PROGRAM CONTACT PERSON LIST

Asbestos Management....................................................Dave Vortherms

AED........................................................................Renee Bullerman
AWAIR.....................................................................Renee Bullerman
Bleacher Safety.......................................................... Dave Vortherms
Bloodborne Pathogen .....................................................Rita Damagala
Community Right-to-Know...................................................Roger Graff
Compressed Gas Safety...................................Dave Vortherms/John Olson
Confined Space Entry...................................................Dave Vortherms
Emergency Action Planning............................................ Dave Vortherms
Employee Right-to-Know/Hazard Communication..................Dave Vortherms
Facilities Safety Management...........................................Dave Vortherms
First Aid/CPR ...............................................................Rita Damagala
Hazardous Waste Management........................................Dave Vortherms
Hearing Conservation...................................................Dave Vortherms
Indoor Air Quality.........................................................Dave Vortherms
Integrated Pest Management..........................................Dave Vortherms
Laboratory Standard/Chemical Hygiene Plan................................. . .Robert
Williams,
Lead Management.......................................................Dave Vortherms
Lockout/Tagout .........................................................Dave Vortherms
Machine Guarding ........................................................Dave Vortherms
Personal Protective Equipment........................................Dave Vortherms
Playground Safety........................................................Dave Vortherms
Radon Gas Safety........................................................Dave Vortherms
Respiratory Protection..................................................Dave Vortherms
USTs/ASTs.................................................................Dave Vortherms
Welding Cutting Brazing.......................................................John Olson
Checklist of E/OHS Activities for Automatic External Defibrillator

Program Contact Person: Renee Bullerman

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

Brand of AED? Heart Start Model: 9300E

Name of Medical Director? The director is yet to be determined.

Year device was placed into use? 2006

Location(s) of devices:
Building Name Location in Building
(2)portable units Travel with athletic teams
(1)Exercise room Public exercise room (gym entrance)
(1)Hall by cafeteria Hall by cafeteria

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

Date of update installation: 4-18-2008

Expiration date of pads? 4-2010

Expiration date of batteries? 08-10

(date)

Has staff been trained on operation of the device? Yes, all school nurses and
Emergency responders are trained biannually. Staff will be trained fall of 2008

• Most recent date of training:2006

(date
• Provider of training:

Location of operators manual: Renee Bullerman’s office

Are battery checks documented? Yes, a check list is available at each AED
station

Notes: The health and safety committee determined that two additional units
are needed to better cover the requirements of the school. Renee will check
into purchasing additional units.
Items have been purchased and installed. 12-15-09 LC
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Dave Vortherms

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: High School and Elementary.

Training for Asbestos Awareness was conducted: September 22, 2007

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; .

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

Name of publication Date

Three-year re-inspection Surveillance was conducted: 6/1/07 .

6-month Periodic Surveillance was conducted: 11-25-08

(first date)

9-7-2009
(second date)

All caution labels have been posted.

Label locations: tunnel entries

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

Is documentation of Operations and Maintenance available? Yes

Location: District Office

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

Pending
Comments:

**For information regarding the medical review and questionnaire, see the
Respiratory Protection Program.**

Click here to view reports.

Checklist of E/OHS Activities for AWAIR

Program Contact Person: Renee Bullerman

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? 4 times per year

Are minutes of the meeting maintained?

Location: District office

Posted: On the Adrian School intranet

How is the program communicated to employees? All staff meetings and the
intranet

Who is the Contact Person for OSHA 300? Renee Bullerman

Is the OSHA 300A Log completed for the previous calendar year? No/last three
years

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

Location: District Office

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

The location/s of the posted log: Staff work rooms

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

Date Location Time

8/30/07 Elementary Commons 8:55 am

1/25/08 District Board room 7:30 am

District Safety Committee Members

Member Position Building

Dave Vortherms Lead Custodian High School
Garret Fritzemeier Instructor High School
Randy Strand Instructor Middle School
Renee Bullerman Dist. Secretary H S Office
Russ Loftus Elementary Principal Elementary Building
Tim Christianson H S Principal High School
Rob Williamson H S School Teacher High School
Kim Vander Lugt Elementary Teacher Elementary Building
Roger Graff Superintendent HS/Elementary
John Olson Instructor HS
Federal Labor Law required postings

Posting
Building Location FMLA EPPA FLSA EEO
High School x X X X
Elementary

Minnesota Labor Law required postings

Building Posting Unemployment Minnesota Age Workers' Minimum

location Insurance OSHA Discrimination Compensation Wage
High East X X X X X
School entry
Elementary

Survey conducted : Fall 2009 By : Lee Carlson

Checklist of E/OHS Activities for Bleacher safety

Program Contact Person: Dave Vortherms

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: The bleacher survey was conducted and required paper work submitted
to Dept of Public Safety on 10-24-2007
Openings and gaps:

X 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:

X They may contain openings of 9 inches or less

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

Approved netting:

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

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

Railings:

X Bleachers 55 inches and under are exempt from railing requirements

X Bleachers with guardrails over 30 inches above grade must not contain openings
greater than four inches, unless safety nets are installed.
X 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:
X Bleacher footboards and guardrails must at a minimum be reinspected 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

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
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Rita Damagala

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 of exposure. Training is provided to staff on line using the schools
intranet.A sign-in log is gathered by Renee and filed in the Activities manual.
Temporary or new staff are provided training information after employment by
the school nurse.

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? All staff is eligible for the Hepatitis B vaccination series. The
local clinic is the source and provider of the series of 3 injections.

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

exposure incidents? Training is provided all staff. Food service and custodial
staff are trained during separate seminars.

New Employees: 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):

Status of Declination forms: Staff is provided the opportunity for the hepatitis
B vaccine at the time of employment. Records are maintain in the employees
personnel file.

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

 Policy regarding cleanup: Custodial staff are considered the first to
respond. Only in limited circumstances such as athletic events would staff be
required to cleanup body fluids.

