PROGRAM CONTACT PERSON LIST

AED..................................................................................Sue Wear
Asbestos Management........................................................Barry Gappa
AWAIR...........................................................................Barry Gappa
Bleacher Safety............................................................... Barry Gappa
Bloodborne Pathogens...........................................................Sue Wear
Community Right-to-Know..................................................Barry Gappa
Compressed Gas Safety........................................................Mark Stone
Confined Space Entry........................................................Barry Gappa
Emergency Action Planning................................................, Barry Gappa
Employee Right-to-Know/Hazard Communication......................Barry Gappa
Facilities Safety Management...............................................Barry Gappa
First Aid/CPR .....................................................................Sue Wear
Hazardous Waste Management.............................................Barry Gappa
Hearing Conservation........................................................Barry Gappa
Indoor Air Quality.............................................................Barry Gappa
Integrated Pest Management...............................................Barry Gappa
Laboratory Standard/Chemical Hygiene Plan.......................................Jeff
Ehmke
Lead Management............................................................Barry Gappa
Lockout/Tagout ..............................................................Barry Gappa
Machine Guarding .............................................Barry Gappa/Mark Stone
Personal Protective Equipment............................................Barry Gappa
Playground Safety............................................................Barry Gappa
Radon Gas Safety.............................................................Barry Gappa
Respiratory Protection......................................................Barry Gappa
USTs/ASTs.....................................................................Barry Gappa
Welding, Cutting, Brazing....................................................Mark Stone
Checklist of E/OHS Activities for Automatic External Defibrillator

Program Contact Person: Sue Wear

School policy for use adopted in place? Yes No N/A

Brand of AED? Phillips Heart Smart Model: Heart Start

Name of Medical Director? Dr. Beecher- St. Peter Clinic. Orders were last
signed 8-30-07

Year device was placed into use? 2006

Location(s) of devices:
Building Name Location in Building
Main School Building Commons are between doors

Have all software updates been installed? Yes No N/A

Date of update installation: 3-1-07

Expiration date of pads? Adult pads-7-09, child pads- 12-08

Expiration date of batteries? 09-2010

(date)

Has staff been trained on operation of the device? Yes, all school staff have
been trained.

• Most recent date of training:

(date
• Provider of training: South Central Technical College EMS

Location of operators manual: School nurse office and one at each building

Are battery checks documented? Yes, daily

Notes: The AED’s were purchased through Bound Tree Medical clinic at St.
Peter.
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Barry Gappa

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 __N/A_________________.

Training for Asbestos Awareness was conducted N/A .

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; N/A .

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

Name of publication Date

Fall News Letter. Fall 2008

Three-year re-inspection Surveillance was conducted: N/A .

6-month Periodic Surveillance was conducted: N/A

(first date)

(second date)

Comments: The Nicollet Public School is considered free of asbestos containing

building materials. A letter dated July 14, 2000 from Rodney E. Erickson,
FCSI/CCS declares to the best of his knowledge no building materials remain
or were used in the construction of the new school. (see letter in Activities
Manual)

Annual notification in the Fall News Letter informs parents and public that
the school buildings are free of asbestos building materials.
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Barry Gappa

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? 1 meeting per quarter

Are minutes of the meeting maintained?

Location: Main School office

Posted: No, minutes are sent to staff via school intranet.

How is the program communicated to employees? All-staff trainings and intra

net

Who is the Contact Person for OSHA 300? Cheryl Otto

Is the OSHA 300A Log completed for the previous calendar year? Yes

Have the Logs been maintained for five (5) years? Yes

Location: Cheryl Otto’s file

Is the Log posted from February 1 until April 30? Yes

The location/s of the posted log: Staff lounge and main office bulletin board

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

Date Location Time

Oct. 2007 High School 7:30-8:00 am

Jan 2007 High School 3:15-4:00 pm
Feb. 2008 High School 3:15- 4:00
April. 2008 High School 3:15- 4:00

