body fluids
chemical
chemical body fluids

Comments on Some item

Missing
Availability, missing. Could
eyewash in the
Condition, & use an eyewash Good
food service
Storage in the boiler
area
room

Completed by Lee Carlson Date Oct. 23, 2008

Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: _________________________

Does this school provide respirators for voluntary use? Yes No N/A
If the school allows employees to use respirators voluntarily the following is
mandatory.
1. Read and follow instructions provided by manufacturer.
2. Choose respirators certified for use against contaminants of concern.
3. Do not wear respirators in atmospheres containing contaminants not
designed to protect from those contaminants.
4. Keep track of respirators so that you do not mistakenly wear someone
else’s respirator.

Is the Respiratory Protection program in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Date of review: _______________

Are all employees in this program identified? Yes No N/A

Employee Intended Type of Medical Exam/ Date of Date of

Use Respirator Questionnaire Medical Fit Test

Fit testing was completed on N/A.

(date)

Note: Respirators are not used at this facility. This program does not affect this
school.
Checklist of E/OHS Activities for Underground and Aboveground
Storage Tanks

Program Contact Person: ___________________________

Is the Underground and Aboveground Storage Tanks Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have forms for inventory tracking been provided? Yes No N/A

Do existing records accurately reflect purchase use correlation? Yes No N/A

Are all USTs registered with the Minnesota Pollution Control Agency? Yes No
N/A

Are removals or additions of tanks anticipated in this facility? Yes No N/A

Notes: This facility no longer has underground storage tanks. The boilers are
duel fired with natural gas as the primary fuel. The second form of fuel is #2
heating oil. (2) 165 gallon tanks serve the church and school. Because of the
limited size these barrels are not considered reportable to the Emergency
Response Commission