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Chapter 9 - Occupational Safety And Health Program

Part 1 - General

Title Section
Introduction 1-9.1
    Purpose 1-9.1A
    Scope 1-9.1B
    Goals 1-9.1C
    Policy 1-9.1D
    Authorities 1-9.1E
    Definitions 1-9.1F
Responsibilities 1-9.2
    Director, Indian Health Service (IHS) 1-9.2A
    Designated Agency Safety and Health Official (DASHO) 1-9.2B
    Area Director (AD) 1-9.2C
    Area Safety Officer 1-9.2D
    Area Office of Environmental Health and Engineering (OEHE) Director 1-9.2E
    Governing Boards 1-9.2F
    Chief Executive Officer (CEO) 1-9.2G
    Occupational Safety and Health (OSH) Committees 1-9.2H
    OSH Committee Chairperson 1-9.2I
    Service Unit or Facility Safety Officer 1-9.2J
    Infection Preventionist 1-9.2K
    Employee Health Specialist 1-9.2L
    Supervisor/Manager 1-9.2M
    Employee 1-9.2N
Occupational Safety and Health Fundamentals 1-9.3
    Culture of Safety 1-9.3A
    Authority to Intervene 1-9.3B
    No Risking of Life 1-9.3C
    Hazardous Conditions 1-9.3D
    Safe Work Practices 1-9.3E
    Physical Fitness and Suitable Equipment 1-9.3F
    Hierarchy of Controls 1-9.3G
    Personal Protective Equipment (PPE) 1-9.3H
    Employee Rights and Protection 1-9.3I
OSH Management Program Elements 1-9.4
    Allocated Resources 1-9.4A
    Safety Officer Staffing and Management 1-9.4B
    Establishment and Maintenance of Active OSH Committees 1-9.4C
    Standards for IHS OSH Program 1-9.4D
    Review, Development and Implementation of OSH Policies and Procedures 1-9.4E
    Dissemination of OSH Program Information 1-9.4F
    OSH Orientation and Training for All IHS Employees 1-9.4G
    Contractor Safety 1-9.4H
    Motor Vehicle Safety 1-9.4I
    Plan Review and Hazard Assessment 1-9.4J
    Inspections 1-9.4K
    Employee Reports of Hazardous Conditions 1-9.4L
    Reporting of Injuries, Illnesses, and Other IncidentsV 1-9.4M
    Incident Investigation and Incident Data Analysis 1-9.4N
    Recordkeeping 1-9.4O
    OSH Program Evaluation 1-9.4P
    Recognition of Safety Efforts 1-9.4Q

Exhibit Description
Manual Exhibit 1-9-A Safety Officer Qualifications and Training


  1. Purpose.   The purpose of this chapter is to establish the Occupational Safety and Health (OSH) responsibilities and functions of the Indian Health Service (IHS). It defines IHS OSH program elements and extends to providing a safe and healthy environment for patients, visitors, and contractors.
  2. Scope.   The primary focus of this chapter is the protection of IHS employees’ and contractors’ safety and health, with ancillary benefits for protection of IHS patients and visitors.
    1. This chapter does not address employee legal protections related to incidents resulting in claims for property damage or personal injury covered by the Federal Tort Claims Act. (For more information on the Federal Tort Claims Act and IHS risk management, see the IHS Risk Management webpage.)
    2. This chapter does not cover compensation benefits for civilian employees who suffer injury, occupational disease, or death due to their employment. (Information on the IHS workers’ compensation program can be found under IHM, Part 1, Chapter 8, "Managing the Workers' Compensation Program.")
    3. This chapter does not provide guidance on the development, implementation, and evaluation of emergency preparedness programs. Guidance on this topic is available through healthcare accrediting organizations, the HHS Safety Manual, Chapter 9 (v2018) (Intranet only). Safety staff may have additional training requirements and assigned responsibilities related to these programs.
  3. Goals.   The goals of the OSH Program are to:
    1. Support an organizational culture of safety, where safety is a principal element in all operations and in which employees trust;
    2. Ensure safe and healthful working conditions for IHS personnel;
    3. Prevent occupationally-related illnesses and injuries among IHS personnel and contractors;
    4. Prevent injuries and illness to IHS personnel and contractors as well as patients and visitors accessing IHS properties;
    5. Maintain at all service locations effective and comprehensive OSH programs, which include current policies and procedures, OSH committees, safety training, hazard assessment, and incident reporting;
    6. Continually improve OSH performance;
    7. Promote specific opportunities for employee and supervisor participation in the IHS OSH program; and
    8. Integrate OSH into business planning, infrastructure, decision-making, and contracts.
  4. Policy.   The IHS, at all levels of the organization, will:
    1. Operate an OSH program in accordance with Section 19 of the Occupational Safety and Health Act of 1970, as amended, and
    2. Operate a comprehensive, effective, and continuous OSH program in accordance with Executive Order 12196: “Occupational Safety and Health Programs for Federal Employees.”
  5. Authorities.  
    1. Occupational Safety and Health Act of 1970, Section 19: Federal Agency Safety Programs and Responsibilities. 29 U.S.C. § 668 (1970), as amended.
    2. 29 Code of Federal Regulations (C.F.R.) Part 1960: “Basic Program Elements for Federal Employee OSH Programs and Related Matters.” Federal Register Vol. 45, No. 69798, October 21, 1980.
    3. Applicable Occupational Safety and Health Administration (OSHA) standards found in OSHA 29 C.F.R. Part 1910 – General Industry Standards and OSHA Part 1926 – Construction Industry Standards.
    4. Emergency Planning and Community Right-to-Know Act as described in the Superfund Amendments Reauthorization Act, Title III, Section 311.
    5. Executive Orders Pertaining to Occupational Safety:
      1. Executive Order 12196 – “Occupational Safety and Health Programs for Federal Employees.” Federal Register Vol. 45, No. 12769, February 26, 1980.
      2. Executive Order 13043 – “Increasing Seat Belt Use in the United States – Section 1(a). Safety belt use requirements for Federal employees.” Federal Register Vol. 62, No. 75, April 18. 1997.
      3. Executive Order 13513 – “Federal Leadership on Reducing Text Messaging While Driving.” Federal Register Vol. 74, No. 192, October 6, 2009.
    6. Other potentially applicable health care accreditation standards:
      1. Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage & Conditions of Participation;
      2. The Joint Commission (TJC) standards; and
