2005 PERFORMANCE APPRAISAL

CONFIDENTIAL: The contents of this form will not be revealed to any unauthorized persons.

Name: _____________________

Position: _____________________

Department: _____________________

I. HEALTH & SAFETY

A. SELF-ASSESSMENT (To be completed by the supervisor)

1. How would you rate your effectiveness in ensuring health and safety over the past 12 months?

__________________________________________________

2. In which safety- and health-related aspects were you most effective and why?

__________________________________________________

3. In which safety- and health-related aspects were you least effective and why?

__________________________________________________

4. Do you feel you received all the necessary training, information, support and other resources to maximize your effectiveness in health and safety? Explain.

__________________________________________________

5. In which direction, if any, would you like your career with [ company ] to develop?

__________________________________________________

6. What do you think you can do to improve your performance in health and safety?

__________________________________________________

B. APPRAISER'S ASSESSMENT

Part 1

1. How do you rate the supervisor's general effectiveness in health and safety over the past 12 months?

__________________________________________________

2. How do you rate the supervisor's effectiveness in the following areas:

• Housekeeping ______________________
• Wearing/Using Safety Equipment ______________________
• Knowledge of Safe Work Procedures ______________________
• Conducting of Safety Meetings ______________________

3. Are there any areas requiring improvement and have you discussed them with supervisor?

__________________________________________________

Part 2

Over the Past 12 Months Did Supervisor:

1. Conduct safety meetings of 15 to 30 minutes for shop room floor workers at least once a week?

2. Address safety on the project at some point during group meetings?

3. Inspect [ specify grounds ] to check all items on the Maintenance Shop Checklist at least once a week?

4. Conduct at least two safety observation tours per month of high risk activities to verify that workers were performing the work in accordance with safe practices, company procedures and OSHA requirements?

5. Conduct at least five one-on-one contact sessions with workers per week to discuss safety issues?

6. Inspect at least once a week to verify that all controlled substances had proper labels and an up-to-date MSDS?

7. File a report in response to all incidents including accidents and near misses within 48 hours?

8. Write and distribute a weekly safety report for the department?

9. Submit a monthly list of safety suggestions or initiatives to make workers more active in safety-related matters?

10. Keep detailed records demonstrating supervisor's carrying out of the above responsibilities?

11. How many safety improvements did supervisor suggest or initiate in the past 12 months?

12. Did supervisor meet the following numerical targets:

• Accidents reported
  
• Near misses
  
• Injury days lost
  

Appraiser's Name: ___________________________

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