PROGRAM CONTACT PERSON LIST

Asbestos Management........................................................Mitch Walski

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

Program Contact Person: Mitch Walski _

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, Custodial Office

.

Training for Asbestos Awareness was conducted: 5-14-2008 .

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; Yes .

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

Name of publication Date

Fall news letter Aug, 2009

Three-year re-inspection Surveillance was conducted: 5-21-08 .

6-month Periodic Surveillance was conducted: May 27, 2010

(first date)

10-3-09
(second date)

All caution labels have been posted.

Label locations: Boiler room lagging

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

Wrap-n- Disposal Respirator Glove

cure bags bag

Is documentation of Operations and Maintenance available? No

Location:

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

Pending
Comments:

Note: During today’s visit I met with the lead food service person and Mike
Pokrzywinski to discuss the asbestos containing materials in the building.

Note: The overarching issue with asbestos at this school is the ceilings consist
of a spray on sound proofing containing asbestos fibers. The ceiling appears to
be in a stable condition and have not noted any delaminating or damage due
to water intrusion. The cost would be prohibitive to remove so recommend
just monitoring and repairing as needed. A significant amount of asbestos TSI
covers the hot water plumbing in the crawl space below the entire structure. I
did do repairs on the TSI during a visit 2008. During that same visit I
conducted O&M on the TSI located in the boiler room. The boiler room pipe
insulation consists of a combination of asbestos containing lagging and some
newer fiberglass lagging. I have repaired both but the heat of the boiler room
is so great that deterioration of the repairs can occur.

The floor covering primarily consists of 9”X9” ACBM. They are in remarkably
good condition. I noted that the north east entry to the gymnasium has had
the FT removed. The lagging in the catacomb has some nicks and scratches
that should be repaired. LC 5-27-2010
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Adam Hollingsworth

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? Not at this time.

How often are meetings held?

Are minutes of the meeting maintained?

Location:

Posted:

How is the program communicated to employees?

Who is the Contact Person for OSHA 300? Sharon Dufault

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

Have the Logs been maintained for five (5) years? N/A

Location: N/A

Is the Log posted from February 1 until April 30? N/A

The location/s of the posted log: N/A

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

Date Location Time

3rd Wednesday Library

Safety Committee Members

Member Position Building

Celia Eitkhos Board Member
Mike Swenson Board Member
Adam Hollingsworth Principal

The safety committee is a subcommittee of the Board of ed. They meet

concurrently with the regular board on a monthly basis.
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Sue Schrader

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.

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? Custodial staff will be called first to clean up spills. Only during
after hours or weekends are teaching staff required to clean.

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

exposure incidents? Yes, either by video tapes or by the hired consultant.

New Employees: _____

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): 1st and 2nd floor janitors closets

Status of Declination forms: This will be reviewed with Sue Schrader

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

Location of biohazard bags at school: biohazard cleanup kit on second floor

janitor closet

Approved disposal location for biohazard waste: local hospital

Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Mitch Walski

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: Activity 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: 5-21-2008

Employees Authorized to Enter Confined Spaces

Name of Employee Building or Buildings Training Date

Mitch Walski Elementary spaces 5-14-2008
 Confined Space Inventory

Cathedral School

Building: K-6

Building Contact: Adam Hollingsworth Program Contact: Mitch Walski

Completed By: Lee Carlson Date: 5-14-2008

Room Identification Opening Dimension Potential Permit/ Labeled Photo

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

South hall 24”X36” Crawl space Limited Non- N/A

Tunnels entry Permit
electricity required
South hall 24”X36” Crawl space Limited Non- N/A
Tunnel entry Permit
electricity required
West Lawn 30” round ? Fuel oil Permit No Click
here
Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Adam Hollingsworth

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

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: Adam Hollingsworth_____________________________

Location of records: Main 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

Note: The plan for this school does exist in a rough form. It had not been
formalized so still under development. I will send a copy of the plan used at
Tracy and adopt it to the school needs.

Fire drills and lockdown drills have been conducted. They are recorded and
kept at the main office. A tornado drill was also completed during the tornado
awareness week. LC 5-27-2010
Checklist of E/OHS Activities for Employee Right-to-Know/Hazard
Communication

Program Contact Person: Mitch Walski

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 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 Custodial Office

Food Service Yes No N/A Kitchen office

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

 Click here to view chemical inventory.
Click here to view chemical inventory.

Checklist of E/OHS Activities for Facilities Safety Management

and Fire Safety in Schools

Program Contact Person: Mitch Walski

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? Lee Carlson

Fire and Life Safety in Schools

Program Contact Person: Mitch Walski

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_2010________ N/A

Most recent inspection of fire extinguishers_2010___________ N/A

Most recent inspection of fume hoods with fire suppressant_2010_______ N/A

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

 Facilities Safety Review

Building: Cathedral Elementary

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art X

Dark Room X

Wood Shop X

Kitchen 5-27-2010 See report in Activities Manual CD

Metal Shop X

Halls, Gym, etc. 5-27-2010 See report in Activities Manual CD

Graphic Arts X

Maintenance/Custodia 5-27-2010 See report in Activities Manual CD

l

Transportation X

Grounds/Garage 5-27-2010 See report in Activities Manual CD

Chemistry/Life X
Science
Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): Sue Schrader

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

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 Crookston Medical 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 N/A

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Mitch Walski

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 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? 3-27-07

Who conducted the evaluation? Lee Carlson

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: _________________.

(date)

Results of technical services are located? __ ________

Click here to view IAQ report,

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Mitch Walski

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__________________________.

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

Program Contact Person: Mitch Walski

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 _10-17-90_________.

(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: Mitch Walski

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.

Note: Playground equipment is of newer vintage and is composed of unpainted

metal and plastic. Leaded paint is no longer an issue at this playground.
Date completed: N/A

Yet to be tested: N/A

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

Building constructed prior to 1978; paint determined to be in good

condition
Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Mitch Walski

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? _________________________

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

Date or dates of completion:

Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Mitch Walski

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:

Yes The equipment has adequate protective surfacing under and around it
and the surfacing materials have not deteriorated

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

Yes 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:

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

No There are no missing or damaged protective caps or plugs

No There are no hazardous protrusions and projections

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

hooks or protruding bolts

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

No 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:

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

it comes in contact with the ground
 No 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

Yes All equipment is securely anchored

Security of Hardware:

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

hooks

No Moving components, such as swing hangers or merry-go-round bearings,

are not worn

Drainage:

Yes 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:

Yes The entire playground is free from miscellaneous debris or litter such
as tree branches, soda cans, bottles, glass, etc.

Yes There are no missing or full trash receptacles

Note: The playground was surveyed on 10-13-2009. It was found to be in

excellent condition. Pea rock been had displaced below the swings so
recommendations were made to Mitch Walski to replace the cushioning
material.
Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Mitch Walski

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:__________________________

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
Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: _ Mitch Walski

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: 10-13-2009

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
Mitch Walski Voluntary AO ½ mask N/A N/A N/A

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: good condition

Location(s): The respirator is located in storage area in cardboard box

with asbestos maintenance supplies. Several new particulate filters were also
located with the respirator.

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

Verified by Lee Carlson