Location of biohazard bags at school: Custodial offices

Approved disposal location for biohazardous waste: Undetermined

Note: the school nurse is only on duty 16 hours per week. Training is left up
to the school’s consulting firm. The school nurse provides the declination
forms and a limited amount of bloodborne pathogen information to new staff.
Checklist of E/OHS Activities for Compressed Gas Safety

Program Contact Person(s): Dave Vortherms/John Olson

Primary Contact: John Olson

Metals Shop: John Olson

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: 1-19-2011 Program Contact Person: John Olson

Department: Industrial Arts Department Responsible Person: John Olson

Location: Metal Shop Area

Cylinders:  CO2 ____________

 O2 2__________  Argon ____________
 Acetylene 2 ____________  Argon/CO2__5__________
 NH3____________  Other ____________

Compliance Check List

Yes
No
1. Are cylinders in well-ventilated area? X
2. Are cylinders stored separate from flammable by at least 20 feet? X
3. During storage are oxygen cylinders separated from fuel gas
cylinders, unless on welding cart? X
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
cylinders? (2/3rds from top of cylinder) X
6. Are empty cylinders maintained separate from full cylinders? X
7. Are cylinders kept away from sources of ignition such as electricity,
excessive heat or oily rags? X
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 Confined Space Entry

Program Contact Person: Dave Vortherms

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: Winter, 2007

 Confined Space Inventory

Adrian Schools

Building: High School

Building Contact: Dave Vortherms Program Contact: Dave Vortherms

Completed By: Lee Carlson Date: 3-25-2008

Room Identification Opening Dimension Potential Permit/ Labeled Photo

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

Boiler Room 36”X36” 36”X36”X6’ LE, A Permit No

Boiler #1 required
Boiler Room 36”X36” 36”X36”X6’ LE, A Permit No
Boiler #2 required
Boiler Room 4’X4’ 4’X4’X>200’ LE, A Non- Yes
Tunnel Access Permit
Boiler Room 4’X5’ 4’X5’X>200’ LE, A Non- Yes
Tunnel Access Permit
South of HS 30” round 30”X6’ LE, A Permit No
Storm Sewer Access Required
South of HS 30” round 30”X6’ LE,A Permit No
Storm Sewer Access Required
AHR 18”round 24’X4’ LE, A Permit No
Tank access Required

Note: Photos of confined space entries. Click here

Checklist of E/OHS Activities for Community Right-to-Know

Program Contact Person: Roger Graff

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? Activities Manual in board Room

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? 2-3-2009

(date)

Has training been provided? Yes No N/A

Date:

Presenter:

Note: Adrian’s ERC ID is: 530050013. The password is BOJO32

Note: The Tier Two was submitted by Renee for Roger Graff on 2-22-08. This
was done electronically. The local fire department will be notified by using a
hard copy of the report submitted to the ERC. Copies of the last three years
reports are located in the Activities Manuals.

For future reference the web site address is:

www.epcra.state.mn.us/tier2manager/
User name: adrian511
Password: district511
 Inventory Form

Client: Adrian Public Schools

Contact Person: Roger Graff/Dave Vortherms Date:3/9/09

Hazardous Reported on Installation

Material Quantity Location Tier Two Date(s)
#2 Fuel oil 10,000 gal High School, Yes
south of
building
#2 Fuel oil 10,000 gal High School, Yes
south of
building

#2 Fuel oil 10,000 gal Elementary Yes

 Submissions Listing for ADRIAN PUBLIC SCHOOL (ID: 7876)

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]
ADRIAN PUBLIC
2/3/2009 2:51:57
2008 Annual SCHOOL, Completed Online Active
PM
Superintendent
ADRIAN PUBLIC
2/22/2008 10:02:15
2007 Annual SCHOOL, Completed Online Active
AM
Superintendent
ADRIAN PUBLIC
2/8/2007 11:46:31
2006 Annual SCHOOL, Completed Online Active
AM
Superintendent
Roger Graff, 2/27/2006 2:01:00
2005 Annual Completed Online Active
Superintendent PM

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

Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Dave Vortherms

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: Dave Vortherms responds at both buildings_________

Location of records: High School and Elementary Offices

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: Training was provided AUG 30, 2008 at an all-staff development

meeting. Additional awareness training will be provided throughout the school
year

Note: A meeting was held between Mr. Graff, Jeremy and Brian Parrie of
Advanced Security Products and Lee Carlson to discuss additional security
cameras for the exterior of the building. 3-9-2009

Checklist of E/OHS Activities for Employee Right-to-Know/Hazard

Communication
Program Contact Person: Dave Vortherms

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

Custodians Yes No N/A Custodial office

Food Service Yes No N/A Cooks desk

Science Rooms Yes No N/A Science lab

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

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

Program Contact Person: Dave Vortherms

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: Dave Vortherms

Is the Fire Marshal approved Emergency Evacuation Plan in place for each
district building? Yes No

Most recent date of sprinkler electronics inspection__7-23-07_______ N/A

Most recent date of alarm inspection_1-2-08________ N/A

Most recent inspection of fire extinguishers___1-08_________ N/A

Most recent inspection of fume hoods with fire suppressant__1-08______ N/A

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

Science safety Checklist completed? Yes No N/A

Note: Samples of curtains were tested for flammability. The curtains would
not sustain an open flame while exposed to fire. The curtains are believed to
be over 50 years old.

Facilities Safety Review

Building: High School and Elementary

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art 12-15-09 Report will be prepared after next during next
visit.
Dark Room X

Wood Shop 8-9-08 09 See Report dated 09-08-08 located in Activities

Manual
Kitchen 8-9-08 See Report dated 09-08-08 located in Activities
Manual
Metal Shop 8-9-08 See Report dated 09-08-08 located in Activities
Manual
Halls, Gym, etc. 8-9-08 See Report dated 09-08-08 located in Activities
Manual
Graphic Arts X

Maintenance/Custodia 8-9-08 See Report dated 09-08-08 located in Activities

l Manual

Transportation X

Grounds/Garage 8-9-08 See Report dated 09-08-08 located in Activities

Manual
Chemistry/Life 8-9-08 See Report dated 09-08-08 located in Activities
Science Manual

Fire and Life Safety Checklist

ART
X Emergency phone numbers posted and MSDS available
X Flammable liquids and combustibles stored properly

COMPRESSED GAS
X Cylinders chained in place so they cannot fall over
X Valve covers in place when cylinder not in use
SPRAY BOOTH
X Fire control sprinkler heads kept clean
X Mechanical ventilation provided when spraying is done in enclosed area
X ‘NO SMOKING’ signs posted in spray areas, paint rooms, booths, and storage
X Spray area at least 20’ from flames, sparks, operating electrical motors

BOILER ROOM
X Fire extinguisher mounted and accessible
X No combustibles stored in boiler room
X Two exits