      3. Accreditation Association for Ambulatory Health Care (AAAHC) standards
  6. Definitions.  
    1. Contractor.   A person or service that is contracted by the IHS, or any subcontractors hired by the prime contracting entity. The person or service may or may not be directly supervised by an IHS employee. For the purposes of this chapter, individuals working within IHS facilities under Tribal or academic programs will be considered contractors.
    2. Culture of Safety.   The attitudes, beliefs, perceptions, and values that employees share in relation to safety in the workplace. Key features to achieving a culture of safety (Section 1-9.3A) include:
      1. Acknowledgement of and determination to address risks (Sections 1-9.1C & D);
      2. Blame-free event reporting (Section 1-9.4N);
      3. Collaboration between staff and departments from top to bottom and across locations (Section 1-9.2); and
      4. Commitment to adequate resources (Sections 1-9.4A & B)
    3. Employee.   Any person employed, or otherwise permitted or required to work, by IHS. This includes full and part-time workers who are salaried, students, and volunteers.
    4. Hazard Surveillance.    A formalized system through which unsafe conditions and hazardous practices are identified before an unwanted event or incident occurs.
    5. Hazardous Chemical.   Any chemical which is classified as a physical hazard or a health hazard, a simple asphyxiant, combustible dust, pyrophoric gas, or hazard not otherwise classified as defined in the Hazard Communication Standard (29 C.F.R. § 1910.1200).
    6. Imminent Danger.   Any condition or practice in any location, which could reasonably be expected to cause death or serious physical harm immediately, or before the presence of such danger can be eliminated through normal procedures.
    7. Intergovernmental Personnel Act (IPA).   An IPA provides for the temporary assignment of federal civilian personnel between the Federal Government and Tribes. The more common IPA in IHS is the assignment of personnel to American Indian/Alaska Native entities that have contracted or compacted under Public Law 93-638, as amended, for federal programs.
    8. Inspection.   A comprehensive survey of all or part of a workplace in order to detect safety and health hazards, conducted routinely or as part of an investigation of a complaint regarding a specific hazard or conditions in a specific location within a workplace.
    9. Service Locations (of IHS).   The IHS organizational levels relevant to this policy include:
      1. IHS Headquarters (HQ) Office.   Located in Rockville, Maryland, the HQ office develops IHS policy, secures agency funding, provides administrative oversight to agency operations, and provides consultative services.
      2. Area Office and District Office.    An IHS Area or District office provides administrative and consultative services in support of field locations or operations including sanitation facility construction projects.
      3. Service Unit.   Designated by the IHS as a geographic location, which usually includes a central hospital or healthcare center, satellite clinics, and the surrounding Indian reservations or Tribal lands. Typically, an IHS Service Unit provides direct health care and community health services within these designated boundaries.
        1. IHS Facility.   Any healthcare, administrative, or support facility operated by IHS, either owned or leased by the Agency, for fulfilling the Agency mission.
        2. Sanitation Facility Construction Sites with direct IHS supervision and without (contractor supervised sites).
    10. Property.   Something owned by, possessed by, or is the responsibility of the United States (U.S.) government.
    11. Qualified.    As defined in Executive Order 12196 and 29 C.F.R. Part 1926, means one who, by possession of a recognized degree, certificate, or professional standing, or who by extensive knowledge, training and experience, is competent to recognize hazards and has successfully demonstrated his/her ability to solve or resolve problems related to OSH.
    12. Recordable Injury or Illness.   Defined by OSHA in 29 C.F.R. Part 1904 as a work-related (See definition 1-9.1F(16)) injury or illness that:
      1. Results in death, loss of consciousness, days away from work (beyond the day of occurrence), restricted work activity or job transfer, or medical treatment beyond first aid; or
      2. Is considered significant and is diagnosed by a physician or other licensed health care professional; or
      3. Involves cancer, chronic irreversible disease, a fractured or cracked bone, or a punctured eardrum; or
      4. Is caused by a needle stick injury or cut from a sharp object that is contaminated with another person’s blood or other potentially infectious material; or
      5. Requires an employee to be medically removed under the requirements of an OSHA health standard; or
      6. Results in tuberculosis infection as evidenced by a positive skin test or is diagnosed by a physician or other licensed health care professional after exposure to a known case of active tuberculosis; or
      7. Determines through an employee hearing test (audiogram) that the employee has experienced a Standard Threshold Shift (STS) in hearing in one or both ears (averaged at 2000, 3000, and 4000 Hertz) and the employee’s total hearing level is 25 decibels (dB) or more above audiometric zero (also averaged at 2000, 3000, and 4000 Hz) in the same ear(s) as the STS.
    13. Safety and Health Officials.   A general term applying to Safety Officers (SOs), Institutional Environmental Health Specialists (IEHSs), and others given the responsibility of designing, implementing, and/or managing an occupational safety program.
    14. Visitor.   A person accessing an IHS property for a purpose other than as an IHS employee or contractor, or to receive health care services as a patient.
    15. Workplace.    The work environment that includes the establishment and other locations where one or more IHS employees and/or contractors are working or are present as a condition of their employment.
    16. Work-related (Injury or Illness).    An event or exposure in the work environment that caused or contributed to the condition or significantly aggravated a pre-existing condition. Work-relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the workplace, unless an exception specifically applies. See 29 C.F.R. § 1904.5(b)(2) for the exceptions.


