Initial Report Of Accident And Illness Prevention Program Status {LIBC-231G}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION Health & Safety Division Report Processing & Audit Section 1171 S. Cameron Street, Room 324 Harrisburg, PA 17104-2501 717-772-1636 COMMONWEALTH OF PENNSYLVANIA INITIAL REPORT OF ACCIDENT & ILLNESS PREVENTION PROGRAM STATUS BY NEW GROUP SELF-INSURANCE FUNDS This Report must be submitted to the Pennsylvania Bureau of Workers222 Compensation, Health & Safety Division. Please type or print all information. Before completing, please refer to the instructions at the end of this form. 1.Proposed fund name: 2. Mailing address: (Street, P.O. Box, City, State, ZIP) Address (line 1) Address (line 2) City003 State ZIP 002 002 a.Member Contribution (%)e. i. b. f. j. g. d. 1. i. 2. ii. 3.Assignment of responsibilities foriii. and disposal4. 5. 6. 7.003 002 002ix.Control of exposure to blood borne 002 002 x. xi.003 002 002 American LegalNet, Inc. www.FormsWorkFlow.com a.003 e.003 Sample formsb.003 f.003 Sample programs g.003 d.003 I.003 II.003 III. IV.003 V.003 I Section 4904 of the Crime Code, 18 Pa. C.S. Subsection 4904, (please print)**003 Title Signature003 Date 002 002 002 002 002 717.772.1636 (Please attach additional sheets where necessary, labeled with appropriate form, section number and letter) *231G*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Form LIBC-231G NOTE: The term Accident & Illness Prevention Program as described in the Pennsylvania Workers222 Compensation Act is synonymous with the terms Safety and Health Program and Loss Control Program222. ITEM 1: ITEM 2: ITEM 3: ITEM 4: ITEM 5: (1) (2) (3) Program (4) (5) (6) American LegalNet, Inc. www.FormsWorkFlow.com ITEM 5: (7)003 : (i)003 (ii)003 (iii)003 American LegalNet, Inc. www.FormsWorkFlow.com ITEM 5:003 (ix)003 (x)003 (xi)003 ITEM 6:003 ITEM 7:003 ITEM 8:003 number of recordable injuries x 200,000 367 hours worked OR Employer222s Report ofOccupational Injury or Disease number Pennsylvania Work Injuriesand Illnesses OR OR NOTE: (PLEASE USE ADDITIONAL SHEETS WHERE NECESSARY) American LegalNet, Inc. www.FormsWorkFlow.com 002 and have two years of acceptable safety experience. This experience must include current, full-time professional experience providing accident and illness prevention services which accounts for at least 60 percent of the individual222s activities. Acceptable activities include: identifying hazards; conducting safety and health surveys; proposing corrective actions; analyzing accident causes; and, recommending or providing industrial hygiene and industrial health surveys and consultations. 1.003 2.003 3.003 4.003 5.003 Professionals (BCSP).6.003 7.003 Safety Professionals (BCSP). 11. 12. 13. 14. 15. American LegalNet, Inc. www.FormsWorkFlow.com 16. 17. Safety Professionals (BCSP). (BCSP).INDUSTRY-SPECIFIC QUALIFICATIONS: 21. 22. 23. 24. 25. Professionals (BCSP).illness prevention services within the designated industry. In-Service Status: New requests for In-Service Status American LegalNet, Inc. www.FormsWorkFlow.com