CORRIDORS, ENTRANCES, STAIRS

X All decorations, artwork in corridors limited to 25% of wall surface
X All EXIT corridors and hallways free of obstructions
X All EXIT doors open in the direction of exit without effort
X All EXIT doors posted as exits with letters 5” high and ½” wide
X All EXIT signs visible and with working lights, if lighted
X Appropriate fire extinguishers are mounted within 75’ of outside areas
containing flammable liquids and within 10’ of any inside storage area for
such materials
X Buildings over two levels have doors that close automatically in stair tower
X Fire extinguishers free from obstruction or blockage
X Fire extinguishers provided for the types of materials in the area where
used
Class A Ordinary combustible material fires
Class B Flammable liquid, gas, or grease fires
Class C Energized-electrical equipment fires

X Fire extinguishers serviced, maintained, and tagged every year

X No dead-end corridor >20’
X Non-exit doors, passages, and stairways labeled, “NOT AN EXIT”
X Panic hardware on all exit doors and rooms with occupancy of 50 or more
X Sprinkler heads protected by metal guards, when exposed to physical
damage

ELECTRICAL
X Extension cords used for permanent wiring
X 36” clear access to all electrical control panels for emergency shutdown

EXTERIOR
X Dumpsters stored at least 5’ from any combustible buildings, doors, and
windows
GYM
X Stage curtain must be flame retardant

HOME EC
X Outlets within 6’ of a water source must be GFC

KITCHEN
X Exhaust hood, ducts, and filters clear of any grease accumulation

X Fire extinguisher within 30’ of cooking equipment (min. 40BC)

X Hood with auto fire extinguishing system inspected every 6 months
X Means to shut off gas supply to the cooking equipment for emergency
X MSDS available
X Outlets within 6’ of a water source must be GFC

SCIENCE LABS
CHEMICALS
X Chemicals stored in open lab work area kept to a minimum
X Neutralizing chemicals and spill kits readily available

FIRE SAFETY
X Aisles serving work areas on 2 sides at least 42” wide; those serving work
areas on one side only must be 36”
X Flammable liquids stored in refrigerated equipment in closed containers
X Flammable/combustible liquids and chemicals must not be stored in fume
hoods or on the floor, except in original container
X Refrigerators, freezers, or coolers that store or cool flammable liquids must
be of explosion-proof construction and properly labeled
X 2A-20BC or larger rated fire extinguisher for each 3,000 feet of lab; travel
distance must not exceed 50’ from anywhere in room

STORAGE
X Acids stored in approved cabinets
X Chemical storage area must have inventory
X Chemical storage area properly ventilated
X Chemicals properly labeled
X Chemicals stored in approved containers (original shipping package)
X Flammable liquids stored in approved cabinets
X Shelves used for chemical storage should have lip or guard to prevent
chemicals from falling off
X Storage cabinets and rooms locked against unauthorized entry
VENTILATION
X Hood tested every year
X Lab hoods achieve 100 lfm
X Means provided for manually shutting down ventilation equipment

STORAGE ROOMS
X Room used for storage of combustibles must have 1-hour fire-rated walls
(sheet rock or plaster) and fire-rated doors (or solid core 1.75” thick wood
doors) with self-closer (or automatic fire sprinklers in them)

TECHNICAL LAB AREAS

X Compressed gas cylinders (oxygen, acetylene, propane, etc.) secured so
they cannot fall over
X Emergency stop buttons colored red
X Fire extinguishers located within 30’ of hazardous processes (painting,
welding, and woodworking)—mounted and inspected
X Flammable liquids stored in approved cabinets
X Oil-soaked, greasy, or paint-soaked rags stored in metal containers with lids
X Solvent wastes and flammable liquids are kept in fire-resistant, covered
containers until they are removed from the worksite
X Worksite clean and orderly with clear paths to exit

Completed by ___________________________Date
Facilities Safety Management Checklist

ART
X Dark room requires eyewash station
X Emergency phone numbers posted and MSDS available
X Flammable liquids and combustibles stored properly

ASBESTOS
X Caution labels and signs used to warn of asbestos

AUTO/METAL SHOP
BAND SAW
X Lower blade fully guarded
X Upper blade guarded with adjustable guard

COMPRESSED GAS
X Cylinders chained in place so they cannot fall over
X Valve covers in place when cylinder not in use

DRILL PRESS
X Drill press permanently mounted
X Guards in place over belts, pulleys, chains, and sprockets

GARAGE DOORS
X Annual inspection
X Automatic reverse mechanism installed and warning sign posted if not
installed

GRINDER
X Adjustable tongue adjusted within ¼” of wheel
X Work rest adjusted to ⅛” of wheel

HAND AND PORTABLE TOOLS

X Extension cords being used are grounded
X Multiple plug adaptors are prohibited
X Portable electrical tools are grounded or double insulated type
X Safety glasses provided if necessary
X Tools and cords in good condition; no broken handles

HOISTS
X Annual inspection
X Controls plainly marked to indicate the direction of travel or motion
X Hook equipped with safety clip
HOISTS (cont’d)
X Overhead electric hoist equipped with a limit device to stop the hook travel
at its highest and lowest point of safe travel
X Rated load of each hoist legibly marked and visible to the operator

METAL LATHE
X Guarding on chuck end

SPRAY BOOTH
X Approved respiratory equipment provided when appropriate
X Area within 3’ around spray booth is clear
X Fire control sprinkler heads kept clean
X Mechanical ventilation provided when spraying is done in enclosed area
X ‘NO SMOKING’ signs posted in spray areas, paint rooms, booths, and storage
X Spray area at least 20’ from flames, sparks, operating electrical motors

BOILER ROOM
X Caution label and signs used to warn of asbestos if needed
X Compressor and moving chains and belts guarded
X Eyewash station provided per pH
X Fire extinguisher mounted and accessible
X Lockout/tagout equipment provided when necessary
X No combustibles stored in boiler room
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals; goggles, face shields, safety glasses
provided when a danger of flying particles or corrosive materials
X Two exits