  1. Director, Indian Health Service (IHS).   The Director, IHS, will support and promote the implementation of a comprehensive OSH program as defined by this chapter. The Director, IHS will:
    1. Ensure that each employee is furnished a place of employment free from recognized hazards which may cause injury, illness, or death;
    2. Support a culture of safety;
    3. Ensure that IHS operations comply with the applicable OSHA standards;
    4. Support the development, implementation, and evaluation of an OSH program in accordance with the authorities described in requirements of section 19 of the OSH Act, Executive Order 12196, this chapter, and the basic program elements defined in 29 C.F.R. Part 1960;
    5. Provide leadership and assume overall responsibility for implementing, maintaining, and monitoring performance of the OSH program;
    6. Designate an Agency Safety and Health Official. This official is delegated authority and responsibility to represent effectively the interests and support of the agency head in the management and administration of the agency OSH program;
    7. Support that SOs and employee health staff are designated at all service locations of the agency with adequate budgets, equipment, materials, authority, and staff to implement the OSH program;
    8. Ensure the agency budget submission includes appropriate financial and other resources to effectively implement and administer the IHS OSH programs; and
    9. Support the recognition of superior performance in discharging OSH responsibilities by an individual or group. Agency OSH officials and committees may establish recognition criteria and awards.
  2. Designated Agency Safety and Health Official (DASHO).   The IHS DASHO is responsible for administering the IHS OSH program. (This role has historically been assigned to the HQ, Director of Office of Environmental Health and Engineering (OEHE).) The DASHO and their designated technical support staff bear responsibility to:
    1. Support a culture of safety;
    2. Evaluate Area programs to determine the general effectiveness of the overall OSH program;
    3. Provide technical assistance to Area programs to assist in implementing and maintaining effective OSH programs;
    4. Coordinate reporting activities, including the annual IHS OSH report to the HHS/Department of Labor (DOL), and recommend system changes, when necessary;
    5. Ensure that procedures are established through policies, circulars, instructions, and guidance documents to ensure effective implementation of OSH program elements;
    6. Develop and review goals and objectives annually for reducing and eliminating occupational injuries and illnesses. Ensure that priorities are established to address the factors associated with the cause and origin of occupational injuries and illnesses to develop intervention plans;
    7. Provide leadership to ensure compliance with new or changing regulations or requirements;
    8. Develop plans and procedures for evaluating the effectiveness of the IHS OSH program at all operational levels;
    9. Monitor and recommend changes in the resources allocated to the entire agency OSH program;
    10. Support activities related to career development and attaining necessary competencies for the IEH Program, Area, and local SO;
    11. Establish recognition criteria and awards; and
    12. Ensure that an OSH program is in place at IHS HQ.
  3. Area Director (AD).    Each AD has the authority and responsibility for developing and implementing the Area’s OSH program. The AD shall:
    1. Support a culture of safety;
    2. Designate in writing, an Area SO (e.g., Area IEHS) to discharge the Area OSH program;
    3. Appoint an Area Safety Committee comprised of Area personnel, with input from Service Unit staff, as appropriate, to assist the Area SO in reviewing safety inspections and reports, setting Area policy, discussing and evaluating any special problems, and recommending corrective actions or program modifications;
    4. Ensure that Committee members have educational training (degrees, credentials, certificates), and/or experience appropriate for responsibilities, and that additional training and resources are made available to Area safety personnel to enable them to fulfill their responsibilities;
    5. Ensure that the Area OSH program is consistent with national policies and tailored as necessary to meet local conditions;
    6. Ensure that OSH programs are operational and effective for every location in their region; and
    7. Ensure performance evaluations of any management official measures performance in meeting the requirements of the IHS OSH Program consistent with the employee's assigned responsibilities and authority, and taking into consideration any applicable regulations of the Office of Personnel Management or other appropriate authority.
  4. Area Safety Officer.   The designated Area SO shall be qualified by previous OSH training, experience, or education. As a collateral duty, the Area SO functions as principal advisor to the AD on OSH matters and as consultant and technical advisor to the Chief Executive Officer (CEO)/Administrators, health directors, administrative officers, facility SOs and employee health contacts. The Area SO will:
    1. Support a culture of safety;
    2. Provide technical assistance to Service Units in implementing and maintaining an effective OSH programs;
    3. Coordinate any necessary reporting activities and contribute Area data to the annual IHS OSH Report;
    4. Develop any necessary OSH related guidance documents, Area policies, Area circulars, and Area chapters;
    5. Provide leadership to the Service Units to ensure compliance with new or changing OSH regulations or requirements;
    6. Assess training and competency needs for SOs and those assigned safety responsibilities at the health care facilities and within OEHE offices/programs. The Area SO will recommend necessary training to be added to the local facility or Service Unit SO Career Development Plan and will assist personnel in gaining required competencies to perform their duties;
    7. Advocate for resources to support Area and facility safety programs from the AD and the Service Unit CEOs; and
    8. Conduct evaluations of Service Unit OSH programs to ensure compliance with this chapter, regulations, and laws.
  5. Area Office of Environmental Health and Engineering (OEHE) Director.   The Area OEHE Director will:
    1. Support a culture of safety;
    2. Ensure compliance with 29 C.F.R. Parts 1960, 1926, 1910 and applicable IHS OSH policy in field offices and on IHS managed construction projects;
    3. Ensure that a risk assessment/plan review on health care construction and renovation projects is conducted appropriate to project phasing to identify potential OSH and infection control issues, and to utilize feasible controls to address any identified issues. See also construction-related infection control risk assessment as required under IHS and Service Unit policies; and
    4. Monitor contractor compliance to 29 C.F.R. Parts 1926 and 1910 for projects performed under contract.
  6. Governing Boards.   Governing Boards play a critical role in ensuring accountability for compliance with standards and policy. Governing Boards should dedicate a portion of every meeting to a review of program plans, documentation, and pertinent quality and performance data related to staff and patient safety. Where deemed necessary, the Governing Boards may require additional data collection or the implementation of additional quality/performance activities and reporting. Governing Boards are responsible for requesting or pursuing training on OSH as needed to carry out their oversight responsibilities.
  7. Chief Executive Officer (CEO).   The CEO will:
    1. Ensure the protection of patients, visitors, employees, and property under their jurisdiction. The CEO shall ensure that all aspects of this policy are adequately implemented within their operations;
    2. Support a culture of safety, including accountability, blame-free investigation, and continuous improvement;
    3. Support an OSH program consistent with the requirements of this chapter and related IHS policy;
    4. Designate in writing, qualified individuals to serve as the SOs to carry out the requirements outlined in this chapter. Qualifications must be consistent with Manual Appendix 1-9-A of this chapter and the IHS Resource Requirements Methodology for staffing standards. The CEOs may delegate the authority to designate SO(s) to Health Services Administrators at smaller facilities;
    5. Assign, in a timely manner, a temporary Safety Officer during permanent SO vacancies or prolonged absences.
    6. Ensure that the SO’s competency is maintained through specialty training and other forms of continuing education offered at least annually; and that training needs are documented in their individual development plan;
    7. Authorize SOs to utilize such expertise from whatever source(s) available, such as universities, other agencies, professional organizations, consultants, and OSH committees in order to provide essential specialized expertise;
    8. Ensure SOs have appropriate time necessary to conduct OSH activities pursuant to this chapter;
    9. Acquire, maintain, and require the use of approved PPE, approved safety equipment, and other devices necessary to protect employees;
    10. Establish a local OSH committee and designate individuals responsible to serve on this committee;
    11. Establish and implement corrective and preventive action processes to:
      1. Address safety deficiencies and inadequately controlled hazards;
      2. Expedite action on inadequately controlled hazards that could cause serious injury and illness; and
      3. Track actions to ensure their effective implementation.
    12. Ensure managers, supervisors, and employees receive and complete required/needed training.
    13. Be responsible for employee involvement in:
      1. Planning, implementation and evaluation of the OSH program;
      2. Ensuring timely employee access to relevant OSH information; and
      3. Identifying and removing obstacles to employee participation.
    14. Ensure a risk assessment process is in place to:
      1. Assess equipment and/or materials being procured at the Service Unit;
      2. Identify any potential OSH issues; and
      3. Take feasible actions to proactively address any of these issues;
    15. Ensure that work performed in the Service Unit or facility by contractors complies with applicable standards found in 29 C.F.R. Part 1910 and 29 C.F.R. Part 1926.
    16. Inform contractors of any hazards they may be exposed to from IHS operations and what procedures to follow to prevent injury or illness to the contractor’s employees;
    17. Ensure that a management review of the OSH program is conducted at least annually. The process will review:
      1. Progress in the reduction of risk;
      2. Effectiveness of the risk assessment processes;
      3. Employee involvement;
      4. Status of corrective actions and follow-up on deficiencies and issues;
      5. Extent to which objectives are being met; and
      6. Overall performance and areas for improvement of the OSH program.
    18. Communicate safety program needs and achievements to the Governing Board. The CEO also must proactively communicate significant deficiencies that could jeopardize accreditation to the Area Office leadership and to IHS HQ, along with any request for assistance necessary to address the deficiencies.
  8. Occupational Safety and Health (OSH) Committees.    The OSH committees are an integral part of the OSH program, and they help ensure effective implementation of the program at the local level. These committees maintain an open channel of communication between employees and management concerning safety and health matters in IHS workplaces and patient care environments. Note that OSH committees are sometimes called Environment of Care Committees or the committee may be combined with other functions such as infection control at smaller facilities. The committees will:
    1. Include at a minimum, a representative of management, the SO, a facility manager, a representative of clinical services (if applicable), non-management staff in accordance with 29 C.F.R. § 1960.37 including union representation (if applicable), and other members deemed important to the OSH program.

