Executive Council

Authorizes Release:

Vice President for Administration and Finance

Responsible Area:

Administration - Risk Management

Review Cycle:

Annually or as required

Last Review:

August 2020

Related Policies and Additional References:



The President and Executive Council of St. Mary’s University are committed to providing a safe and healthful work environment for all our employees, students, and others that may work, visit, or enter our facilities.

It is our policy to provide a working environment that is free from any recognized or potential hazards and comply with all federal, state and local safety and health regulations.

We recognize that the success of a safety and health program is contingent and dependent upon support from the executive level of management down to involvement of all employees of St. Mary’s. This policy applies to all employees and persons affected or associated in any way by the scope of this business.

Authority and Accountability

The Vice President for Administration and Finance of St. Mary’s is responsible for the development and implementation of the safety and health program, and may delegate any or all portions of the plan to subordinates but will be held responsible for the performance of the plan. The Vice President for Administration and Finance also has the authority to approve or carry out disciplinary actions against those that violate policies, procedures, or rules.

Faculty and supervisors are responsible and will be held accountable to ensure that all employees under their control follow all safety and health policies, procedures, and rules established by St. Mary’s University. They are also responsible for administering training and guidance to employees under their direction. Faculty and supervisors have the authority to reprimand and recommend disciplinary actions against employees that violate the safety and health policies of St. Mary’s University.

Employees are responsible and will be held accountable for providing St. Mary’s University with a commitment to the safety and health program, abiding by the policies, procedures, rules set forth by the program, and becoming actively involved in the program to assist in providing a safe and healthful workplace for all involved.

Employees are encouraged to communicate their safety and health concerns with management to implement changes in our program where needed to reduce injury exposures in the workplace.

Contractors that provide or perform services for this company, at any location, are responsible to ensure that all employees’ actions and services delivered are in a manner consistent with our commitment to safety and health. The Accident Prevention Plan will be made available to all con-tractors for review.

Record Keeping

St. Mary’s University believes that the only valid means of reviewing and identifying trends and deficiencies in a safety program is through an effective record keeping program. The record-keeping element is also essential in tracking the performance of duties and responsibilities under the program.

St. Mary’s University is committed to implementing and maintaining an active, up-to-date record-keeping program.

Injury and Illness Data

Human Resources will maintain records of all work-related injuries and illnesses to our employees.

The following records are applicable only to work-related injuries and illnesses.

Applicable forms or records:

  • OSHA 300, Log of Recordable Injuries and Illnesses or equivalent if required;
  • Texas Workers’ Compensation Commission form TWCC-1, Employer’s First Report of Injury;
  • Record of first aid or other non-recordable accidents/incidents.

The OSHA 300, Log of Recordable Injuries and Illnesses, or an equivalent record will be maintained in Human Resources.

The completed OSHA 300 Log will be posted in Human Resources for employee review no later than each Feb. 1, for the previous calendar year and will remain in place for the period required by OSHA.

All data pertaining to injuries or illnesses that did not require medical treatment or were otherwise not recordable on the above-mentioned documents will be maintained in written record form. This will include first aid treatment of any kind. All injury and illness documentation will be reviewed annually in January by management and supervisors to analyze occurrences, identify developing trends, and plan courses of corrective actions. These records will be maintained a minimum of five years or as required by law.

Safety and Health Surveys and Inspections/Program

Safety audits and inspections will be conducted under the supervision of the Vice President for Administration and Finance. The Enterprise Risk Management Team will review the results of all safety audits and inspections that are conducted within or that affect St. Mary’s, our employees, or facilities.

Applicable forms or records:

  • Comprehensive survey reports and records of action taken; and
  • Documented checklists of self-inspection and records of action taken.

Reports generated as a result of comprehensive surveys conducted by outside professional agencies will receive immediate attention and consideration. All hazards identified and recommendations will be acted upon in a timely manner. All methods of addressing the issues contained in the reports will be documented in writing and a copy maintained with the survey report. This documentation will also show the date corrections were made or actions taken. These reports and all associated documentation will be maintained for record and periodic review. Members of management that receive these reports will ensure the corrective actions are taken.