District Safety Committee Members

Member Position Building

Barry Gappa Custodian K-12
Jeff Ehmke CHO K-12
Brad Koning Staff Instructor K-12
Sue Wear School nurse K-12
Joan Martens Staff instructor K-12
Cheryl Otto Business Manager K-12
Checklist of E/OHS Activities for Bleacher safety

Program Contact Person: Barry Gappa

Is the BSM 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 an annual survey of school bleachers been conducted? Yes No N/A

Is the five-year recertification required by December 31, 2007 complete and

submitted to the Minnesota Department of Labor and Industry? Yes No N/A
Note: Completed, Sept25, 2007
Follow link to Bleacher Letter
Openings and gaps:

Openings limited to four-inch gap between the railings and between the footboards
and seat boards, starting at a height of 56 inches or more.

Retractable bleachers:

They may contain openings of 9 inches or less

If exempt from standards must have a safety management plan in place and an
amortization schedule to plan for their future replacement

Approved netting:

Netting may be provided to prevent persons from falling through the bleachers
between the seat and footboards

Chain link fencing may be used but must be secured tightly to the underside of the
bleachers.

Railings:

Bleachers 55 inches and under are exempt from railing requirements

Bleachers with guardrails over 30 inches above grade must not contain openings
greater than four inches, unless safety nets are installed.
State building inspectors shall determine whether the safety nets and guardrail climb
ability meet the requirements of the alternate design section of the State Building
Code.

Periodic inspections:

Bleacher footboards and guardrails must at a minimum be re-inspected at least every

five years and a structural inspection at least every ten years. The equipment has no
rust, rot, cracks, or splinters, especially where it comes in contact with the ground
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
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Sue Wear

Is the Bloodborne Pathogens Written Plan in place? Yes No

Note: Plan is located in nurse’s office.
Has the Plan been reviewed this school year? Yes No

List job categories that may be at risk to exposure:

Nurse Playground supervisors
First aid providers Custodial/Maintenance
Special Ed. Staff Bus Drivers
P.E. Staff
Coaches

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? Vaccinations are offered to “at-risk” staff

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

exposure incidents? Yes. Training is provided at All-staff, meetings held each
fall.

New Employees: Training is provided by the School Nurse within ten days 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): All classrooms

Status of Declination forms: Acceptance /Declination forms are maintained by

the School Nurse, Sue Wear. These records are stored in securely in the District
Office Records Room.

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

Policy regarding cleanup: Custodians are required to respond to bodily fluid

spills
 Location of biohazard bags at school: Nurses office and the custodial
storage area

Approved disposal location for biohazardous waste:

Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Barry Gappa

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

Date of completion: September 30, 2008

 Confined Space Inventory

Building: Nicollet Public Schools

Building Contact: Barry Gappa Program Contact: Barry Gappa

Completed By: _Lee Carlson Date: 9-30-2008

Room Opening Dimension Potential Permit/ Labeled Photo

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

Gym, Upper 32”X24” 32”X36”X8’ Limited Entry Non Yes

Mechanical
A.H.U.
Gym, Upper 30”X30” 10’X3’X4’ Limited Entry Non Yes
Mechanical
A.H.U.
Fresh air intakes N/A

Man hole 30” round 30”X6’ deep L.E. Permit No

90 feet south of atmosphere required
elementary
playground
Checklist of E/OHS Activities for Community Right-to-Know

Program Contact Person: Barry Gappa

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? Barry’s Office

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? 1/25/2008 1/28/09

(date)

Has training been provided? Yes No N/A

Note:

Inventory Form

Client: Nicolette Public schools

Contact Person: Barry Gappa Date:2/15/2008

Hazardous Reported on Installation

Material Quantity Location Tier Two Date(s)
#2 Fuel Oil 4,000 gal North of Yes 1995-
loading dock 1997

Note: The user name and password for online response is:
User name: nicollet1
Password: nicollet

Submissions Listing for NICOLLET PUBLIC SCHOOL (ID: 7808)

 312 (Tier II)

Shown below is a listing of all Tier II Report submissions. Click on the reporting year to edit the Report for that year. The
link in the Reporting Year column will be enabled if you can edit the data for that year.