      The Service Unit should provide adequate support to the committee in terms of meeting space, time to meet, and staff to provide administrative support (e.g., taking meeting minutes);
    2. Support a culture of safety, including collaboration, accountability, open communication, blame-free investigation, and continuous improvement;
    3. Assist in the development or review of OSH policies and procedures, when processes or equipment are changed, or otherwise as needed;
    4. Analyze issues arising out of injury/incident statistics and determine whether there are trends or general issues that need resolving;
    5. Assist in workplace safety surveys in support of the SO;
    6. Report to the organization’s governing board and provide assurance that OSH matters are considered; and
    7. Regularly inquire with staff regarding OSH concerns and provide regular updates to employees regarding OSH committee activities and OSH program activities/information.

    Further requirements regarding safety committees can be found in OSHA § 1960.36, Subpart F, Occupational Safety and Health Committees.
  9. OSH Committee Chairperson.    The SO should not be the chair of the OSH Committee. The SO should report to the committee on key program activities and issues. The OSH Committee Chairperson will:
    1. Establish a regular schedule of meetings and special meetings to be held as necessary to comply with OSH, CMS, and accreditation standards. Each organization should apply reasonable and prudent professional judgment when establishing meeting frequency so that risks, hazards, problems, failures, and incidents are minimized and resolved in a timely manner:
      1. Service Unit-level committees will meet at least quarterly;
      2. National and Area Office committees will meet at least annually, or preferably at least twice annually, and on an ad hoc basis as needed;
    2. Ensure that employee union representation is invited to attend safety committee meetings;
  10. Service Unit or Facility Safety Officer.    This section details responsibilities and duties for SOs at all operational levels within the agency. The SO shall:
    1. Support a culture of safety;
    2. Conduct, monitor, and evaluate the OSH program to meet current professional guidelines and regulations; specifically to include the Hazard Communication Standard (29 C.F.R. § 1910.1200);
    3. Develop, monitor, and maintain a program and documentation that are compliant with applicable regulations and health care accreditation standards;
    4. Participate in internal and external emergency management drills;
    5. Inform their leadership and OSH Committee of the results of OSH activities in accordance with this chapter or within more frequent timelines determined by local leadership;
    6. Consult with or assist supervisors and/or managers in preparing and maintaining safety manuals;
    7. Conduct or assist in job hazard analyses;
    8. Consult in, or develop safe working procedures, or other control measures including PPE use;
    9. Identify hazardous conditions through hazard surveillance rounds, reporting systems, or informal reports. All hazards identified must be documented (i.e. inspection reports, event reporting system) and monitored until corrected;
    10. Ensure that appropriate safety training and educational efforts are provided to supervisors, employees, and contractors;
    11. Conduct or coordinate specialized studies (e.g., industrial hygiene surveys) as needed to characterize OSH problems or issues; notify employees through their supervisors of the results of monitoring, testing, or safety inspections that were conducted in the work area;
    12. Provide review on new construction or renovation projects for compliance with applicable standards and codes (e.g., pre-construction risk assessments);
    13. Consult with other IHS OSH program personnel as necessary;
    14. Monitor, investigate, and manage occupational injury and illness incidents for facilities under their responsibility;
    15. Ensure that all reported incidents are investigated and analyzed. This includes all incidents or situations having potential for injury, illness, property damage, or affecting security. Incidents including near misses with a high potential for serious illness, injury or high property costs should also undergo a causal analysis (e.g., 5 Whys, root cause, fishbone) to determine the underlying management system weaknesses needing to be improved;
    16. Ensure the accuracy of OSHA recordable incidents entered as OSHA 301 Incident Reports in US DOL Employees’ Compensation Operations and Management Portal (ECOMP);
    17. Track progress toward correcting OSH deficiencies;
    18. Ensure that employee union representation is invited to attend hazard surveillance activities; and
    19. Ensure that appropriate OSH documentation and record keeping is being maintained.
  11. Infection Preventionist.   The Infection Preventionist will collaborate with the OSH program on areas of joint responsibility including, but not limited to:
    1. Pre-Construction Risk Assessments;
    2. Respiratory Protection Program implementation; and
    3. Job Hazard Analysis.
  12. Employee Health Specialist.   The Employee Health Specialist will collaborate with the OSH program on areas of joint responsibility including, but not limited to:
    1. Respiratory Protection Program implementation; and
    2. Employee Medical Surveillance.
  13. Supervisor/Manager.    Supervisors/Managers will:
    1. To the extent of their authority, furnish employees an environment which is free from recognized hazardous conditions;
    2. Comply with the OSH standards applicable to IHS – including this chapter, and with all rules, regulations, policies, procedures, and orders issued by any IHS OSH official with respect to implementing the agency OSH program;
    3. Develop safe work practices based on a job safety/hazard analysis, regulations, consensus standards, and other best practices. (See OSHA publication on Job Hazard Analysis, including forms in the appendices);
    4. Provide each new employee with a job-specific or department-specific safety orientation prior to commencing duties, when work processes or equipment change, and ensure all employees attend required safety training;
    5. Develop competencies for their employees in performing their jobs safely. Periodically evaluate and document the competency of their employees and where indicated, providing training where gaps in competency are identified during this evaluation;
    6. Provide required training as specified in policy and by applicable OSHA regulations;
    7. Ensure that all incidents in their department or to their staff are reported and investigated.
      1. The supervisor has the responsibility to file incident reports (IHS event reporting system and ECOMP as appropriate) in cases where the employee does not or is unable to submit the report.
      2. Supervisors additionally should complete their review of ECOMP reports within two days of receiving the ECOMP case notification email.
    8. Identify hazardous conditions and take corrective action to resolve deficiencies. Hazardous conditions that are repetitive, cross multiple departments, or require more significant permanent corrections should be reported to the SO and/or committee;
    9. Take timely and prompt corrective action on items identified during hazard surveys and other safety-related assessments;
    10. Notify employees of the results of monitoring, testing, or safety inspections that were conducted in the work area;
    11. Establish and support a culture of safety; set an example by following OSH policies and procedures, and enforce safety policy and procedure compliance by their employees; and
    12. Encourage meaningful employee participation (e.g., participation on committees, in safety inspections, training activities, incident investigations, job hazard analysis) in the OSH program.
  14. Employee.   Occupational safety and health is an integral part of every job and requires the effort and support of every person involved. Each employee shall:
    1. Comply with the standards, rules, regulations, and orders issued by any supervisor or IHS OSH official with respect to implementing the agency OSH program in accordance with section 19 of the OSH Act, Executive Order 12196, this chapter, and 29 C.F.R. Part 1960, which are applicable to their own actions and conduct;
    2. Be familiar with and comply with facility and department OSH policies and procedures;
    3. Learn and maintain competencies, and seek assistance when unsure how to conduct work safely, to include:
      1. Understanding the potential hazards in the workplace and using hazard control methods as directed by the supervisor and/or policy;
      2. Using safety equipment, PPE, and other devices provided or directed by IHS and necessary for their protection; and
      3. Keeping their equipment in safe working condition, with all safety guards on equipment and in functional condition, or turning equipment in for repair or replacement as needed.
    4. Maintain good housekeeping in the specific work areas, and remaining alert to hazardous conditions so as to protect health, safety, and property;
    5. Be responsible for reporting all incidents, near misses, and hazardous conditions to their supervisor and the SO through the IHS event reporting system;
    6. At the direction of the SO or infection control officer, enter OSHA recordable incident reports into ECOMP; and
    7. Contribute to a culture of safety by encouraging OSH policy and procedure compliance by their coworkers.