CONFINED SPACE
X Warning labels present

CORRIDORS, ENTRANCES, STAIRS

X All decorations, artwork in corridors limited to 20% of wall surface
X All EXIT corridors and hallways free of obstructions
X All EXIT doors open in the direction of exit without effort
X All EXIT doors posted as exits with letters 5” high and ½” wide
X All EXIT signs visible and with working lights, if lighted
X Appropriate fire extinguishers are mounted within 75’ of outside areas
containing flammable liquids and within 10’ of any inside storage area for
such materials
X Buildings over two levels have doors that close automatically in stair tower
X Fire extinguishers free from obstruction or blockage
X Fire extinguishers provided for the types of materials in the area where
used
Class A Ordinary combustible material fires
 Class B Flammable liquid, gas, or grease fires
Class C Energized-electrical equipment fires

X Fire extinguishers serviced, maintained, and tagged every year

X No dead-end corridor >20’
X Non-exit doors, passages, and stairways labeled, “NOT AN EXIT”
X Panic hardware on all exit doors and rooms with occupancy of 50 or more
X Sprinkler heads protected by metal guards, when exposed to physical
damage

ELECTRICAL
X Cover plates present on outlets and switches
X Disconnecting switches and circuit breakers labeled to indicate service area
X Exposed wiring and cords with frayed or deteriorated insulation are repaired
or replaced promptly
X Extension cords used for permanent wiring
X Flexible cords and cables are free of splices and taps
X Light fixtures below 7’ grounded and guarded
X 36” clear access to all electrical control panels for emergency shutdown
X Unused openings in electrical panels and fittings are closed with
appropriate covers, plugs, or plates

EMPLOYER POSTINGS
X OSHA workplace poster displayed in a prominent location
X Summary of OSHA 300/300A log posted in February

EXTERIOR
X Dumpsters stored at least 5’ from any combustible buildings, doors, and
windows

GYM
X Basketball hoops that raise and lower over a seating area have a 2nd safety
strap
X Bleachers must not have >9” gap between seat and footrest (may become
4”)
X Stage curtain must be flame retardant

HOME EC
X First Aid Kit and fire extinguisher available
X ‘Microwave in Use’ sign posted
X Outlets within 6’ of a water source must be GFC
KITCHEN
X Doors on cold storage rooms provided with an inside release mechanism
X Emergency phone numbers posted
X Exhaust hood, ducts, and filters clear of any grease accumulation
X Eyewash if exposed to injurious corrosive materials (oven cleaner)
X Fan should be 3-prong when used in wet area
X Fire blanket available
X Fire extinguisher within 30’ of cooking equipment (min. 40BC)
X First Aid Kit available
X Hood with auto fire extinguishing system inspected every 6 months
X Means to shut off gas supply to the cooking equipment for emergency
X ‘Microwave in Use’ sign posted
X MSDS available
X Outlets within 6’ of a water source must be GFC
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals

NOISE
X Approved hearing protection available to every employee working in the
area
X Employees in high noise area given periodic audiometric testing
X Noise levels at acceptable levels (<85 dBA) where continuous noise

SCIENCE LABS
CHEMICALS
X Chemicals stored in open lab work area kept to a minimum
X Neutralizing chemicals and spill kits readily available

ELECTRICAL
X Electrical outlets properly grounded
X 36” clear access to electrical panel

FIRE SAFETY
X Aisles serving work areas on 2 sides at least 42” wide; those serving work
areas on one side only must be 36”
X Fire blanket available
X Flammable liquids stored in refrigerated equipment in closed containers
X Flammable/combustible liquids and chemicals must not be stored in fume
hoods or on the floor, except in original container
X Heat sources not left unattended
X Refrigerators, freezers, or coolers that store or cool flammable liquids must
be of explosion-proof construction and properly labeled
X 2A-20BC or larger rated fire extinguisher for each 3,000 feet of lab; travel
distance must not exceed 50’ from anywhere in room

GENERAL
X Emergency phone numbers posted and MSDS available
X Eyewash station and quick drench shower where employees are exposed;
station required if pH <2 or >11, and shower required if pH <1 or >12
X Eyewash station flushed weekly and shower monthly for 3 minutes
X First Aid Kit accessible with necessary supplies

STORAGE
X Acids stored in approved cabinets
X Chemical storage area must have inventory
X Chemical storage area properly ventilated

STORAGE (cont’d)
X Chemicals properly labeled
X Chemicals stored in approved containers (original shipping package)
X Flammable liquids stored in approved cabinets
X Shelves used for chemical storage should have lip or guard to prevent
chemicals from falling off
X Storage cabinets and rooms locked against unauthorized entry

VENTILATION
X Hood tested every year
X Lab hoods achieve 100 lfm
X Means provided for manually shutting down ventilation equipment

STAIRS
X Handrails on all stairways with 4 or more risers; 1.5” clearance between
handrail and wall; handrail capable of withstanding a load of 200 pounds
X Mid-rail on open stairway
X Slip-resistant step surfaces

STORAGE ROOMS
X Room used for storage of combustibles must have 1-hour fire-rated walls
(sheet rock or plaster) and fire-rated doors (or solid core 1.75” thick wood
doors) with self-closer (or automatic fire sprinklers in them)

TECHNICAL LAB AREAS

X Compressed gas cylinders (oxygen, acetylene, propane, etc.) secured so
they cannot fall over
X Electric power can be locked out for maintenance, repair, or security
X Emergency phone numbers posted and MSDS sheets available
X Emergency stop buttons colored red
X Eyewash station and quick drench shower provided if necessary per pH
X Fire extinguishers located within 30’ of hazardous processes (painting,
welding, woodworking)—mounted and inspected
X First Aid Kit accessible with necessary supplies
X Flammable liquids stored in approved cabinets
X Oil-soaked, greasy, or paint-soaked rags stored in metal containers with lids
X Power shut off switch within reach of operator’s position
X Protective eyewear provided when a danger of flying particles or corrosives
X Protective gloves, aprons, shields, or other means provided against cuts,
corrosive liquids, and chemicals
X Pulleys and belts within 7’ of the floor properly guarded
X Radial arm saws arranged so that cutting head will gently return to the back
of the table when released
X Saws used for ripping are equipped with anti-kickback devices
X Solvent wastes and flammable liquids are kept in fire-resistant, covered
containers until they are removed from the worksite
X Worksite clean and orderly with clear paths to exits

WOOD SHOP
JOINTER
X Anti-magnetic shut off switch
X Guarding on both sides of blades

RADIAL ARM SAW

X Anti-kick fingers
X Cutting head will gently return to the back of the table when released
X Equipped with anti-magnetic shut off
X Guards on left side should fall when saw is pulled forward
X Saw will not extend beyond table edge