Checklists may be developed as part of the periodic self-inspection process. Checklists will be maintained including the name of the person performing the evaluation and the date the inspection takes place. The self-inspection checklists will be reviewed by management upon completion. All discrepancies identified during the survey will be evaluated as soon as possible. The periodic self-inspection checklists will be reviewed and evaluated on a regular basis to ensure current applicability. This review will be performed throughout the workplace with input from supervisors and employees. The checklist will be retained along with other applicable data for review. The list will be developed with the assistance of professionals providing comprehensive surveys (insurance field safety representatives, local fire inspectors, the Commission, etc.). The hazards and recommendations noted in the comprehensive surveys will be given consideration for addition to the periodic self-inspection checklist. Supervisors will be responsible for requisitioning and assisting in the correction process.

The formal Accident Prevention Plan components will be reviewed in July each year to identify insufficiencies or component failure. Each will be audited individually with the findings documented and recorded. This documentation will be used to identify trends in the program element deficiency and to track improvement modifications. This documentation will be maintained for review.

Human Resources will maintain accurate records of all proceedings associated with the safety and health program of St. Mary’s University.

Applicable forms or records:

  • Minutes, records, and data resulting from safety meetings or other gatherings in which discussion occurs that affects the safety and health program.

Records will be kept of all proceedings and appropriate management or other designated staff actions affecting the safety and health program. These records will include the name of the recorder, date, a list of attendees, details of the topics discussed, and action or corrective measures suggested, recommended or taken. The purpose of these is to ensure that decisions affecting the safety and health program of this company are carried out, implemented, and that results are tracked.

Designate a recorder who will be responsible for the minutes or records at each meeting. During each subsequent meeting, the record of minutes for the previous meeting will be reviewed, discussed, resolved, and the document closed with an authorized signature.

Training Records

Human Resources will document and maintain records of all safety and health-related training.

Applicable forms or records:

  • Training documentation records.

All safety and health related training provided to employees of St. Mary’s University will be documented. This documentation will be maintained as proof of attendance and reviewed to assist in determining the need for additional or repeated training for employees on an individual basis. Records and documentation of training will include the presenter’s name, date of training, topic or subject, legible identification of the attendee, and attendee’s signature. The person providing the training is responsible for generating the documentation. The training record will become part of the employee’s permanent file and will be maintained by Human Resources for a minimum of five years or as required by law.

Accident Investigation

Human Resources and each division/department will ensure proper records and documentation of all accident and incident investigation activities are maintained and reviewed.

Applicable forms or records:

  • Accident investigation forms and supporting data including photographs; and
  • Records of corrective action or preventative measures implemented.

All accidents and near miss incidents resulting in injury or illness to a person, property damage of any magnitude, or the potential for either will be investigated and documented. All items on the designated accident investigation form will be addressed in detail as soon as possible following the accident/incident. The information acquired will be used and reviewed by management, supervisors, and effected employees to establish all contributing factors and causes. From the investigation, a plan of corrective action will be established to prevent recurrence of the mishap. The plan of corrective action and implementation will be documented and reviewed by management.

Employees involved in any incidents/accidents will be interviewed to learn how to prevent any future recurrences. The investigations are to find out the facts, not to place blame. Any suggestions employees may provide on how to prevent future incidents/accidents are encouraged.

Equipment Inspection and Maintenance

Each department will maintain records and data pertaining to equipment inspection and maintenance programs performed at or with each facility for a minimum of 5 years or as required by law.

Applicable forms or records:

  • Routine inspection and maintenance records;
  • Documentation of services performed by contract agreement; and
  • Documentation of repair and replacement of parts or equipment.

Accurate records will be maintained involving all routine inspection and maintenance procedures performed on equipment at this company. This documentation will be periodically reviewed by those responsible for maintaining equipment and facilities. The documentation will be utilized to determine an effective, ongoing equipment maintenance program and to ensure compliance with regulations that require inspections on certain equipment.


The Enterprise Risk Management Team will review and analyze all records and documentation pertaining to the safety and health program. This review will be conducted on an annual basis and will focus on hazard and injury analysis, and recognition of developing trends. Trend analysis will identify recurring accidents and near-miss incidents resulting in or potentially involving, injury, illness, or property damage. The analysis will also recognize repeatedly identified hazards/violations needing corrective action to establish what program component is failing that allows the hazard to exist.

Each Vice Presidential division will provide information and recommendations for corrective measures for trends developing in their areas. Employees will be made aware of developing trends and hazard exposures as they are recognized. Employees will be contacted to provide their input on the methods they think would be successful in reversing any identified negative trends. Trends of accidents or hazard recurrences will be a focal point for corrective action and employee training as needed.