  1. Culture of Safety.   All IHS employees contribute to safety culture by integrating safety practices in how their daily responsibilities are carried out. As laid out in this chapter, elements of a culture of safety include: management commitment, common safety goals, collaboration across departments/disciplines, defined responsibilities for all levels of the organization, awareness and accountability of every individual in the organization, open communication regarding safety concerns, active reporting of safety issues, and effective, blame-free investigations that promote continuous organizational learning and quality improvement.
  2. Authority to Intervene.   In the event that a life threatening condition develops or imminent hazard exists, the SO, supervisor, or designee is authorized to terminate immediately the activity until the hazard is abated.
  3. No Risking of Life.   No person is expected to risk their life in the performance of any job.
  4. Hazardous Conditions.    All IHS employees, contractors, and management have a responsibility to identify and report conditions that are unsafe or unhealthful and may cause injury, illness or death to workers, patients, visitors; or may cause damage to property.
  5. Safe Work Practices.   Proper work practices shall be followed to ensure that personnel will not be exposed to serious injury or health hazards. All employees shall be provided on-the-job orientation and training regarding the hazards of the work environment and method(s) to perform their duties safely.
  6. Physical Fitness and Suitable Equipment.    Employees will be assigned only to those jobs they are physically qualified to perform safely and will be provided with appropriate equipment to carry out their job duties safely. It is the employee's responsibility to be fully aware of the physical requirements of the job as per the position description for that job. All facilities and locations will also comply with IHS policy and HHS policy on Reasonable Accommodation.
  7. Hierarchy of Controls.    When workplace hazards exist that cannot be eliminated, appropriate engineering controls, changes in work practices, or appropriate personal protective equipment (PPE) will be used to mitigate the hazard. The use of engineering controls shall be considered first for all hazardous operations. Where engineering controls are not possible, administrative controls or changes in work practices shall be used. Where hazards remain, PPE shall be used by all personnel engaged in hazardous operations. (For additional information on this topic, refer to OSHA Recommended Practices for Safety and Health Programs.)
  8. Personal Protective Equipment (PPE).  
    1. Indian Health Service Furnished Items.   Protective equipment not normally owned by workers in non-hazardous occupations will be furnished without cost to the individual as determined by a job hazard assessment. Examples of IHS furnished PPE include respirators, safety eyewear, hearing protection, helmets, and clothing impervious to blood and other body fluids or chemicals (e.g., gowns, aprons, and special gloves). For additional information, refer to OSHA Instruction Directive Number: CPL 02-01-050 - Enforcement Guidance for Personal Protective Equipment in General Industry and Respiratory Protection Program requirements of 29 C.F.R. § 1910.134. All PPE will meet the applicable design requirements [e.g., respirators approved by the National Institute for Occupational Safety and Health, eyewear compliant with the American National Standards Institute (ANSI), gloves rated by the American Society for Testing and Materials].
    2. Employee Furnished Items.   Any PPE that is readily adaptable to private use will not ordinarily be furnished. Examples are coveralls, ordinary gloves, and work shoes.
  9. Employee Rights and Protection.  
    1. Employees have the right to stop or suspend work, if they feel an imminent danger exists, until such time that the condition can be evaluated by a competent person. A Competent Person, per OSHA requirements:
      1. Has developed competence through education, training, mentoring, experience, certification, licensing and performance assessment; and
      2. Is capable of identifying existing and predictable hazards in the surroundings or working conditions which are unsanitary, hazardous or dangerous to employees, and who has authorization to take prompt corrective measures to achieve feasible risk reduction to that hazard.
    2. Employees have the right to consult confidentially with the designated Service Unit Employee Health Specialist regarding potential or existing health hazards related to their work environment or a change in their health status.
    3. Employee reports of incidents will be treated as blame-free except when investigation clearly indicates willful or reckless action.
    4. No person shall discharge, or in any manner, discriminate against any employee because such employee has:
      1. Filed any complaint;
      2. Instituted or caused to be instituted any proceeding related to safe and healthful working conditions;
      3. Testified or is about to testify in any such proceeding; or
      4. Exercised on employee’s own behalf or on behalf of others of any right afforded by law.
    5. Employees may request access to incident data compiled per OSHA Recordkeeping requirements in accordance with 29 C.F.R. § 1904.35 and HHS Safety Manual Chapter 4.
    6. Employees will be authorized official time to participate in OSH program activities.
    7. Employees will be encouraged to participate in the development, implementation, and evaluation of the OSH program.
    8. All IHS Federal civilian employees assigned under an IPA or U.S. Public Health Service Commissioned Corps Officers detailed under a Memorandum of Agreement will be afforded the same level of OSH protection as prescribed in this policy.
    9. If collective bargaining is present, Union representation must be considered in the management of the OSH program. Union representatives must be invited to OSH committee meetings (attendance is not mandatory) and may accompany OSH personnel during the evaluation of any workplace. Employees will be authorized official time to participate in union activities per collective bargaining agreement.


The minimum OSH program for the IHS shall include the following elements:

  1. Allocated Resources.    Appropriate resources for an agency’s and a facility’s OSH programs shall include, but not be limited to:
    1. Sufficient personnel to implement and administer the OSH programs at all levels;
    2. Appropriate financial, human, and organizational resources to plan, implement, operate, check, correct, and review the OSH programs;
    3. Abatement of hazardous conditions related to agency operations or facilities;
    4. Safety and health sampling, testing, procuring diagnostic and analytical tools, equipment, and/or services, including laboratory analysis;
    5. Any necessary contracts to identify, analyze, or evaluate hazardous conditions and operations;
    6. Program promotional costs such as publications, posters, or media;
    7. Technical information, documents, books, standards, codes, periodicals, and publications; and
    8. Medical surveillance programs for employees.
  2. Safety Officer Staffing and Management.  
    1. Safety Officer Requirements.   The SOs will function as staff advisors to program managers in OSH matters.
      1. All TJC-accredited facilities and CMS-certified inpatient facilities will have a SO whose primary duties are to ensure the safety and health of IHS staff, patients, and visitors.
      2. Accredited ambulatory health centers are to have at least a collateral-duty SO with a recommended minimum of 50 percent of staff time and duties devoted to OSH.
        1. Collateral-Duty SOs should have their position descriptions amended to describe the OSH duties.
        2. Duties should also be placed in the employee’s performance assessment (e.g., Performance Management Appraisal Program or Commissioned Officer Effectiveness Report).
      3. During interim periods when the SO position is vacant, Chief Executive Officers (CEOs) must assign a local Temporary Safety Officer to be actively supported by the facility OSH Committee. (Refer to Manual Appendix 1-9-A for additional qualification and training requirements and recommendations.)