STORAGE
X Quantities or flammable and combustible liquids in excess of 10 gallons
stored in approved storage cabinet or storage room; less than 10 gallons
stored in approved safety cans

TABLE SAW
X Anti-kickback mechanism
X Anti-magnetic shut off switch

Completed by ___________________________Date
Checklist of E/OHS Activities for First Aid/CPR

Program Contact Person(s): __Mrs. Rita Damagala_________________________

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 Adrian First Responders
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

Note: Training for staff will be coordinated through school nurse Mrs.
Damagala. Training on the AEDs located at the fitness center and mobile units
will be coordinated also with the school nurse.
Checklist of E/OHS Activities for Hazardous Waste Management

Program Contact Person(s)

Primary Contact Person: Dave Vortherms

Secondary Contact Person: _Roger Graff__________________________

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 is not required 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:
Date Scheduled:

Has annual report and license application sent in? Yes No N/A
Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Dave Vortherms

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: 9-26-07

Presenter: Lee Carlson

Have regulatory changes occurred that may affect this program? No

Note: Sound level testing was conducted. Additional information will be

gathered during small engine operation. Also information regarding stationary
and hand tools will be collected during a future visit. LC 3-9-09
 Sound Level Monitoring

Client: Adrian 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

Metals Shop Band Saw 78.8-80.3 No protection
required
Metals Shop DeWalt Hand 80.3-81.0 No protection
Grinder required
Gymnasium Jazz band 78.3-80.1 No protection
ensemble required

Completed by Lee Carlson Date 3-9-2009

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Dave Vortherms/Rene Buller

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

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?

Who conducted the evaluation?

Were occupied areas of the district evaluated using the EPA’s Tools For Schools
check list or equivalent? Yes, the teacher checklists are distributed through the
school’s intranet. Results will be compiled at the end of the year.

• Teachers check list? An information fact sheet was provided all –staff.
# of forms distributed 42 # of Forms returned: 42

• Building maintenance checklist?

• Building ventilation checklist?

Training conducted Aug 30, 2007

(date)

Training has been scheduled for ___N/A____________.

(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? __ ________

IAQ Survey Review Form

Building:

Building Contact: Program Contact:

Room Identification Water Ventilation Building failures Cleanliness/ O&M

Contact individual Intrusion proble i.e. foundation Proper Carpets
ms or roof problems storage

Recommendations:.

Walk-through conducted by: _____________________Date: ____________

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Dave Vortherms

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:_Fall news letter.

Note: Plunkett’s Pest Control provides pest control services for the school.
Checklist of E/OHS Activities for Laboratory Standard/Chemical
Hygiene Plan

Program Contact Person: Robert Williams, 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 12-15-09.

(date)

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

Chemical inventory:

Date of most recent survey 11-17-09

Location of inventory listing

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:

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

 General Science Safety Considerations
For All Rooms Where Science Laboratories Are Conducted
And/or Demonstrations Are Given

Client: Adrian Public Schools, Survey date 12-15-09

Room Number(s): 418

Description: A school science laboratory is defined as a classroom where

demonstrations and/or laboratory instructions are provided for individual or group
experiments. They are places where science is taught. In addition, any condition
listed under either the storage section or the chemical laboratory section that
may apply to any area, for instance, must keep inventories of all biology reagents
and chemicals.

CONDITION
ITEM CITATION EXISTS LACKING N/A
1) Laboratories must be equipped with adequate
ventilation. For new labs (build after July 1990) an UBC (97) 305.2.4, X
manual shutoff control for the laboratory exhaust 307.5.2, & 1202.2.3
ventilation system must be provided outside of the room, UFC (97) 8004.1.11 &
in a position adjacent to the access door to the room or 8003.1.4.2
in such other location as approved by the fire chief.
2) At least one 2A-20BC, or larger, rated and approved X
portable fire extinguisher must be provided for each
3,000’ of laboratory. Travel distance must not exceed 50’ UFC (97) 1002.1
from anywhere in the lab. At least one fire extinguisher UFC Std. 10-1-3-2
suitable for class D fires must be provided in laboratories
where combustible metals are used and stored.
3) At least one approved fire blanket must be provided in X
UFC (97) 1001.9
each laboratory.
4) Students must be under the direct supervision of a X
faculty member or an assistant at all times. In most
cases it is recommended that direct supervision means
direct eye contact. It is recommended that no more than NFPA 45 (91) 1-4 X
two students be assigned to a lab station, a place in the
room equipped with water, gas, and electricity, or a
place where students do labs.
5) Aisles serving work areas on two sides must be at x
least 42” wide; those serving work areas on one side UFC (97) 1204.2.2 (2)
only must be 36”.
6) Minimum of two means of exit access must be x
provided when:
Existing: lab exceeds 1,000 sq. feet NPFA 45 (91) 3-4.1
New: lab exceeds 200 sq. feet (built after 7/90) UBC (97) 1007.3.8
7) Labs must be separated from each other and other x
portions of the building by not less than a 1-hour
occupancy separation.*
Existing: labs located in buildings protected by automatic UFC (97) Appendix 1-A
extinguishing systems—only smoke separation required 7.2 as amended
New: (built after 7/72)
*Recommend this be determined by a licensed design UBC (97), 305.2.4
professional
8) Labs must be equipped with automatic detection x
electrically interconnected with the building fire alarm UFC (97) 1007.2.4.2 &
system. Exception: labs protected by a complete 1007.2.4.1.1 as
automatic sprinkler system that is interconnected to the amended
building fire alarm require no additional detection.
9) All electrical outlets must be properly grounded and all UFC (97) 8504 x
fixed electrical equipment and appliances must be 99NEC 250-112
plugged in to grounded outlets as required by the
electrical code.
CONDITION
ITEM CITATION EXISTS LACKING N/A
10) Electrical receptacles, switches, and controls must X
NFPA 45 (91) 3-6.1
be located so as not to be subject to liquid spills.
11) Extension cords must not be used as a substitute for X
UFC (97) 8506.1
permanent wiring.
12) The use of multi-plug adapters, octopus X
arrangements, cube adapters, strip plugs, or any other
UFC (97) 8507
device that does not comply with the electrical code is
prohibited.
13) A minimum of 30” of clearance must be maintained X
UFC (97) 8509.2
in front of electrical control panels for access.
14) Written procedures for laboratory emergencies, X
including emergency evacuation, must be developed for NFPA 45 (91) 4-6.3.1
each lab.
15) Piping systems must comply with nationally X
NFPA 45 (91) 8-1.1
recognized standards.
16) Enough eye protection devices (goggles) must be X
provided for every student in the room, visitors, and the MN Public Law, section
teacher whenever potentially hazardous activities are 126.20
taking place.
17) Refrigerators, freezers, and other cooling equipment X
used to store of cool flammable liquids must be of NFPA 45 (91) 9-2.2.2
explosion-proof construction
18) Each refrigerator, freezer, or cooler must be X
prominently labeled to indicate whether it is or is not NFPA 45 (97) 9-2.2.1
suitable for storing flammable liquids.
19) Flammable liquids stored in refrigerated equipment X
NFPA 45 (91) 9-1.6.6
must be in closed containers.
 General Science Safety Considerations
For All Laboratories And/or Rooms Where Chemical Demonstrations Are
Conducted

