PROGRAM CONTACT PERSON LIST

Asbestos Management..............................................................Jo Pyle

AED..............................................................................Mary Carter
AWAIR.................................................................................Jo Pyle
Bleacher Safety..................................................................... Jo Pyle
Bloodborne Pathogens........................................................Mary Carter
Community Right-to-Know........................................................Jo Pyle
Compressed Gas Safety............................................................Jo Pyle
Confined Space Entry..............................................................Jo Pyle
Emergency Action Planning.................................Superintendent/Principals
Employee Right-to-Know/Hazard Communication............................Jo Pyle
Facilities Safety Management.....................................................Jo Pyle
First Aid/CPR ..................................................................Mary Carter
Hazardous Waste Management...................................................Jo Pyle
Hearing Conservation..............................................................Jo Pyle
Indoor Air Quality...................................................................Jo Pyle
Integrated Pest Management.....................................................Jo Pyle
Laboratory Standard/Chemical Hygiene Plan...................................Monica
Headlee
Lead Management..................................................................Jo Pyle
Lockout/Tagout ....................................................................Jo Pyle
Machine Guarding ..................................................................Jo Pyle
Personal Protective Equipment..................................................Jo Pyle
Playground Safety..................................................................Jo Pyle
Radon Gas Safety...................................................................Jo Pyle
Respiratory Protection.............................................................Jo Pyle
USTs/ASTs............................................................................Jo Pyle
Welding Cutting Brazing....................................................John Lanoue
Checklist of E/OHS Activities for Automatic External Defibrillator

Program Contact Person: Mary Carter

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

Brand of AED? Zoll Model #

Name of Medical Director? No one at this time. Mary will check on.

Year device was placed into use? 2006

Location(s) of devices:
Building Name Location in Building
Tracy High School (1) Across from Main Office (1) hallway
by west side gymnasium
Tracy Elementary Locker Banks by second Grade entry

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

Date of update installation: May 2006

Expiration date of pads? 9-2009

Expiration date of batteries? 2015, or when battery indicator has reached one-
half life left (date)

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

• Most recent date of training: Oct, 2008

(date
• Provider of training: Mary Carter

Location of operators manual: School nurse office at high school , and at the
Elementary School nurses office or available online.

Are battery checks documented? Yes, a check list is available at each AED
station
Notes: The AED’s were purchased by the local medical clinic. The effort was
coordinated between the PTO and the clinic.

Note: Brian Michelson is the instructor and teaches AED and CPR to students in
Health class.
Checklist of E/OHS Activities for Asbestos Management

Program Contact Person: Jo Pyle

Is the Asbestos Management Plan in place? Yes No N/A

Is the Plan current for all buildings? Yes No N/A

Has the Plan (or Plans) been reviewed this school year? Yes No N/A

The Plan is located at affected building: the original plans along with updates
are located at each building_.

Training for Asbestos Awareness was conducted 3/3/06 .

New PT employees received training on N/A .

(date)

Annual written notification has been prepared; Fall of 2008 .

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

Name of publication Date

Spotlight August 2009

Three-year re-inspection Surveillance was conducted: 10/11/2010.

6-month Periodic Surveillance was conducted: 10/10

(first date)

05/09
(second date)

All caution labels have been posted.

Label locations: Boiler room tunnels

Are supplies of repair materials adequate to meet the requirements of

maintenance and repair of ACM? Yes No N/A
 Asbestos Maintenance Supplies on Hand

Bags Glove bags 6 mil Respirators Respirator

sheeting filters

Is documentation of Operations and Maintenance available?

Location: Yes

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

Comments: All repairs are outsourced. Repair materials are not

routinely used.
Supplies on hand are located in the boiler room in the metal gray cabinet. LC
9-9-09

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

Note: The tunnels were crawled today (4/14/09). The tunnels are limited in
scope and are in very good condition. One elbow is damaged and should be
repaired. Almost all of the hot water lines are located above the ceiling tile.
Checklist of E/OHS Activities for AWAIR

Program Contact Person: Jo Pyle

Is the AWAIR Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is the Safety Committee organized? Yes No N/A

How often are meetings held? Attempt quarterly

Are minutes of the meeting maintained?

Location: teachers work rooms

Posted: District office

How is the program communicated to employees? All staff development

meetings

Who is the Contact Person for OSHA 300? Jeanette H.