      According to 29 C.F.R. § 1960.25, OSHA requires that the SO be qualified and competent. The IHS will follow the U.S. Office of Personnel Management (OPM) established minimum criteria for Safety and Occupational Health Specialists. (Refer to Manual Appendix 1-9-A for additional qualification and training requirements and recommendations.) The SO must meet minimum requirements, and continued competence in the position is needed, which may be fulfilled through additional education, training, and/or experience.
    2. Organizational Placement.  
      1. The SO position should be located in the chain of command of Executive Leadership.
      2. Placing the SO under a leadership position demonstrates a commitment by the CEO to managing all risks in their facility as fundamental to a culture of safety and consistent with health care accreditation standards. Organizations are cautioned about placing safety staff under the supervision of departments where potential conflicts of interest could occur.
  3. Establishment and Maintenance of Active OSH Committees.   Facilitating the involvement of leadership, department managers, and employees in the OSH program is fundamental to the success of the program. Each Area and facility leader must establish a multi-disciplinary committee of leadership, managers, and employees to oversee the implementation of the OSH program and to provide support to SOs. Where collective bargaining agreements are in place, the OSH committee chairperson will advise the union representative of all OSH committee meetings. The OSH committees must be engaged in hazard identification, staff development, formulation of policies and procedures, incident analysis, hazard communication, and program evaluation. Records of OSH committee meetings, reports, and actions shall be maintained in accordance with the records management schedule, and as appropriate, be made available to employees.
  4. Standards for IHS OSH Program.  
    1. The IHS will comply with all OSHA standards applicable to its operations. For information on alternate and supplemental OSH standards see 29 C.F.R. §§ 1960.16, 17, and 18.
    2. When an issue is not specifically addressed by this chapter, the IHS will comply with Department of Health and Human Services (HHS) policy as presented in the HHS Safety Manual.
    3. The use of consensus standards, guidelines, and other best practices (e.g., the Occupational Health and Safety Standard of the International Organization for Standardization: ISO 45001) are encouraged and should be used to ensure employees’ optimal protection against OSH hazards and to reduce the risk of injury and illness.
  5. Review, Development and Implementation of OSH Policies and Procedures.    The formulation of appropriate policies and procedures is essential to ensuring the safety and health of all employees. Policies may be established at the Area, Service Unit, facility, or department level. Procedures based on best practices, current standards, and facility needs should be developed at the department or facility level, but are encouraged to be standardized across locations when feasible. Policies and procedures must be reviewed on a regular basis by the relevant OSH committee with input from affected stakeholders, and with final approval by facility leadership or governing boards in accordance with standard practice. Policies and procedures should be maintained available to all staff, and appropriate training should be provided as per this chapter.
  6. Dissemination of OSH Program Information.  
    1. Copies of the OSH Act, Executive Order 12196, OSH program elements published in 29 C.F.R. Part 1960, details of the IHS OSH program, and applicable OSH standards will be made available upon request to employees or employee representatives for review.
    2. Electronically accessible copies of the IHS OSH program policies and procedures will be made available to each supervisor, each OSH committee member, and to employee representatives.
    3. All IHS facilities will display conspicuously and continuously a poster informing employees of the provisions of the OSH Act, Executive Order 12196, and the IHS OSH program. Per 29 C.F.R. § 1903.2, this poster should be posted where notices to employees are customarily posted (e.g. Human Resources Department, Safety bulletin board, union offices, employee break areas). A copy of the basic poster is available from OSHA’s Free Workplace Poster webpage.
  7. OSH Orientation and Training for All IHS Employees.   Orientation and training is required under 29 C.F.R. Part 1960 Subpart H. Timely training is essential to ensure successful implementation of the OSH program. This includes the development, promotion, and distribution of educational materials and activities designed for patients, employees, and the public. Based on the scope of services provided and potential hazards at each location, specific and mandatory training may be required by regulatory and accreditation entities. Individual facilities should identify those training courses that will meet these requirements and identify them by policy.
    1. Executives and Senior Leaders.   The IHS management, at both the HQ and Area level, shall be briefed on the IHS OSH program and statutory safety requirements during orientation. Topics to be covered during the briefing are Section 19 of the OSH Act, Executive Order 12196, 29 C.F.R. Part 1960, and Indian Health Manual, Part 1, Chapter 9. Required orientation training will include the Managers and Supervisors Safety Awareness Training (MSSAT) Part 1 (or equivalent), which can be found on the HHS Learning Portal.
    2. Managers and Supervisors.   The IHS supervisors are one of the most important assets for implementation of an effective OSH program. The supervisor is responsible for providing their employees with job-specific safety training, ensuring competence in performing their jobs safely, and providing a safe environment for their employees. Training and orientation of supervisors in OSH issues must be a priority. Required orientation training includes the MSSAT Parts 1, 2a, 2b, 3a, and 3b (or equivalents), which are available on the HHS Learning Portal. Supervisor OSH training will cover the following topics:
      1. Supervisory responsibility for providing and maintaining a safe and healthful work environment;
      2. Indian Health Manual, Part 1, Chapter 9;
      3. Executive Order 12196;
      4. Section 19 of the OSH Act;
      5. OSH standards applicable to specific work environment supervised;
      6. Procedures for reporting and investigating allegations of reprisal;
      7. Procedures for the identification, mitigation, and abatement of hazards;
      8. Training and reference materials to enable supervisors to recognize, reduce, or eliminate OSH hazards within their work unit;
      9. Training to develop skills for managing the OSH responsibilities within the work unit to include training and motivation of employees within the work unit to participate fully in the OSH program;
      10. Training and involving their employees when performing job safety/hazard analysis and developing standard operating procedures (SOP); and
      11. Best practices for occupational injury and illness prevention.
    3. Employees.    The IHS employees are the primary beneficiaries of a successful OSH program. Their full participation is fundamental to its implementation and success. Employees must receive a safety orientation within 30 days of hire, annually thereafter, following any changes to hazards or processes, and following the identification of a knowledge deficiency. Orientation and training will cover general safety rules and any special precautions to cover local conditions or unusual circumstances pertaining to their particular type of work or work environment. Employees will receive OSH training to include:
      1. Specialized job safety and health training for specific tasks within the work unit. In addition to job specific training, key safety information (e.g., lock-out/tag-out procedures for safe maintenance on energized/pressurized systems) should be incorporated by their supervisor into SOPs and/or included on computer generated preventive maintenance/work order requests.
      2. Detailed orientation to the IHS OSH and employee health program with emphasis on the employee’s rights and responsibilities.
      3. Representatives of employee groups, such as labor organizations, which are recognized by the IHS, will receive OSH training on par with Service Unit employees.
      4. Service Unit employee OSH training will be determined based on requirements from findings from occupational risk assessments, health care accreditation requirements, hazard surveillance activities, and incident statistics.
    4. Safety Officers (Including Collateral Duty and Temporary).    Training and competency for facility SOs and IEHSs within the IHS shall be commensurate with the breadth and scope of their duties and responsibilities, along with the services provided and the inherent risks of their facility (refer to Manual Appendix 1-9-A for more detailed training requirements and recommendations). Regularly scheduled continuing education is strongly recommended. The SO should work with their supervisor to develop an Individual Development Plan based on the information in the SO section, and in conjunction with Service Unit SO and Area IEHSs.
  8. Contractor Safety.  
    1. Contractors working in IHS facilities must be informed of IHS safety policies and procedures, and hazards to which they may be exposed (see OSHA Recommended Practices for Safety and Health Programs section on Communication and Coordination). If contractors are managed by IHS staff, the agency has a responsibility to ensure their safety.
    2. If OSH hazards are identified in construction and/or renovation locations managed by IHS, the agency shall inform the contractor of said hazards.
  9. Motor Vehicle Safety.  
    1. All government motor vehicle operators and all IHS employees riding in Government or private motor vehicles on Government business must use seat belts.
    2. Government motor vehicle operators shall require all passengers to be properly restrained with seatbelts and/or appropriate child-restraint devices.
    3. The use of a cellular phone by operators of government motor vehicles, or private motor vehicles on government business, while the vehicle is in motion is only permissible through the use of a hands free device and only where permissible by state or local law. Additionally, cellular phone use is prohibited during fueling operations, or when flammable vapors are present.
    4. All government motor vehicle operators are required to possess a current and valid driver’s license in any recognized U.S. State. Employees required to drive in the course of their work must immediately inform their supervisor if their license is suspended, revoked, or restricted. At no time should the employee operate a vehicle without a valid license.
    5. Vehicle operators are prohibited from operating a vehicle within eight hours of the consumption of alcohol, or longer if residual effects remain.
    6. Vehicle operators must inform their supervisor if prescription medications, fatigue, or other health conditions may impair their ability to operate vehicles.
    7. Employees operating Personally-Owned Vehicles on HHS campuses or facilities will obey all Federal, state, and locally posted traffic laws; and ensure that their vehicle is in safe and proper working order at all times.
  10. Plan Review and Hazard Assessment.    New construction, repairs, or improvements shall be reviewed by the Facility Manager and SO for compliance with applicable safety codes and standards (e.g., The National Fire Protection Association and TJC).