Client: Adrian Public Schools

Room Number(s): #418

Description: In addition to the provisions that are outlined for any science
laboratory area, the following provisions are specific for chemistry classes (but
may apply to any lab where similar activities are carried on).

CONDITION
ITEM CITATION EXISTS LACKING N/A
1) Proper eyewash facilities must be installed that X
produce 25 psi of water for 15 minutes. Squeeze bottles
do not meet this specification. It is recommended that
eyewash fountains should be located within 25’ of
ANSI Z-358.1-1981
students in any area of the room. The device must be
plumbed into a drinkable water supply. This rule applies
to any rooms where labs are conducted that are
potentially harmful to the eyes.
2) Emissions generated at workstations must be X
confined to the area in which they are generated UBC (97) 1202.2.3
(laboratory hoods).
3) In new labs (build after 7/90) a manual shutoff control X
for the laboratory exhaust ventilation system must be
UBC (97) 1202.2.3
provided outside of the room in a position adjacent to the
UFC (97) 8003.1.4.2
access door to the room or in such other location as
approved by the fire chief.
4) Chemicals stored in the open in the laboratory work X
area must be kept to the minimum necessary for the NFPA 45 (91) 7-2.3.1
work being done.
5) A complete inventory of chemicals on hand must be
maintained and must be available to the fire chief. All UFC (97) 8001.6 X
materials must be dated upon receipt.
6) Persons responsible for each lab must be familiar with X
the chemical nature of the materials present in the lab
UFC (97) 8001.11.1.1
and the appropriate mitigating actions to be taken in
case of fire, leak, or spill.
7) Incoming shipments of chemicals must be transported X
an opened by school personnel familiar with the potential NFPA 45 (91) 7-2.2.1
hazards.
8) Neutralizing chemicals spill kits, dry sand, vermiculite, X
EM Absorbent, and other spill control methods must be UFC (97) 8001.11.1
readily available while the lab is in use.
9) Written maintenance procedures must be established, X
including regular inspection, testing, and maintenance of
NFPA 45 (91) 4-6.2
lab utilities, hood and exhaust systems, pressure
equipment (autoclaves, steam sterilizers, etc.), and
emergency equipment.
10) Lab hoods and special local exhaust systems must X
be labeled to indicate intended use. Hoods in which
NFPA 45 (91) 6-13
radioactive materials are handled must be identified with
the radiation hazard symbol.
11) Provide a properly marked, easily accessible main x
UFC (97) 8004.1.12
gas shutoff valve in the room.
12) Fume/exhaust hoods must be listed (e.g., UL or FM) UFC (97) 8001.4.4 & X
and maintained in proper operating condition. 8001.4.7.1
13) Heat sources (e.g., gas burners, hot plates, heating X
Recommendation
mantles, etc.) should never be left unattended.
 CONDITION
ITEM CITATION EXISTS LACKING N/A
14) It is recommended that due to the serious explosion
hazard present, the following chemicals not be used in
an instructional setting:
Benzoyl Peroxide Percholoric Acid Recommendation
Carbon Disulfide Picric Acid
Ethyl Ether Potassium Metal
Magnesium Powdered Metal
15) Loose clothing (e.g., full cut blouses, neckties, etc.)
and long hair should be properly restrained. Also, some
Recommendation
laboratory activities could be dangerous to persons
wearing contact lenses.

Note: Potassium metal is handled by the instructor only.

 General Science Safety Considerations
For Chemical Storage Facilities

Client: Adrian Public Schools

Room Number(s): #418

Description: Chemical Storage Facilities means any area or room where

chemicals are stored. Usually this refers to the chemistry storage area, but
occasionally there may be other facilities in the school, most likely located within
a classroom, that store chemicals. These rules apply to all areas where
chemicals are stored.