Is the OSHA 300A Log completed for the previous calendar year? Yes

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

Location: Jeanette’s office and the Activities Manual

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

The location/s of the posted log: Staff lounges

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

Date Location Time

District Safety Committee Members

Member Position Building

Checklist of E/OHS Activities for Bleacher safety

Program Contact Person: Jo Pyle

Is the BSM Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has an annual survey of school bleachers been conducted? Yes No N/A

Is the five-year recertification required by December 31, 2007 complete and

submitted to the Minnesota Department of Labor and Industry? Yes No N/A

Openings and gaps:

Openings limited to four-inch gap between the railings and between the footboards
and seat boards, starting at a height of 56 inches or more.

Retractable bleachers:

They may contain openings of 9 inches or less

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

Approved netting:

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

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

Railings:

Bleachers 55 inches and under are exempt from railing requirements

Bleachers with guardrails over 30 inches above grade must not contain openings
greater than four inches, unless safety nets are installed.
State building inspectors shall determine whether the safety nets and guardrail climb
ability meet the requirements of the alternate design section of the State Building
Code.

Periodic inspections:

Bleacher footboards and guardrails must at a minimum be reinspected at least every

five years and a structural inspection at least every ten years. The equipment has no
rust, rot, cracks, or splinters, especially where it comes in contact with the ground
There are no broken or missing components on the equipment (e.g., handrails,
guardrails, protective barriers, steps, or rungs on ladders) and there are no damaged
fences, benches, or signs on the playground
Checklist of E/OHS Activities for Bloodborne Pathogens

Program Contact Person: Mary Carter, School Nurse

Is the Bloodborne Pathogens Written Plan in place? Yes No

Has the Plan been reviewed this school year? Yes No

List job categories that may be at risk to exposure:

School nurse Playground supervisor
Custodians Art
Secretaries Industrial Arts
Bus drivers Special ed
Coaches

Most recent date of “at risk” employees? 8-09

Mary Carter School Nurse provided the training for all-staff.

What is this school’s policy regarding Hepatitis B vaccinations for employees

considered at risk versus employees considered not at risk in the Exposure
Control Plan? All staff are given the opportunity to receive the 3 part HBV
vaccine at no cost.

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

exposure incidents? Annual training is provided by the school nurse.

New Employees: _within ten days of employment

Have the employees identified as first aid responders been given at a minimum
Red Cross First Aid Training? Yes No N/A

Are Exposure Control Kits available to staff? Yes No N/A

Location(s): all rooms are provided kits

Status of Declination forms: the forms are maintained by the school nurse

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

Policy regarding cleanup: Custodial staff routinely clean up all fluid spills.

Location of biohazard bags at school: Nurses office

Approved disposal location for biohazardous waste: Tracy Hospital

Checklist of E/OHS Activities for Compressed Gas Safety

Program Contact Person(s) Jo Pyle

Department Contacts:

Maintenance Jo Pyle

Metals Shop John Lanoue

Industrial Tech. John Lanoue

Bus Garage Bob Bruder

Is the Compressed Gas Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has the facility been surveyed for compressed gas inventories? Yes No N/A

Has training been conducted for affected personnel? Yes No N/A

Date: summer 2008

Are records established/maintained to monitor gas inventory? Yes No N/A

 COMPRESSED GAS FIELD REVIEW

Compressed Gas Inventory

Date: Feb. 13, 2009 Program Contact Person : Lee Carlson

Department: Metals Shop Department Responsible Person: John Lanoue

Location: Metals Shop Room

Cylinders:
 O2 ___(5)_________  CO2 __(4)__________
 Acetyl _(2)___________  Argon __(2)__________
 NH4 ____________  Argon/CO2__(5)__________
 Other( helium) __(1)__________

Compliance Check List

No Yes
1. Are cylinders in well-ventilated area? X
2. Are cylinders stored separate from flammable by at least 20 X
feet?
3. During storage are oxygen cylinders separated from fuel gas X
cylinders, unless on welding cart?
4. Are cylinders kept away from sources of heat (below 130 F)? X
5. Are safety chains used at all times on both full and empty X
cylinders? (2/3rds from top of cylinder)
6. Are empty cylinders maintained separate from full cylinders? X
7. Are cylinders kept away from sources of ignition such as X
electricity,
excessive heat or oily rags?
8. Are carts designed specifically for gas cylinders available? X
9. Are damaged cylinders, valves/hoses removed from service? X
10. Are all cylinders properly labeled with the contents? X
Checklist of E/OHS Activities for Confined Space Entry

Program Contact Person: Jo Pyle

Is the Confined Space Entry Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Have confined space areas been identified? Yes No N/A

Have measurements to include CCI/ft been completed? Yes No N/A

Are permit entry forms in place? Yes No N/A

Location: Activities Manual

Are confined space labels in the proper locations? Yes No N/A

Is a list of employees eligible to enter confined spaces complete? Yes No N/A

Has training for affected employees completed? Yes No

Date of completion: 2/25/05

Note: Confined space entry activities at this school are limited to licensed
contractors only. School staff does not enter confined space areas.
 Confined Space Inventory