    New processes or tasks will be evaluated for potential or recognized hazards by department supervisors, with the support of the SO or Infection Preventionist. Where hazards are identified, appropriate protective measures such as eliminating the hazard, engineering controls, OSHA-approved warning signage, ANSI-approved eyewashes, or administrative controls will be implemented through the department and/or OSH committee as necessary. High-risk tasks or processes, or those tasks identified as of concern to employees or supervisors, will be periodically reviewed and will be surveilled during standard annual surveys and inspections.
  11. Inspections.    As required by 29 C.F.R. § 1960.25, IHS will conduct inspections of all workplaces annually, prepare reports prescribing recommendations for corrective action, and complete follow-up to ensure that appropriate actions were taken to mitigate or remove the hazard.
    1. Refer to the OSHA Recommended Practices for Safety and Health Programs for guidance on hazard identification and assessment.
    2. Frequency of Inspections.
      1. An inspection of all workplaces to identify safety and health hazards will be completed at least annually by the SO/OSH Committee in collaboration with department supervisors and employees. Inspections should be completed by September 30 of each year to allow corrective actions within the calendar year.
      2. Locations with stored hazardous chemicals shall be evaluated for hazards twice per year at a minimum. Patient care environments will be inspected at frequencies consistent with applicable accreditation requirements. Additional assistance may be sought from employee health staff, infection preventionist, and Area IEHSs, or other specialists as appropriate to the hazard.
      3. Inspections shall be conducted more frequently in environments where there is an increased risk of incident, injury, or illness due to the nature of the environment, the condition and mobility of the patients, or activities occurring in the facility that may negatively affect the patient population.
    3. Hazardous conditions identified through surveys, employee reports, or other methods must be promptly abated. Where immediate or short-term correction is not feasible, appropriate interim control measures will be implemented, and a summary of the issue and resources required for correction will be provided to leadership staff for their review and action.
  12. Employee Reports of Hazardous Conditions.   
    1. Any hazardous condition identified on or in IHS property, or resulting from a work practice must be reported promptly.
    2. The preferred means by which any employee can report a hazardous condition is through the IHS event reporting system as described below.
    3. In the case of imminent danger situations, employees shall make a verbal report to the supervisor and SO by the most expeditious means available.
    4. Since many OSH problems can be eliminated as soon as they are identified, the existence of a formal reporting mechanism shall not preclude immediate corrective action by an employee's supervisor in response to oral reports of hazardous conditions where such action is possible. Nor should an employee be required to await the outcome of such an oral report before filing a report utilizing the IHS event reporting system or other written means.

      Further requirements regarding reports of hazardous conditions are found in OSHA § 1960.28, Employee Reports of Unsafe or Unhealthful Working Conditions.
  13. Reporting of Injuries, Illnesses, and Other Incidents.  
    1. Types of Incidents.   
      1. Incident.   (See Serious Incident definition below.) The following list provides a range of events considered incidents.
        1. Motor Vehicle Incident.   Any motor vehicle mishap whether or not an injury resulted, that involved employees:
          1. On IHS property; or
          2. Off IHS property while conducting IHS business.
        2. Occupational Injury.    Work-related injuries to an employee, contractor, student, or volunteer.
        3. Occupational Illness/Disease.    Work-related illnesses to an employee, contractor, student, or volunteer including:
          1. Physiological harm or loss of capacity produced by systemic infection;
          2. Continued or repeated stress or strain;
          3. Exposure to toxins, poisons, or fumes; or
          4. Other continued and repeated exposures to conditions of the work environment over a long period.
        4. Patient Incident.    An injury or illness not related to the receipt of medical care that occurs to a patient while:
          1. In an IHS facility;
          2. On IHS property; or
          3. In IHS care.
        5. Property Damage.    Any damage to government property; any damage to privately owned property used on official business; or any damage to private property by IHS employee(s) while on official business.
        6. Security Incident.    Any breach of defined security policies. This includes instances of workplace violence, such as verbal, physical, or sexual assault; domestic violence or stalking; intimidation or threatening behavior.

          Incidents of workplace harassment should be reported in accordance with IHM Part 11 - Chapter 6 - Prevention of Workplace Harassment for investigation and response by Human Resources and Equal Employment Opportunity Staff.
        7. Visitor Incident.   An injury or illness that occurs to a member of the general public while in an IHS facility or on IHS property but not for purposes of receiving treatment or medical attention.
      2. Serious Incidents.   
        1. Types of Incidents.  
          1. Fatality resulting from a work-related injury or illness/disease, or fatalities of others at IHS facilities or on IHS properties that are not related to that person’s receiving medical treatment. (Patient care related fatalities must be reported according to other applicable policies and regulations (e.g., 42 C.F.R. § 482.13(g), 42 C.F.R. § 482.23(c)(5), and TJC Sentinel Event Policy).);
          2. Work-related inpatient hospitalization, amputation, or loss of an eye;
          3. First-aid treatment of five or more workers, patients, or visitors, in a single event or occurring at an IHS facility, duty location, or during work-related travel;
          4. Property damage of $25,000 or more;
          5. All aircraft incidents reportable to the National Transportation Safety Board per Federal aviation regulations;
          6. Radiation overexposure (as set forth by OSHA in 29 C.F.R. § 1910.1096(b)(1); or
          7. Biological exposure (excluding “routine” blood borne pathogen exposure) or unintentional release of biological substances where the public may be exposed.
        2. Authorities Receiving Reports.  
          1. Fatalities, hospitalizations, amputations, losses of an eye (items (i)(a)-(b) above) must be reported to OSHA. See Section (2)c – Reporting Systems below; and
          2. All serious incidents must be reported to HHS through the IHS IEH Program.
    2. Reporting Systems and Processes.  
      1. Internal IHS Reporting System.    All incidents, regardless of cause, consequence, damage, or location, will be reported to the immediate supervisor on duty and through the IHS event reporting system.

        Staff should also be aware of and comply with IHM Part 11 - Chapter 6 - Prevention of Workplace Harassment.
      2. HHS/Department of Labor (DOL).    All HHS Operating Divisions are mandated to use the currently approved data submission process [such as US DOL Employees’ Compensation Operations and Management Portal (ECOMP)] to submit OSHA recordable injury information to the Bureau of Labor Statistic as required by 29 C.F.R. Part 1904 and for filing of claims to Office of Workers’ Compensation Programs.
      3. Reporting Serious Incidents, Injuries, and Illnesses.    All serious incidents must be reported to the CEO, the AD, the Area IEH Program, the Headquarters (HQ) IHS IEH Program Manager, and the HHS Safety Manager as soon as practical (within eight hours). Within eight hours, a report of any employee fatalities and severe injuries (including in-patient hospitalizations, amputations, or losses of an eye) must be reported to OSHA by calling 1-800-321-OSHA (1-800-321-6742) or by using the online report form. The report must also be submitted to IHS management.
        1. A message or report shall be sent immediately, via secure FAX or secure, encrypted electronic mail, to the IHS HQ and the respective Area IEHS who will coordinate notification of the HHS Safety Manager. The message must include the following information:
          1. Name(s) of individual(s) involved;
          2. Number of fatalities and/or injuries and illnesses and their extent;
          3. Establishment name, time, date, location, type of incident, and kind of operation conducted at the incident site;
          4. A narrative describing the incident;
          5. Actions taken by the IHS to investigate the incident; and
          6. Whether OSHA assistance is needed.
        2. More information on the Serious Incident Notification procedure is available in the HHS Safety Manual.
    3. Retention of Records.    Incident reports prepared in accordance with these procedures are for the management and improvement of the safety program throughout the IHS. Every effort shall be made to ensure their security for future reference against loss or destruction. All reports and related information shall be retained within the Agency for a period of at least five years following the end of the calendar year in which the incident occurred in accordance with records management policy. Disclosure of this information should be in accordance with the record keeping regulations and Privacy Act procedures for IHS employees.
  14. Incident Investigation and Incident Data Analysis.   Effective safety interventions are based on timely and comprehensive reporting and analysis of all incidents. All occupational injury and illness incidents shall be reported using the approved IHS event reporting system. Data entered into the IHS event reporting system will be used by SOs to identify trends and develop successful intervention strategies. Consistent with blame-free reporting culture, investigations will focus on system attributes that contributed to incidents, and only assign individual responsibility where willful or reckless acts are involved. Where feasible, root cause analysis to determine all levels of causes (worker, supervisory, management) of the incident will be performed to reduce the risk of a similar incident from reoccurring.