Reporting Submission Signed By Signed Date Submission Tier Submission Report Export to
Year Class Status II Type Status Tier II
Submit
2009
Not Started
[Edit]
Barry Gappa,
1/28/2009 3:01:16
2008 Annual Head of Completed Online Active
PM
Maintenance
Nicollet Public
School, 1/25/2008 2:02:28
2007 Annual Completed Online Active
Head of PM
Maintenance
Barry C. Gappa,
2/22/2007 3:13:56
2006 Annual Head of Completed Online Active
PM
Maintenance
Barry Gappa,
3/20/2006 11:54:03
2005 Annual Head of Completed Online Active
AM
Maintenance

Click here to request an edit for a Previous Reporting Year.

Checklist of E/OHS Activities for Compressed Gas Safety

Program Contact Person(s) Barry Gappa

 Primary Contact Barry Gappa

Department Contacts: Mark Stone

Art N/A

Custodial N/A

Metals Shop/Ag. FFA Mark Stone

Science N/A

Transportation N/A

Is the Compressed Gas Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the facility been surveyed for compressed gas inventories? Yes No

Has training been conducted for affected personnel? Yes No

Are records established/maintained for gas inventory? Yes No

COMPRESSED GAS FIELD REVIEW

Compressed Gas Inventory

Date: 05-15-2008
Program Contact Person: Barry Gappa

Department: Ag. FFA Department Responsible Person: Mark Stone

Location: Metals Shop

Cylinders:
 O2 _1___________  CO2 ____________
 Acetyl 1____________  Argon ____________
 NH4 ____________  Argon/CO2__3__________
 Helium __1__________

Compliance Check List

Yes
No
1. Are cylinders in well-ventilated area? X
2. Are cylinders stored separate from flammables by at least 20 feet? X
3. During storage are oxygen cylinders separated from fuel gas cylinders, X
unless on welding cart?
4. Are cylinders kept away from sources of heat (below 130 F)? X
5. Are safety chains used at all times on both full and empty X
cylinders? (2/3rds from top of cylinder)
6. Are empty cylinders maintained separate from full cylinders? X
7. Are cylinders kept away from sources of ignition such as electricity, X
excessive heat or oily rags?
8. Are carts designed specifically for gas cylinders available? X
9. Are damaged cylinders, valves/hoses removed from service? X
10. Are all cylinders properly labeled with the contents? X
Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Barry Gappa

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: Barry Gappa

Location of records: District Office bulletin board_____________________

Forms provided: Yes No State Fire Marshal forms are used to track
emergency response exercises.

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

Note: the Emergency Plan is located next to Pat’s desk. Pat reviewed and
updated 2007-2008 school year.
Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Barry Gappa

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 Art room, instructors desk

Custodians Yes No N/A Custodial office, on file cabinet

Food Service Yes No N/A Kitchen, desk

Science Rooms Yes No N/A Chemistry lab, electronically

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

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?

Note: All-staff training was conducted in September24, 2008.

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

Note : click link for chemical inventory information
Contact List for Employee Right-to-Know Program

Client: Nicollet Public School

Key Contact for Department

Department (person responsible for making MSDSs)
Michelle Koppien
Art

Dana Smith
Biology

N/A
Consumer Life Science

Barry Gappa
Custodial/Maintenance

Barb Rosin
Food Service

N/A
Photo

Jeff Ehmke
Science

Mark Stone
Shop—Welding

Shop—Wood Mark Stone

Transportation and Maintenance N/A

Other

Completed by: Lee Carlson Date: 9-30-2008

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

Program Contact Person: _ Barry Gappa

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: Barry Gappa

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
district 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_8/10/2008

