|DIVISION OF OCCUPATIONAL SAFETY AND HEALTH
POLICY AND PROCEDURES MANUAL
FORMS COMPLETION for the CAL/OSHA 1A, 1AX, 1AY & 1AZ
Issue Date: 12/1/00
Enter the identification number of the safety engineer or industrial hygienist who conducted the inspection which would normally be the ID number as assigned by Federal OSHA.
2. Rpt No.
RPT represents the three (3) digit compliance personnel report number. Each compliance personnel numbers his or her reports sequentially starting with 001 for the first report of each fiscal year.
Enter the last two digits of the current Fiscal Year.
NOTE: A Fiscal Year begins on 1 July and ends on 30 June of the following year.
4. Insp. No.
Enter the preprinted nine-digit number from the Cal/OSHA 1.
5. Region -- Enter the number of the appropriate Region.
Dist -- Enter the number of the appropriate District.
6. Employer Legal Entity Name:
Enter the legal entity name, dba, and address of the employer inspected. Get copies of the business license, State Employer Tax ID Number, CSLB, Garment Registration, Farm Labor Contractor number, and other licenses as appropriate.
7. Management Officials Contacted
Enter the name and job title of each employer, or employer's representative, contacted and indicate whether they were present at the Opening Conference, the walkaround and the Closing Conferences.
NOTE: Denote management officials contacted by telephone by placing an * (asterisk) next to their names.
8. Union Representatives Contacted
Enter the name, job title, affiliated labor union name and telephone number of each labor union representative contacted, and indicate whether they were present at the Opening Conference, the Walkaround and the Closing Conference.
Indicate the dates of the Opening Conference, any subsequent visits to the worksite, and the date of the Closing Conference.
10. Small Employer Relief
Yes/No -- Indicate whether the employer inspected qualifies for IIP Program small employer relief. See P&P C-45A and 45B.
Ex-Mod -- If available, indicate the employer's experience modification rate from the most recently available year.
Documentation -- Indicate whether the employer has any documentation from its workers' compensation insurer to verify their experience modification rate. If no experience modification rate documentation is available, or the employer has no rating from its insurer, then the employer shall be considered to have an experience modification rate of 1.1 or greater.
Insurer -- Enter the name of the employer's workers' compensation insurer.
11. Opening Conference
Check the Items covered during the Opening Conference.
12. Exit Conference
Check the Items covered during the Exit Conference.
13. Closing Conference
Check the Items covered during the Closing Conference.
14. Recommend Follow-up Insp.
Indicate if a follow-up inspection of the employer's worksite is recommended, and the reason why.
15. IIP Program Review
Review the employer's IIP Program and indicate with a check in the boxes provided if the IIP Program elements are acceptable. If an IIP Program element is not acceptable, leave the box blank and specify the deficiency in Item 21 (Comments/Notes).
16. Hazard Communication Program
Review the employer's Hazard Communication Program and indicate with a check in the boxes provided if the Hazard Communication Program elements are acceptable. If a Hazard Communication Program element is not acceptable, leave the box blank and specify the deficiency in Item 21 (Comments/Notes).
17. Other Requirements
Review other requirements and indicate with a check in the boxes provided if the requirement is acceptable. If a requirement is not acceptable, leave the box blank and specify the deficiency in Item 21 (Comments/Notes). Write "NA" if the requirement does not apply.
18. Cross Jurisdictional Referral
Indicate whether the employer can demonstrate proof of workers' compensation insurance and whether the applicable Industrial Welfare Commission Posters are posted by checking the appropriate boxes.
19. Evaluation of Safety and Health Program
Indicate whether the listed items are effective, average or poor.
20. Adjustment Factors
Indicate the appropriate degree of Good Faith, Size and History.
21. Comments/Notes/Additional Information
Circle if company is a Corporation, Partnership, Sole Proprietorship, or LLC.
Enter the company address, phone, and fax number information where official mail is to be mailed to.
Enter Owner or Officer of Corporation, etc.
Enter location where all records are kept.
Enter information on the following, along with expiration dates:
Business License number, FEIN (Federal Employer ID number), State ER Tax ID number, CSLB license number, Garment Registration, Farm Labor Contractor ID#, and Other License number.
22. Employees/Persons Interviewed/Contacted During Inspection
Enter the interviewed/contacted person's name, title, telephone number or other contact information, e.g., name, address and telephone number of parent, friend, relative or other contact person.
23. Multi-Employer Worksite
For each employer involved at the multi-employer worksite, enter the employer's name, address and specific worksite activities. Obtain a copy of any written contracts governing each employer's work at the multi-employer worksite. Document if the particular employer is aware of the violation(s), whether the violation(s) were foreseeable to the particular employer and whether any steps were taken by the particular employer to protect their employees working at the multi-employer worksite. Check all the employer categories that apply to the particular employer, e.g., the particular employer is one who has exposed their employees to the violative(s) (Exposing); is an employer who created the violation(s) (Creating); is an employer who, by contract or practice controls the multi-employer worksite (Controlling); and/or is an employer who failed to correct the violation(s) (Correcting). See P&P C-1C.
24. Opening and Closing Conference Summary and Additional Comments
Summarize the Opening and Closing Conferences and enter any additional comments. Check whether the scope of the inspection which was conducted was comprehensive or partial. If a partial inspection was conducted, the locations to which the inspection was limited shall be documented.
25. Checked Prior History
None -- Check if the employer has no prior history of Title 8 citations.
Inspected-results -- Check if the employer has a prior history of Title 8 citations and indicate the specific violations previously cited. Use additional sheets if necessary.
26. Publications Provided
Check the appropriate boxes if the employer was provided with any of the following: Guide to Cal/OSHA, Cal/OSHA Poster or Other informational materials.
Cal/OSHA 1AX -- NOTICE OF NO VIOLATION AFTER INSPECTION
1. District Office -- Enter the local district office's mailing address.
2. Employer's Name and Address -- Enter the employer's name and mailing address.
3. Inspection Information -- Enter the name of the compliance personnel conducting the inspection, the location of the inspection and the date of the inspection.
4. Worksite Areas Inspected -- Describe in detail the area(s) of the employer's workplace which were inspected and the date the inspection was completed.
5. Compliance Personnel Signature -- Compliance personnel conducting the inspection sign the 1AX.
6. District Manager Signature -- After the inspection and prior to compliance personnel giving the 1AX to the employer, the District Manager signs the 1AX.
7. Date of Issuance -- Enter date of issuance of the Notice of No Violation After Inspection.
8. Date Inspection Was Completed -- Enter the date the inspection was completed.
Region -- Enter Regional identification number.
District -- Enter District identification number.
SE/IH ID No. -- Enter compliance personnel identification number.
Optional Rep. No. -- Enter compliance personnel optional report number, if directed by the District Manager.
Cal/OSHA 1 Report No. -- Enter the 9-digit IMIS number for the inspection.
Cal/OSHA 1AY -- DOCUMENT REQUEST SHEET (.doc, pdf)
When requesting documents from the employer which are not available during the time that compliance personnel are present at the worksite, compliance personnel shall request that the employer provide the appropriate documents and complete a Document Request Sheet (Cal/OSHA 1AY) (.doc, pdf) by checking the appropriate boxes corresponding to the documents requested.
Leave a copy of the Cal/OSHA 1AY (.doc, pdf)with the employer and retain a copy in the employer's inspection file.
Cal/OSHA 1AZ -- CHAIN OF CUSTODY
Complete all entries on the Cal/OSHA 1AZ with regard to Acquisition of Evidence, Storage and Release.