Human Resources will follow up on corrective measures at each location until the causal factor has been eliminated or controlled. Employee training records will be reviewed annually in the month of September to ensure an adequate and effective training program is maintained. Employees will be interviewed from time to time to establish retention of training and determine when information should be supported or repeated.

Safety and Health Training

St. Mary’s University is committed to making safety and health related orientation and training available to all employees at all levels of the company. Human Resources and each division/department will develop, implement, and maintain necessary safety and health orientation and training programs to educate and familiarize employees with safety and health procedures, rules, and work practices of the facility. The management of this organization will encourage and require involvement and participation of all managers, supervisors, and employees. Furthermore, the executive level will support the orientation and training program with allocations in funding, staff, resources, and time to develop and implement this program.

Training Program Development

The training subjects and materials are developed utilizing industry and site specific criteria relating to identified and potential hazards, accident and incident data, and training required by federal regulations. The orientation, and subsequent training sessions will include, but not be limited to, the following:

  • Hazards associated with the work area;
  • Hazards of the job or task assignment;
  • Emergency procedures;
  • Personal protective equipment;
  • Hazard communication (hazardous chemicals and materials);
  • Specific equipment operation training;
  • Employee reporting requirements;
  • Accident investigation (supervisors and other designated personnel);
  • Confined Space Entry; and
  • Any federally required training not included or addressed above.

The training program shall be administered in two phases consisting of new employee or reassigned orientation and regular periodic training and refresher sessions. Aside from the formal safety and health related training classes, employees will receive guidance and instruction on safe operating procedures of each assigned job or task.

Employees are expected to provide feedback or to communicate with management on the usefulness or applicability of the training provided to them.


The departmental orientation training will be administered to all new employees prior to the initial work assignment and to employees assigned to new or different tasks or jobs. The orientation will consist of all required training programs as well as job and site specific safety and health information. All new employees will be given a tour of the facility and an opportunity to pose questions to expedite the familiarization process. New employees will not be released to an individual job assignment until it has been determined by the supervisor that the individual has retained the minimal acceptable elements of the training provided and pertinent information to safely perform the assigned duties.

Ongoing Training

All managers, supervisors, and employees are required to participate and become involved in the ongoing safety and health training program. All employees assigned to attend a training session must demonstrate competency and retention of the minimal acceptable information prior to returning to any job assignment. Supervisors have the authority to assess training effectiveness and are responsible for enforcing implementation of criteria requirements of all training.


Any and all safety and health related training administered or provided by St. Mary’s University will be documented with the following minimum information:

  • Date of training session;
  • Provider (name of person conducting training and affiliation, if not an employee of the University);
  • Subject matter;
  • Legible name of attendee(s) and supplemental identification if needed or required;
  • Signature or acknowledgement of attendance.

All training records and documentation will become a permanent part of each employee record as well as a master record used to determine participation of all employees. Individual training records will be maintained for the current year plus five more.

Safety and Audit Inspection

Each Vice Presidential division will implement a program to identify, correct, and control hazards on an ongoing basis. This program will utilize multiple resources to ensure effectiveness.

Safety and Health Self-inspections

Annual in-house safety and health self-inspections that will cover the entire facility and equipment will be conducted under the supervision of the Vice President for Administration and Finance. Employees will conduct constant informal inspections of their work areas and tools. If any potential exposures or deficiencies are identified, employees are expected to communicate these to their supervisors if the employees are not able to rectify the situation immediately.

All inspections will be conducted on an ongoing basis without interruption. Management will allocate adequate time and resources to perform the surveys.

Accident/Hazard Investigation

Management is committed to and will correct or control all hazards identified through any of the avenues of recognition established. All identified hazards will receive a timely response.

Hazard Correction

Whenever possible and feasible, hazards identified at facilities will be corrected eliminating the cause of the hazard at the source. This will include, but not be limited to, the following:

  • Discontinuation or removal of hazardous chemicals, materials, or substances from the workplace;
  • Discontinuation from use or removal of hazardous equipment until replaced or repaired;
  • Correction of any unsafe acts or conditions in existence, by service or training.

Hazard Control

When identified hazards cannot be eliminated, the hazard will be effectively controlled by engineering, administrative procedures, work practices, personal protective equipment, or any suitable combination of these measures.

Engineering controls will include, but not be limited to, the following:

  • Isolation of employee exposure to the hazard;
  • Guarding or displacement of employee exposure to the hazard; and
  • Preventive maintenance and repair of machinery and equipment.