Most recent inspection of fume hoods with fire suppressant_8/2008

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

Science safety Checklist completed? Yes No N/A

Note: Click link for Emergency Evacuation Plan

 Facilities Safety Review

Building: Nicolette Public School

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art X See written report

Dark Room X

Wood Shop 12-18-08 See written report

Kitchen 12-18-08 See written report

Metal Shop 12-18-08 See written report

Halls, Gym, etc. 12-18-08 See written report

Graphic Arts X

Maintenance/Custodial 12-18-08 See written report

Transportation X

Grounds/Garage 112-18-08 See written report

Chemistry/Life 12-18-08 See written report

Science

Note: Click this link to view Facility Safety Reports

Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): Sue Wear___________________________

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 Nicollet Fire Department
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: Barry Gappa

Secondary Contact Person:

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

Have the program and goals been approved by the School Board for the current
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 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 do not count include 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: N/A
Date Scheduled: N/A

Has annual report and license application sent in? Yes No N/A
 Evaluation of Hazardous Waste Generating Locations
(complete form for each facility)

Area N/A Type Quantity/Month Disposal Method

Chemistry/Biology Acetone N/A

Acids N/A
Bases N/A
Graphic Arts, Paints N/A
Scene Shops, etc. Thinners N/A

Computer Science Monitors Tri-county Solid Waste

Computer components Tri-county Solid Waste

Art Printing Fluids N/A

Grounds and Pesticides N/A

Maintenance

Custodial PCB Oil Ballast Onyx Special Services

Bulbs Retrofit Companies
Paint Stripper
Boiler Treatments N/A
Asbestos N/A

Automotive-related Crankcase Oil

Repairs Lead-balancing Weights
Used Batteries
Paint
Paint Thinners
Filters
Antifreeze N/A

Metal Shop Parts Washer

Wood Shop Degreaser N/A
Ag Shop Used Batteries N/A
Paint
Paint Thinners
Filters N/A
Paint Strippers N/A

Note: Recently Tri-county Solid Waste has been a source for recycling bulbs and
computer monitors. This annual event is held in Nicollet so has been easy for Barry to
recycle materials during the event.
Waste chemicals generated in the chemistry lab are now neutralized and disposed of
in the sanitary sewer as per instructions in the Flynn Manual.

Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Barry Gappa

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 program been approved by the School Board for the current 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: 3-13-09

Presenter: Lee Carlson

Have regulatory changes occurred that may affect this program? No

Client: Nicollet Public Schools

Measuring Device: Center 325 Sound Level Calibration: Pre___________

Meter Post___________
Reason for Testing: General Survey

Affected Personnel: Band Custodial, Maintenance, Shop

Location Equipment Results Recommendations

Boiler room boiler 81.7 dBA
Shop JD X485 77.dBA
Shop JD 1435 73.9 dBA
Shop Rockwell Drill 81.5 dBA
Press
Shop Surface Planner 91.87 dBA Provide Protection
Shop Makita Chop Saw 91.9 dBA Provide Protection
Shop Porter Cable 91.5 dBA Provide Protection
Router
Shop Wood Lath 80.0 dBA
Shop Drum Sander 87.0 dBA Provide Protection
Shop Powermatic Drill 91.5 dBA Provide Protection
Press
Shop Stationary belt 81.5 dBA
sander
Shop Delta band saw 88.0 dBA Provide Protection
Shop Ryobi Router 99.3-100.1 dBA Provide Protection
Shop Skill Saw 99.8 dBA Provide Protection
Kitchen Compressors 72-73 dBA
Kitchen Disposer 78-80 dBA
Band Room Drums and 78-93 dBA Provide Protection
Instruments

Completed by Lee Carlson Date 3-13 -2009

Note: No over limit exposures could be determined. However due to the

exceptionally loud readings it is recommended that hearing protection be
provided to affected staff. Motorized mowers and lawn mowers could not field
tested

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Barry Gappa

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? Yes, The Safety Committee responds
to concerns and IAQ issues.

Have the program and goals been approved by the School Board for the current
school year? Yes 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? 2/5/04

Who conducted the evaluation? AirTech Environmental, Inc.

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? N/A

• Building ventilation checklist? N/A

Training conducted Aug. 2006

(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: 2-5-04.

(date)

Results of technical services are located? Activities Manual

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Barry Gappa

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: Raider Report 2008.