    Incident reports will not be used by the IHS as evidence or to obtain evidence in any disciplinary, administrative, or legal action unless internal investigation into the incident clearly indicates willful or reckless action.
    1. Incident Investigation.    The objective of blame-free incident investigation and analysis is to determine underlying safety deficiencies and other factors that may be causing or contributing to the occurrence of incidents. The information obtained from the investigation is used to develop procedures essential to the maintenance and improvement of the OSH programs throughout the IHS.
      1. The SO shall ensure that all reported incidents are investigated and analyzed until closure of cases with documentation of completion. Investigations may be delegated by the organization to other relevant staff (e.g., risk manager, employee health specialist, security supervisor, facility manager).
      2. Departmental supervisors, OSH committee members, employees, and administrative personnel may also be called upon to assist in the investigation.
      3. The department head or supervisor shall provide prompt and factual information regarding injuries/illnesses occurring to staff, patients or visitors, security issues, and property damage or allegations thereof.
      4. The results of the investigation shall be treated confidentially and released to appropriate individuals or entities limited to, and consistent with IHS policy.
      5. The SO will ensure that the results of the incident investigation and analysis are documented in the IHS event reporting system. Where the data initially entered is determined to be incorrect, the SO will correct/update the data.
      6. In support of continuous learning, the SO in collaboration with management will implement the hierarchy of controls and revise policies and/or procedures based on opportunities for improvement identified during the investigation. Employees will receive training on any changes to the environment, policies, or procedures from their supervisors, with the support of the SO or other pertinent staff.
    2. Incident Data Analysis.   The SO will analyze incident data to report aggregated or de-identified incident investigation findings to leadership (CEO/Service Unit Director/Administrator) and the OSH committee to solicit input and support for recommended corrective or preventive action, or to receive advice and recommendations on the proper course of action. Solicitation of input is useful when incidents are complicated or a pattern of recurring incidents are happening, but does not limit the SO by the authority in Section 1-9.3N(1)a.
  15. Recordkeeping.   Upon notification of an occupational injury or illness, the SO should log into the IHS event reporting system as soon as possible to initiate the investigation. Within seven days of notification of the incident, the SO must make a determination whether, based on the investigation, the reported incident meets the OSHA recording criteria.

    All cases reported into the DOL reporting system (ECOMP) must also be reviewed and a determination of recordability registered.
    1. OSHA Recordkeeping Requirements.  
      1. Log of Occupational Injuries and Illnesses.   The Facility SO or designee shall maintain a log of OSHA recordable occupational injury and illness incidents (OSHA Form 300, or equivalent). This information will be electronically available through the IHS event reporting system. Copies of this log will be available in accordance with current OSHA recordkeeping regulations.
      2. Annual Summary of Federal Occupational Injuries and Illnesses.    The Annual Summary of Federal Occupational Injuries and Illnesses (OSHA Form 300A, or equivalent) will be completed based on data available in the IHS event reporting system based on data from the OSHA Log of occupational injuries and illnesses meeting the OSHA recording criteria. The Facility SO, or authorized reporting system user, will ensure the report for their facility:
        1. Covers the most recent full calendar year (January 1 through December 31) just ended;
        2. Is signed by a high-level IHS manager (i.e., Executive Officer, AD, or CEO).
        3. Is posted conspicuously within the facility from February 1 through April 30; and
        4. Is available for review by current employees, past employees or their representatives in its entirety upon request in accordance with 29 C.F.R. § 1904.35.
      3. Sharps Injury Log.    The facility SO, Infection Preventionist, and/or Employee Health contact will investigate and ensure that percutaneous injuries from contaminated sharps are recorded on a Sharps Injury Log. The Sharps Injury Log must contain all the elements required 29 C.F.R. § 1910.1030(h)(5) and be retained in accordance with 29 C.F.R. § 1904.33. This information will be available electronically within the IHS event reporting system.
    2. Incident Accountability.  
      1. Incidents involving employees while on long-term detail to Tribal organizations are to be reported to, and recorded by, the activity and agency to which the employee is detailed.
      2. Commissioned Corps and civilian personnel on temporary tour of duty to other Federal agencies or divisions will report all occupational injuries and illnesses to their parent organization and will be included in the injury recordkeeping system of that parent organization.
      3. Incidents involving employees while visiting another location or agency for official purposes (on official travel) are to be reported and charged to the parent organization.
      4. Employees that do not primarily report or work at a single facility and are not generally supervised in their daily work will have their incidents documented and maintained at the base facility from which they operate.
      5. Employees injured while in a permanent change of station status will be reported by the gaining activity and charged to its injury surveillance.
  16. OSH Program Evaluation.  
    1. The OSH Committees will conduct program evaluations using methods or tools such as the OSHA Assessment Tool for Hospitals to determine:
      1. Compliance with requirements set forth in Executive Order 12196;
      2. Effective implementation of the OSH program at the field level; and
      3. Success of maintaining a culture of safety. Examples of culture assessments include:
        1. OSHA Hospital Safety and Health Management System Self-Assessment Questionnaire
        2. Leading a Culture of Safety: A Blueprint for Success.
    2. Annual Agency Occupational Safety and Health Program Evaluation.
      1. This report is developed by the DASHO, or designee, each calendar year to communicate the status of IHS OSH programs. The IHS self-evaluation format will follow the guidelines developed by the HHS Safety Manager and mandated by the DOL for the annual safety report. The results of the IHS self-evaluation will be reported to the Secretary of Labor through the appropriate administrative procedures within the IHS and the HHS. The annual IHS OSH self-evaluation report will also be presented to the Director, IHS.
      2. The DASHO may request safety information from IHS facilities and Area Offices to complete the annual evaluation.
    3. Health care facility safety programs must be evaluated in accordance with applicable accreditation requirements. The results of these evaluations shall be communicated to the OSH committee, facility leadership, and the governing board.
  17. Recognition of Safety Efforts.    Leadership and Management at all levels of the organization are strongly encouraged to recognize, and as appropriate, reward employees and OSH staff for their contributions to a culture of safety or notable accomplishments toward achieving the goals of this policy. Recognition should be both informal, and formal through nominations for Service Unit, Area, or national awards.