Administrative procedures will include, but not be limited to, the following:

  • Written programs to establish administrative guidelines for safe work practices; and
  • Established and implemented work rules and procedures.

Work practices will include, but not be limited to the following:

  • Careful planning and performance of each assigned job, duty, or task;
  • Reduction in duration of exposure to hazards; and
  • Adherence to safety and health rules and procedures.

Personal protective equipment will be the control of last resort when all other means of eliminating the hazards have not provided adequate protection to the employee. When personal protective equipment is issued, the employee will be informed of the requirements, use, and limitations of the equipment.

Accident Reporting and Investigation

Human Resources and each division/department per the Accident Review Policy will investigate all work related accidents and near-miss incidents involving employees or University property to develop preventive measures and implement corrective actions.

Employee Reporting

All emergency accidents must be reported to the St. Mary’s University Police Department. All employees are also required to report to their immediate supervisor, any of the following:

  • Accidents/incidents with injury/illness of any magnitude (including first aid related cases);
  • Accidents/incidents resulting in property or equipment damage of any magnitude; and
  • Any near miss incidents that could potentially have resulted in injury/illness or property damage.

Employer Reporting

Human Resources will report the following accidents to local, state, and federal agencies as required:

  • Commission: Fatalities and accidents involving hospitalization of five or more injuries will be reported within 24 hours;
  • OSHA: Fatalities and accidents involving hospitalization of three or more injuries will be reported within eight hours;
  • Lost workday cases other than fatalities;
  • Covered employers report to the Commission using form TWCC-1, Employer’s First Report of Injury; and
  • Non-covered employers report to the Commission using form TWCC-7, Non-Covered Employer’s Report of Occupational Injury or Illness.
  • Nonfatal cases without lost workdays which result in transfer to other employment require medical treatment other than first aid; involve loss of consciousness, or restriction of work motion. This category also includes any diagnosed occupational illnesses which are reported to the employer but are not classified as fatalities or lost workday cases.

Accident Investigation

Human Resources and each Vice Presidential division/department will be responsible for conducting investigations of accidents that occur in their areas or that affect employees under their supervision as per the Accident Review Policy. Upon notification of an accident or near-miss incident, the responsible supervisors will begin investigation to determine the following:

  • How the accident or incident occurred;
  • Special circumstances involved;
  • Underlying, indirect, or associated causes; and
  • Corrective actions or preventive measures and controls.

Accidents and incidents involving situations where multiple supervisors are affected (an employee of one department injured in another), will be investigated jointly. The supervisor of the area where the incident occurred will be in charge of, and be held accountable for, the investigation.


All activities and findings of the investigators will be documented and recorded for review.

Accident investigation documentation will record as a minimum; the following information is required for injury records per Commission Rule 120.1:

  • Date and time of occurrence;
  • Name of person involved, job title, and area assigned;
  • Date of birth, sex, and wage, length of service and social security number;
  • Location of occurrence;
  • Nature and severity of injury or illness;
  • Name of person conducting the investigation;
  • Name of immediate supervisor of employee;
  • Job assignment or duties being performed at time of incident;
  • Special circumstances or encumbrances;
  • Details of how the accident occurred;
  • Injury and part of body affected;
  • Description of any equipment affected or involved;
  • Names and comments of witnesses;
  • Direct cause;
  • Indirect, underlying, or contributing factors (including fault or failure in safety and health program elements); and
  • Corrective action implemented or preventive measures taken (including safety and health program adjustments).

Review and Revision

The Enterprise Risk Management Team will review and revise the components of the Accident Prevention Plan annually for effectiveness and implementation. Special attention will be devoted to areas and criteria that demonstrate failure in a program component, introduction of new procedures, processes, or equipment. Corrective measures will be taken as needed to reemphasize or restructure the Accident Prevention Plan to perform at the optimum effectiveness.

Information will be solicited from area supervisors and employees to determine the effectiveness of each program component, and assistance in developing adjustments and corrections.

Goals and Objectives


An effective Accident Prevention Plan will achieve the following goals:

  • Effective involvement of each and every employee of the University;
  • Eliminate any and all hazards (current and potential) that expose or create risk of any nature;
  • Reduce all work-related incidents resulting in injury or illness to any employee or other person associated with our operations or business;
  • Reduce all losses due to incidents resulting in injury or illness to any employee or other person or property damage from such incidents;
  • Increase awareness of the overall safe operation of all facilities;
  • Increase employee morale by knowing their work environment is maintained as free as possible from any and all recognized hazards;
  • Eliminate all work-related injuries and illnesses, property damage, and all associated losses.