Checklist of E/OHS Activities for Laboratory Standard/Chemical

Hygiene Plan

Program Contact Person: Jeff Ehmke, CHO

Is the Laboratory Standard/Chemical Hygiene 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

Fume hood was tested on: Feb, 2008.

(date)

The results indicate air velocity to be: satisfactory, unsatisfactory.

Chemical inventory:

Date of most recent survey: May, 2008

Location of inventory listing: Chemistry Lab

Are Material Safety Data Sheets (MSDSs) located with inventory? Yes No N/A

Are the MSDS readily accessible? Yes No N/A

Has the DCFL Science Lab Checklist been completed? Yes No N/A

Is training for affected personnel complete? Yes No N/A

Date(s) of instruction: May, 2007

Roster signed? Yes No N/A

Lesson plan outline available with roster? Yes No N/A

Status of Emergency Eye Wash/Deluge Shower:

Is flushing conducted weekly? Yes No N/A

Is descriptive signage properly posted? Yes No N/A

Is flushing activity documented? Yes No N/A

Fume Hood Evaluation

Inspector : Lee Carlson Date 2/15/2008

Chemical Hygiene Officer: Jeff Ehmke

Hood #1 Location: Room C-130

FIELD TEST (lf/min)

130 135 130

108 100 108

‫ ٱ‬Pass ‫ ٱ‬Fail (face velocity of 100 lf/min cannot be

achieved)

Sash Height:15.5” low power, 20.5” high power

Used as Storage? Yes No

Clean? Yes No

Comments

Completed by Lee Carlson Date 2/15/08

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

Program Contact Person: Barry Gappa

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 __________.
(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: Barry Gappa

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 replace 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
___N/A___________ condition

Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Barry Gappa

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? Custodial Office

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:

Note: Hands-on training was provided during custodial seminar. Lockout

equipment was located and applied to various pieces of equipment. Additional
lockout devices will be needed for some applications.
Checklist of E/OHS Activities for Machine Guarding

Program Contact Person: Barry Gappa

Is the Machine Guarding Plan for each affected work area in place? Yes No

Is the plan/plans current? Yes No

Has the Plan been reviewed this school year? Yes No

Has a survey of all district fixed equipment been conducted?

Yes `No

When was the evaluation completed? _5-14-2008______________________

Who conducted the evaluation? _Lee Carlson______________________

How are corrections documented? _Activities Manual____________________

Is all fixed equipment safeguarded to meet OSHA criteria? Yes No

Has the alternative MDE “best practices” criteria used to safeguard equipment?
Yes No

Has equipment determined not in compliance scheduled for repair or

replacement? Yes No

If replaced, was “best practices,” bid specification criteria used for

procurement? Yes No

Note: Some “best Practices have been used to update stationary equipment. All
of the equipment has been updated to meet OSHA standards. LC 1-30-2009
 Identified Fixed Equipment Locations

Location Building/Buildings Staff Affected # of item

Automotive Shop N/A
Wood Shop
Custodial/Maintenanc
e
Welding Shop
Ag Shop
Bus Garage
Art
Scene shop N/A
Science N/A

Contracted technical services to review and recommend? __________________.

Name of person or contractor conducting survey? ___________________.

(date)

Results of technical services located where? ________________________

Checklist for minimum requirements:

• Power outage protection provided for required equipment
• Emergency stops provided for required equipment
• Safe work practice placards at applicable fixed tool stations
• Proper guards provided and used
• Color coding as prescribed by OSHA standards
• Non-slip surfaces by each piece of equipment
• Fixed equipment secured to prevent “walking” or movement

Has a log of employee accidents and near misses been established and used?
Yes No
Annual training for affected staff is provided? Yes No

Training conducted ____________.