CONDITION
ITEM CITATION EXISTS LACKING N/A
1) Quantities of flammable and combustible liquids shall x
not exceed the amounts necessary for demonstration,
treatment, laboratory work, maintenance purposes, or UFC (97) 7902.5.7.2 #3
operation of equipment. Not in any case will it exceed
the limits set forth in table 7902.5-A.
2) Quantities of flammable and combustible liquid in x
excess of 10 gallons must be stored in a flammable
UFC (97) 7902.5.8
liquids cabinet. Quantities not exceeding ten gallons
must be stored in an approved location.
3) The maximum quantity of flammable and combustible x
liquids in storage and use in a lab must not exceed 120
gallons.
Exception: These quantities may be doubled in areas
UFC (97) table 7902.5-A
protected by an automatic extinguishing system.
Exception: These quantities may be doubled if stored in
approved storage cabinets.
(Both exceptions may apply.)
4) Class I flammable liquids may be stored in glass x
containers of not more than one-gallon capacity only if
the required liquid purity would be affected by storage in
a metal container, or if the liquid would cause excessive
corrosion of a metal container. Otherwise, Class I-A
UFC (97) 7902.1-A
liquids are restricted to glass containers not exceeding
one-pint capacity and Class 1-B liquids are restricted to
glass containers not exceeding one-quart capacity.
Class 1-C liquids are permitted to be stored in containers
up to one-gallon capacity.
5) No container for Class I or II liquids in any lab may x
exceed a capacity of one gallon. See table 7902.1-A for UFC (97) 7902.1-A
other limitations.
6) Materials that will react with water or other liquids to x
produce a hazard must not be stored in the same room UFC (97) 7902.5.4
with flammable or combustible liquids.
7) Stored gas cylinders shall have all protective devices x
UFC (97) 7401.7.1
on (caps, collars, and similar devices).
8) All gas cylinders must be secured in a place to x
UFC (97) 7401.6.4
prevent falling.
9) Material Safety Data Sheets (MSDS) must be readily x
UFC (97) 8001.6
available on the premises for all hazardous chemicals.
10) All chemicals must be stored in approved containers x
(if possible, chemicals should be stored in the original UFC (97) 8001.4.2
shipping package).
11) Incompatible materials shall be segregated to x
prevent accidental contact with one another. (Storage of
UFC (97) 8001.11.8
materials which are incompatible shall not be allowed in
the same cabinet or exhausted enclosure.)
 CONDITION
ITEM CITATION EXISTS LACKING N/A
12) All shelving must be of substantial construction and x
properly secured to prevent falling over. (Shelving above
UFC (97) 8001.11.9
work areas should be kept free of chemicals; storage
above eye level should be avoided.)
13) Shelving must be equipped with a lip or guard to x
UFC (97) 8001.11.9
avoid products rolling off.
14) Defective containers must be removed and disposed x
UFC (97) 8001.4.7.3
of in a proper manner.
15) Disposal of chemical wastes must be in accordance x
with applicable federal and state regulations and good UFC (97) 8001.5.1
safety practices.
16) All storage cabinets and storage rooms must be x
UFC (97) 8001.11.2
locked or otherwise secured against unauthorized entry.
17) All containers must be properly labeled to identify the X
UFC (97) 8001.7
contents.
18) Toxic and highly toxic compressed gas, Class IV x
liquid, solid oxidizers, unclassified detonable, Class I
UFC (97) 8001.15.2.4
organic peroxides, Class III and IV unstable and reactive
material shall not be allowed in the classroom.
19) When transferring flammable liquids between metal x
containers, the containers must be properly bonded
UFC (97) 8001.11.5
together. The practice of purchasing large containers
and dispensing into smaller ones is discouraged.

TABLE 7902.1-A: MAXIMUM SIZE OF CONTAINERS AND PORTABLE TANKS

CONTAINER TYPE CLASS I-A CLASS I-B CLASS I-C CLASS II CLASS III
1. Glass1 1 pt. 1 qt. 1 gal. 1 gal. 5 gal.
2. Metal or listed approved plastic2 1 gal. 5 gal. 5 gal. 5 gal. 5 gal.
3. Approved plastic 0 gal. 0 gal. 0 gal. 0 gal. 5 gal.
4. Safety cans 2 gal. 5 gal. 5 gal. 5 gal. 5 gal.
5. Metal drum 60 gal. 60 gal. 60 gal. 60 gal. 60 gal.
6. Approved portable tanks 660 gal. 660 gal. 660 gal. 660 gal. 660 gal.
7. Polyethylene3 Note 4 Note 4 Note 4 60 gal. 60 gal.

TABLE 7902.5-A: EXEMPT AMOUNTS OF FLAMMABLE AND COMBUSTIBLE LIQUIDS—

MAXIMUM QUANTITIES STORED PER CONTROL AREA1,2,3

TYPE OF LIQUID EXEMPT AMOUNT (gallons)

Flammable
Class I-A 30
Class I-B 60
Class I-C 90
Combination I-A, I-B, I-C 1204
Combustible
Class II 120
Class III-A 330
Class III-B 13,2005
1
Control areas shall be separated from each other by not less than a one-hour fire-resistive occupancy separation. The
number of control areas within a building used for retail or wholesale sales shall not exceed two. The number of control
areas in buildings with other uses shall not exceed four. See Sections 204 and 8001.10.2.
2
Quantities are allowed to be increased 100 percent when stored in approved storage cabinets. When Note 3 applies, the
increase for each Note is allowed.
3
Quantities are allowed to be increased 100 percent in buildings equipped with an approved automatic sprinkler system.
When Note 2 applies, the increase for each Note is allowed.
4
Combinations shall not contain more than the exempt amounts of any individual class.
5
Quantities permitted in a building equipped with an approved automatic sprinkler system are not limited.
 Carcinogen/Substances of Known High Chronic Toxicity
Standard Operating Procedures

Client: Ellsworth Public School

Which carcinogens are present in district science laboratories?

KNOWN CARCINOGENS SUSPECT CARCINOGENS OTHERS

‫ٱ‬ ‫ٱ‬ Cadmium/Cadmium Compounds ‫ٱ‬
Asbestos
‫ٱ‬ Arsenic ‫ٱ‬ Carbon Tetrachloride ‫ٱ‬
‫ٱ‬ Benzene ‫ٱ‬ Chloroform ‫ٱ‬
‫ٱ‬ Benzidine ‫ٱ‬ DDT ‫ٱ‬
‫ٱ‬ Bis (Chloromethyl) Ether ‫ٱ‬ 2,4D ‫ٱ‬
‫ٱ‬ Chloromethyl Methyl Ether ‫ٱ‬ Methylene Chloride ‫ٱ‬
‫ٱ‬ Chromium/Chromium ‫ٱ‬ Formaldehyde (Gas) ‫ٱ‬
Compounds
‫ٱ‬ Mustard Gas ‫ٱ‬ Lead Acetate
‫ٱ‬ Vinyl Chloride ‫ٱ‬ Lead Phosphate
‫ٱ‬ Nickel/Nickel Compounds
(Powder)
‫ٱ‬ Saccharin
‫ٱ‬ Urethane

List total time (in hours) employee is exposed to carcinogens (checked

chemicals above) per academic year.

N/A hours per academic year

Are checked chemicals required, or could acceptable substitutes be

implemented?

‫ ٱ‬Will retain carcinogen in curriculum ‫ ٱ‬Will discontinue use of

chemicals

If retained in curriculum, use table to log/document usage:

CARCINOGENIC NAME(S) OF NUMBER OF

CHEMICAL AMOUNTS DATES USED USER(S) HOURS USED
USED
Carcinogen/Substances of Known High Chronic Toxicity
Storage Guidelines

1. Store in a well-ventilated area chemical storage room

2. Use secondary containers or trays with sufficient capacity > 100% primary
container.

3. Label with the following information:

WARNING!

