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UW Medical Foundation
SAFETY POLICIES AND PROCEDURES
Subject: OSHA Inspection Policy
Effective Date: 7/05 Approved: Steve Sibley, VP Clinic Ops
Supersedes Policy Date: Revision #
Distribution: Safety Manual
I. POLICY STATEMENTS:
This guide sheet is intended to be used should an OSHA Compliance
Officer arrive at your facility. It is important that the below steps are
followed in sequential order. Attached is a checklist for quick reference.
A. Notify the site supervisor and have officer sit in waiting room area.
The site supervisor should ask to see officer’s credentials and find
out why he/she is present.
Is he/she investigating an accident?
Is he/she following up on a complaint?
Is this a programmed inspection?
B. Contact the site’s Vice President and Legal Counsel immediately.
Also contact OSHA District Office at [insert phone number ] to verify
1. OSHA regulations suggest that the employer has one to two hours to
gather their representatives. Note: Absent an “imminent danger”,
an employer always has the right to demand that OSHA obtain a
warrant prior to inspection. If OSHA insists on inspecting without
the authorized representative present, a suggestion to the officer
that a warrant will be necessary in the absence of the authorized
representative may gain cooperation in scheduling the inspection
such that necessary personnel can be located and brought into the
2. An opening conference will be held in which the compliance officer
explains how the facility was selected and determines whether an
inspection will occur. The site’s Vice President (or designee), and
a representative from Legal Services, Facilities, Human
Resources, Employee Health/Infection Control and Safety
should participate (on location or via conference call) in an opening
conference with the compliance officer. If there is a contractor issue,
have the general contractor representative present as well.
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3. During the opening conference, determine the scope of the
inspection. The scope must bear an appropriate relationship to the
violation alleged in the complaint or the focus of the programmed
inspection. If a complaint inspection, obtain a copy of the complaint
without the complainant’s name. If a programmed inspection,
obtain a copy of the program protocols. Verify proper selection of
the facility under the protocol (i.e. proper SIC Code, type of work,
injury and illness incidence rates or presence of equipment and
operations covered by the protocols). Depending upon the reason
for inspection, the officer may chose to do a wall-to-wall inspection,
which could last upwards to a week. An employee representative
may be selected by OSHA to accompany the inspection.
C. During the Inspection:
The officer must conduct the inspection within normal business
Stay with the officer and take notes. Volunteer nothing.
When stating a violation, the officer should cite the appropriate
standard that speaks to the violation.
The officer may talk with the employees in private, but cannot
disrupt operations. Take note of all employees interviewed, but do
not do so in a manner that intimidates the employees.
Never admit to wrong doing and avoid discussions committing to
Write up a complete report and point out any variance between
The officer may wish to take photos or video tape, use air sampling
equipment and/or examine injury/illness records and other safety
related policies/procedures. Proper consideration must be given to
patient rights and confidentiality of medical information. When in
doubt, discuss privacy concerns with OSHA and contact legal
Again, the focus of the inspection should be limited to the purpose of
The closing conference is held after the inspection with the
compliance officer. The people present for the opening conference
and inspection will attend the closing conference.
D. During the Closing Conference:
1. Continue to make a record of what is said.
2. Question the officer as to all the possible/probable violations, but
3. Insist on a full explanation of findings.
4. After officer leaves, prepare a full memorandum of the inspection.
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E. Inspection Results
1. The area OSHA director reviews the compliance officer’s findings and
determines if citations will be issued and if penalties will be proposed
(up to $7,000 each for service violations and up to $70,000 for
repeat or willful violations).
2. Upon receipt, a copy of the citation(s) must be posted at the
3. If employer wishes to contest any of the citations, a notification
must be sent to OSHA within 15 working days of a Notification of
4. An informal conference may be scheduled with OSHA to discuss the
citations, but this does not stop the clock on the 15
deadline. Therefore, the informal conference must be scheduled
soon enough during the 15 day period to leave time for the decision
regarding settlement or contest of the citations.
5. Because all citations may be used against other facilities within the
organization, legal services must be notified of any citations and
approve any resolutions with OSHA.
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OSHA INSPECTION CHECKLIST
Recommended Action Action
1. Notify supervisor, have
officer wait in waiting room
2. Verify officer credentials,
call Madison OSHA office
3. Contact Vice President,
safety coordinator and other
opening conference members
(ask officer for time to
have members present)
4. Opening conference:
determine scope of
inspection, request copies of
complaint or program
5. Inspection: take notes,
cite standards for each
violation, protect privacy
6. Closing conference:
7. Safety Coordinator to
create final report for
8. Upon receipt, post OSHA
citations at affected facility
9. If necessary, contest
citations within 15 working
IMPORTANT PHONE NUMBERS:
Madison OSHA District Office 608-441-5388
OPENING CONFERENCE MEMBERS:
Administration (VP’s, Legal Services, HR) 608-821-4100
Clinic Operations 608-287-2880
Theresa Soik, Director of Facilities Mgmt 608-282-8188
Mike Holman, Safety Coordinator 608-287-2182
Debbie McDonnell, Employee Health/Infection Control Coord 608-287-2595