UCLA Be Smart About Safety (BSAS) Cost-Sharing Program

Injury Prevention Committee (IPC) Application

Fiscal Year 2018-19

Instructions for Applicants

To Qualify:

Requests for IPC funds shall be between a minimum of $500 and maximum of $40,000 for safety projects that focus
on occupational safety. IPC Applications must be submitted by May 15th of the fiscal year referenced on the
application.

NOTE: Funds may get exhausted prior to this deadline. In those instances, applications are prioritized on a first come
first serve basis, and any pending proposals will be considered if additional funds become available.

Application Process:

1. Contact a Safety Liason to guide you through the application process. This could be your departmental
Safety Specialist, a member of the IPC, or any third party facilitator who is familiar with your project and
the IPC.

2. To initiate the IPC Application process, the following documents shall be submitted to
contact@ergonomics.ucla.edu:
a. IPC Application
b. Quote/Estimate or Purchase Order (PO) for the project
c. Supporting documentation, if applicable (e.g. Safety Assessment, cost-benefit analysis, etc.)

3. IPC Applications will be reviewed by the UCLA Injury Prevention Committee in the order in which they are
received.

4. An IPC Notification Letter will be issued to the department to confirm the approval, denial or deferment of
the application. If deferred, further instruction will be sent to the applicant regarding next steps.

5. Approved awards must be financially ledgered, expensed and transferred by June 15th of the fiscal year in
which the IPC Application is submitted. Late financial processing will result in a loss of the award.

Application
Department: Address:

Proposal Submitted By: E-mail: Tel:

Departmental Finance Contact (for NPEAR): E-mail: Tel:

Safety Liason: E-mail: Tel:

Total Cost of Proposed Project: Funding Requested (Max. 50% of Total Cost):

$ $
 Project Description

Provide the basic details of the project (vendor, brand/model, location/building, persons affected).
Remember to attach quotes or a purchase order.

Project Goals

Review attached Appendix A and describe the goals of your project using the S.M.A.R.T. format. Include all
identified hazards and provide information on the how the proposed project will address safety
concerns/issues (e.g. persons affected, historical injuries/incidents resulting from the unsafe condition,
safety benefits, etc.).

1. Specific

2. Measurable

3. Achievable

4. Relevant

5. Time-Bound

Submitter Signature Date

Departmental Manager Signature Date

Safety Liason Signature Date

 APPENDIX A – SMART GOAL DEVELOPMENT GUIDE

IPC Proposals must include specific goals designed to promote safety and reduce potential risk of injury. These
goals must be SMART: (S - specific, M - measurable, A - achievable R - realistic, and T - time-bound).

1. Specific - Consider who, what, when, where, why and how in developing the goal.
2. Measurable - Include a numeric or descriptive measurement.
3. Achievable - Consider the resources needed and set a realistic goal.
4. Relevant - Make sure the goal is consistent with the mission.
5. Time-bound - Set a realistic deadline.

Is It Specific?
Sample Goal: Decrease work related injuries in Facilities Management.
This goal lacks specificity. The author needs to detail how the decrease will occur and who will be affected.
SMART Goal: Decrease strain injuries to custodians who are hand mopping corridors by purchasing six automated
scrubbing systems.

Is It Measurable?
Sample Goal: Decrease strain injuries to custodians who are hand mopping corridors by purchasing six automated
scrubbing systems.
How would you know if a decrease was achieved? Include a metric to measure progress in meeting the goal.
SMART Goal: Decrease strain injuries to custodians who are hand mopping corridors by 10% by purchasing six
automated scrubbing systems.

Is It Achievable?
Sample Goal: Decrease custodial strain injuries to custodians assigned to hand mopping corridors by 10% by
purchasing six automated scrubbing systems.
The goal is specific and measurable and is pretty SMART if there has been an analysis of the actual injuries
associated with the task of mopping corridors, and if the cost of the automated equipment identified to reduce
mopping is significantly less than the cost of the injuries that have been incurred over a specified period of time,
typically 3-5 years. Other considerations include the time and cost of training employees to use the equipment,
maintenance of the equipment and space to store the equipment so that custodians have access to it.
SMART Goal: Decrease strain injuries to custodians who are hand mopping corridors by 10% by purchasing six
automated scrubbing systems.

Is It Relevant?
Sample Goal: Decrease custodial strain injuries associated with hand mopping corridors by 10% by purchasing six
automated scrubbing systems.
This sounds like a reasonable goal at face value. However, has an analysis of the injuries in the department been
completed to determine that this is a high frequency and high cost injury relative to other groups and injuries in the
department? Will a 10% reduction make a significant reduction in the cost of injuries? Has a return on investment
(ROI) been completed? ROI measures the gain or loss generated on an investment relative to the amount
of money invested over a period of time, generally the number of months required to pay back the cost of
implementing the goal.

Is It Time-Bound?
Sample Goal: Decrease custodial strain injuries involving hand mopping corridors by 10% by purchasing six
automated scrubbing systems.
There is no deadline for meeting this goal. Checking off that a deadline is included in a goal is fairly straightforward.
Making sure that it is realistic may be an entirely different matter. Consider all of your priorities and time constraints
and set a realistic deadline. If outside pressures are making the deadline unrealistic, then look at ways to change the
strategy for completion. For example, can you outsource some tasks associated with the goal?
SMART Goal: Decrease custodial strain injuries associated with hand mopping corridors by 10% within 12 months
of integrating six automated scrubbing systems into the cleaning protocol.