  • Implementation of an effective Accident Prevention Plan;
  • Commitment for ongoing support from each and every level of management and personnel;
  • Assigned responsibilities and accountabilities for the safety program;
  • Allocation of adequate resources to the safety program;
  • Establish lines of communication involving management and employees at all levels for safety and health concerns;
  • Effective records and documentation maintenance and review;
  • Completion of comprehensive surveys and periodic self-inspections;
  • Implementation of effective measures for hazard identification, correction and control;
  • Implementation of effective orientation and training programs; and
  • Initiation of regular program review and revision procedures.

The goals will be realized only if the objectives are carried out without hesitation or interruption, and if every employee becomes interested in the safety program and its success.

Employee Commitment and Responsibilities

We recognize the success of any University endeavor is largely dependent on the entire workforce. St. Mary’s recognizes the value of employee involvement to assist us in realizing the goals we have set for ourselves.

The University President aggressively solicits from all employees the assistance for, and commitment to, the implementing of the Accident Prevention Plan.

Employees are encouraged and expected to become involved in all aspects of implementing the Accident Prevention Plan.

Employees are expected to utilize established avenues to solicit and receive comments, information, and assistance where safety and health is concerned.

Employees are expected to perform their job duties in a manner that is safe for themselves, as well as those around them. Employees are required to abide by all safety and health policies, procedures, and rules established by the University.

Employees of St. Mary’s University will adhere to the safety and health regulations established by federal, state, and local agencies.

Employees are expected and required to adhere to the University’s safety and health program. Your continued employment with St. Mary’s University is contingent upon your recognizing and abiding by the safety and health policies, procedures, and rules established by the University.

Employee Involvement

Management encourages employee involvement in each part of the implementation process for the ongoing safety and health program of this facility. We solicit this involvement by giving each employee an opportunity to participate and be responsible for implementation of the safety program for their respective areas.

Departmental Safety Meetings

St. Mary’s University will encourage all employees meet on a regular basis to discuss safety and health issues or concerns and increase employee awareness of the safety and health program. Regular meetings will keep the program active in the minds of the employees, and offer an avenue for employees to voice concerns regarding workplace safety and health.

Meeting minutes and attendance records will be kept on file. Minutes will include all safety items and procedures discussed as well as the date and time of the meeting.

Reporting of Hazards and Unsafe Conditions

As a condition and requirement of employment, all employees are required to report hazards and unsafe conditions in the workplace to Facilities Services. They will take prompt and appropriate action to determine if a hazard exists. If it is determined that a hazard does exist, immediate attention for correction or interim protective measures will be taken. Whether a hazard is identified, the reporting employee will be notified of the corrective action taken or the procedures used to conclude that no hazard existed. If practical, this information will be shared with all facility employees.


All hazard reports and corrective measures/action taken will be documented and recorded. This documentation will be reviewed by management. Pertinent information will be made available for employee review.

Disciplinary Actions

St. Mary’s University will follow its standard disciplinary policy as it applies to the safety and health program of this University. The disciplinary policy will be a tool to ensure enforcement of the rules and procedures for a safe and healthful working environment. The disciplinary policy applies to all employees of St. Mary’s University.

Verbal Warnings

Management or supervisors may issue verbal warnings to employees that commit minor infractions or violations of the safety rules or safe work practices. Continued violations or verbal warnings will lead to more stringent action.

Written Warnings

Management or supervisors may issue written warnings for the following:

  • repeated minor safety rule violations or procedures;
  • Single serious violations of a rule or procedure that could have potentially resulted in injury to themselves or an-other employee or could have caused property damage; or
  • Activities that could potentially result in injury or property damage.


Supervisors may recommend, and management may institute, disciplinary leave for the above reasons and the following:

  • A single serious violation of a rule or procedure that results in injury to an employee or property damage; or
  • Repeated violations, nonconformance to safety rules or procedures.


Supervisors may recommend and management may concur in the termination of any employee for repeated serious violations of the above circumstances.


Violations of University rules or safety rules, regulations or procedures will be documented by filling out a report on the employee. The report will state the type of violation and corrective action taken. The employee must read and sign the report acknowledging that they understand the seriousness of the violation.

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