HIGH CHRONIC TOXICITY

OR
CANCER-SUSPECT AGENT

4. Limited access should be provided for these chemicals.

5. Areas should be posted.

6. District Storage Location:

7. Guidelines (from above) that need to be implemented: 1 2 3 4 5

 Carcinogen/Substances of Known High Chronic Toxicity
Handling Guidelines

1. Use a “controlled area” (an exhaust hood, glove box, designated area in a
laboratory with localized ventilation).

District Controlled Area: Fume hood located in room 418

2. Controlled areas should possess the following signage, conspicuously

posted:

WARNING!

TOXIC SUBSTANCE IN USE

OR
CANCER-SUSPECT AGENT:

AUTHORIZED PERSONNEL ONLY

3. Use of Personal Protective Equipment, like impermeable gloves, aprons, and

face shields.

4. Protect surfaces where carcinogens are handled by using chemically resistant

trays or pans that can be decontaminated.

5. On leaving a controlled area, laboratory workers should remove any

protective apparel that has been used and thoroughly wash hands, forearms,
face, and neck. If disposable apparel or absorbent paper liners have been
used, these items should be placed in a closed and impervious container that
should then be labeled in some manner such as the following: CAUTION—
CONTENTS CONTAMINATED WITH SUBSTANCES OF HIGH CHRONIC
TOXICITY. Non-disposable protective apparel should be thoroughly washed,
and containers of disposable apparel and paper liners should be incinerated.

6. Wastes and other contaminated materials from an experiment involving

substances of high chronic toxicity should be collected together with the
washings from flasks and such and either decontaminated chemically or
placed in closed, suitable labeled containers for incineration away from the
controlled area. If chemical decontamination is to be used, a method should
be chosen that can reasonable by expected to convert essentially all of the
toxic materials into nontoxic materials. For example, residues and wastes
from experiments in which B-propiolactone, bis (chloromethyl) ether, or
methyl chloromethyl ether have been used should be treated for 10 minutes
with concentrated aqueous ammonia.
 In the event that chemical decontamination is not feasible, wastes and
residues should be placed in an impervious container that should be closed
and labeled in some manner such as the following: CAUTION—
COMPOUNDS OF HIGH CHRONIC TOXICITY or CAUTION—CANCER-
SUSPECT AGENT.

7. Transfer of contaminated wastes from the controlled area to the incinerator

should be done under the supervision of authorized personnel and in such a
manner as to prevent spill or loss. In general, liquid wastes containing such
compounds should be placed in glass or polyethylene (usually preferable)
bottles half-filled with vermiculite, and these should be transported in plastic
or metal pails of sufficient capacity to contain the material in case of
accidental breakage of the primary container.

8. Normal laboratory work should not be resumed in a space that has been used
as a controlled area until it has been adequately decontaminated. Work
surfaces should be thoroughly washed and rinsed. If experiments have
involved the use of finely divided solid materials, dry sweeping should not be
done. In such cases, surfaces should be cleaned by wet mopping or by use of
a vacuum cleaner equipped with a high efficiency particulate air (HEPA) filter.
All equipment (e.g., glassware, vacuum traps, and containers) that is known
or suspected to have been in contact with substances of high chronic toxicity
should be washed and rinsed before they are removed from the controlled
area.

9. In the event of continued experimentation with a substance of high chronic

toxicity (i.e., if a worker regularly uses toxicologically significant quantities of
such a substance three times a week), a qualified physician should be
consulted to determine whether it is advisable to establish a regular schedule
of medical surveillance or biological monitoring.
Checklist of E/OHS Activities for Lead-in-Water Management

Program Contact Person: Dave Vortherms

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: Dave Vortherms

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 replaced with lead free materials.

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
____good__________ condition

Information was left with staff on the health risk associated with lead on
small children. 10-24-07
Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Dave Vortherms

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 room

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:

Checklist of E/OHS Activities for Machine Guarding
Program Contact Person: Dave Vortherms/ John Olson

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? _______________________

Who conducted the evaluation? _______________________

How are corrections documented? _______________________________

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 N/A
 Identified Fixed Equipment Locations

Location Building/Buildings Staff Affected # of item

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

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: Dave Vortherms

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
Note: Loose fill had deteriorated at several locations on south playground.
Cement foundation was exposed.

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

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

Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Dave Vortherms

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:_11-17-09_________________________

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

Note: Garbage Disposer Notice was posted at both food service kitchens.
Training had been provided during the training session of 11-17-09.
12-15-09 LC
 Personal Protective Equipment Assessment

Location: Location: Location: Location: Location:

Custodial/Building Kitchen Shop Laboratory Art

Employee: Employee: Karla Employee: Employee: Employee:
Dave Vortherms Kavale, Elaine John Olson Robert Christine
Klingenburg,Cheryl Williamson Tromblay
Polzine,Joyce
Habbena,Christina
Crow

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

Comments on
Availability, Good Good Good Good Good
Condition, &
Storage

Completed by: Lee Carlson Date: 12-14-2009

 Hazard
(Heat, Noise,
Radiation)
Heat, chemical, bod
fluids, noise, asbest
Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: Dave Vortherms

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: November, 2008

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
Dave Misc. (1) AO ½ N/A N/A N/A
Vortherms Voluntary mask

Dave Voluntary (1) Plastic N/A N/A N/A

Vortherms filter
mask

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): In the oak cabinet located in the custodial room at the west
end of the building.

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

Verified by Lee Carlson

Note: The respirators are used only on a very limited basis. Paper type masks
are also available to be used in dusty conditions. The units were found to be
in useable clean condition.
Checklist of E/OHS Activities for Underground and Aboveground
Storage Tanks

Program Contact Person: Dave Vortherms/Roger Graff

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

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

1 High School 10,000 gal #2 Fuel Oil Yes
 South of
Building
2 High School 10,000 gal #2 Fuel Oil Yes
South of
Building
3 Elementary 10,000 gal #2 Fuel Oil Yes

Regulated Tanks: Motor fuel tanks larger than 110 gallons

Non-regulate 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 STPIapproved
--Leak detection

Tightness Testing Results on File:

Dates of past testing: N/A

Records on file:N/A

Underground Storage Tank Status

Checklist of E/OHS Activities for Welding and Brazing Safety

Program Contact Person(s) John Olson

Department Contact:
 • Metals Shop/Ag. FFA John Olson

• 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.