(date)
Training has been scheduled for ____________.
(date)
Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Barry Gappa

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:

X 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: Click link for playground photos

Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Barry Gappa

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: 12/17/07__________________________

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:

Custodial Office Kitchen Shop Laboratory

Employee: Employee: Joan Employee: Mark Employee:
Barry Martens Stone Jeff Ehmke, Dana
Gappa/staff Smith

Nitrile X X
Latex
Hand Vinyl X
Leather X X X
Neoprene X X
Respirator X X
Face Splash X X
Shield X X
Muffs X
Ear
Plugs X X X
Neo Apron X X X
Body
Denim X
Steel Toes
Foot
Metatarsal
Head Hard Hat
Body fluids, heat, noise,
electrical, heat, chemicals
Hazard(s) noise, chemicals

Comments on Good Good Good Good

Availability,
Condition, &
Storage

Completed by: Lee Carlson Date: 4/18/09

1

Checklist of E/OHS Activities for Radon Gas Safety

Program Contact Person: Barry Gappa

Is the Radon Gas Safety 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

Testing was last conducted: No records on file.

(date)

Results of tests:

Room Name & No. Level Tested Recommendation

Has training is not requirement of this program. However if elevated levels are
determine present training of affected persons is recommended.

Date training complete: N/A

Testing is / is not now in progress:

Note: The Nicollet School is built completely on or above grade. Testing is

technically not required at this time.
Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: Barry Gappa

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: April , 2009_______________

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
Voluntary AO1/2 mask N/A N/A N/A
Barry Gappa Misc.

Fit testing was completed on N/A.

(date)

Type of testing protocol; Irritant Smoke (Stannic Chloride) or

Bitrex (Denatonium Benzoate)

Condition and location of respirators:

Condition: The respirators were found to be functional sound but in an

unclean condition. Respirators should be cleaned prior to storage.
The respirators were disassembled and cleaned. Several valves were missing. I
will discuss with Barry in future visit. 2/15/2008
 Location(s): Grey file cabinet by work bench in Custodian Office.

Are the appropriate adequate accessories on hand? Yes No N/A

Verified by: Lee Carlson

Note: The respirators are available for staff use on a voluntary use only. The
employer does not require that staff enter hazardous environments at any
time. Currently Barry is the only staff person that may elect t to use a
respirator.
Checklist of E/OHS Activities for Underground and Aboveground
Storage Tanks

Program Contact Person: Barry Gappa

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

Note: Underground tanks are consistently monitored. Records are kept in the
boiler room

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:
Underground Storage Tank Status

Tank No. Location Size Contents Registered Install date

High 10’Northwes 4,000 #2 Fuel oil Yes 1995-1997
School t of loading gal/single
dock wall steel

Regulated Tanks: Motor fuel tanks larger than 110 gallons

Non-regulated Tanks: Heating oil tanks

Requirements for All USTs: Tank must be registered with MPCA

Requirements for Regulated Tanks: Annual tightness testing and inventory

control Tank must be updated, replaced, or removed by December 22, 1998
Upgrades:
--Overfill protection
--Corrosion protection STPI approved
 --Leak detection

Tightness Testing Results on File:

Dates of past testing: Testing is conducted daily.

Note: The underground tank is checked daily. The automatic system is located
in the boiler room. The monitor is called the TS 750 Tank Sentinel. Barry
writes down the information daily to assure that inventory is not lost.
L C 1-30-09
Checklist of E/OHS Activities for Welding and Brazing Safety

Program Contact Person(s) Barry Gappa

Department Contact:

• Metals Shop/Ag. FFA Mark Stone

• Art (jewelry) N/A

• Custodial N/A

Is the Welding and Brazing Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Method or methods used to control airborne particulate matter? External

negative air and internal filters

Has training been conducted for affected personnel? Yes No

Type of welding equipment available

• Electric arch…………………. Yes No N/A
• Wire feed/TIG MIG………. Yes No N/A
• Electric spot weld………… Yes No N/A

Personal Protective Equipment: availability and condition

• Gloves………… Yes No N/A

• Goggles………… Yes No N/A
• Welding mask………… Yes No N/A
• Apron………… Yes No N/A
• Steel toed shoes………… Yes No N/A

Describe location of welding activities, example; out-of-doors, booth, floor, all

of the above:
Welding can conducted indoors or out. The air filter is adequate to handle a
significant particle load.