Building: Tracy High School

Building Contact: Jo Pyle Program Contact: Lee Carlson

Date: 2-11-09

Room Opening Dimension Potential Permit/ Labeled Photo

Identification Dimension Of Confined Hazards Non- ID #
Name Given Space Permit/Alternat
Space e
Boiler room 18” 7’X3’X3.5’ Ele.O2, Heat Permit Yes
Boiler #1
Boiler Room 18” 7’X3’X3.5’ Ele.O2, Heat Permit Yes
Boiler #2
Boiler Room 4’X15’ 100’X15’X4’ Heat, Non-permit Yes
Tunnel electricity
(2)Chimney 18”X18” 30” round X Particulate Permit No
stacks 24’ high matter, heat

Building: Tracy Elementary School

Building Contact: Jo Pyle Program Contact: Lee Carlson

Date: 2-11-09

Room Opening Dimension Potential Permit/ Labeled Photo

Identification Dimension Of Hazards Non- ID #
Name Given Confined Permit/Alternat
Space Space e

Boiler room 18” 7’X3’X3.5’ Ele.O2, Heat Permit Yes

Boiler #1
Boiler Room 18” 7’X3’X3.5’ Ele.O2, Heat Permit Yes
Boiler #2
Note: View entry points with this link Confined Space Photos.

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

Program Contact Person: Jo Pyle

Is the Community Right-to-Know Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Are quantities of stored and used designated hazardous materials documented

and verified? Yes No N/A
Where are the documents stored? Custodial office /Activities Manual

Have the State Emergency Response Commission and local fire department
been notified of hazardous materials on school grounds? Yes No N/A

When were they notified? Winter, 2006

(date)

Has training been provided? Yes No N/A

Date: 2/25/05

Presenter: Steve Musser

Note: Pat Sommervold typically submits the Tier Two form. The forms were
prepared and sent 2/5/2009. A signed copy has been sent t the local fire
department.

Jo Pyle keeps records on heating oil usage. The oil is used only in case of
emergencies. If the oil is not used after two years an attempt is made to burn.
A fuel stabilizer is used to keep the fuel in good condition.
 Inventory Form

Client: Tracy Public Schools

Contact Person: Jo Pyle Date:2-11-09

Hazardous Reported on Installation

Material Quantity Location Tier Two Date(s)
Mid
#2 Fuel Oil 10,000 gal High School Yes 90’s
‘02
#2 Fuel Oil 10,000 gal Elementary Yes
Checklist of E/OHS Activities for Emergency Action Planning

Program Contact Person: Chad Anderson

Is the Emergency Action Planning program in place and as outlined in the

Minnesota Executive Order 93-27 and Model Crisis Management Plan? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Are information maps posted to indicate travel routes in the event of fire,
tornado shelter locations, and procedures during lockdown? Yes No

Located where? Maps are located in each classroom.

Are all drills timed and recorded? Yes No

Responsible person: Chad Anderson, High School, Elementary School

Location of records: At each building principal’s respective offices

Forms provided: Yes No

Does this school coordinate drills with local government authorities to assure
sheltering in school, evacuating to their homes or use of congregate care
centers? Yes No N/A

Has this school completed the Fire Marshall required Fire Safety and Emergency
Evacuation Plan? Yes No N/A

Training provided for affected staff? Yes No N/A

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

Program Contact Person: Jo Pyle

Is the Employee Right-to-Know/Hazard Communication Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the chemical inventory been completed for the following functional areas?

Location of Chemical Inventory

Form

Art Instruction Yes No N/A

Custodians Yes No N/A Board room/ Custodial office

Food Service Yes No N/A Lead cooks desk

Science Rooms Yes No N/A Lab prep room

Shop (metals, wood, auto) Yes No N/A

Are MSDS available and located with the chemical inventory? Yes No

Do the MSDS concur with the chemical inventory? Yes No

Has training been provided for the following staff?

Art Instructors Yes No N/A Science Yes No N/A

Custodians Yes No N/A Shop Yes No N/A

Food Service Yes No N/A Transportation Yes No N/A

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

Program Contact Person: Jo Pyle

Is the Facilities Safety Management program in place? Yes No

Does this school use contracted services for the Management Assistant
Program? Yes No N/A

If no, who is the designated person or persons?

Fire and Life Safety in Schools

Program Contact Person: Jo Pyle

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

Most recent date of sprinkler electronics inspection_________ N/A

Most recent date of alarm inspection July, 09 N/A

Most recent inspection of fire extinguishers__8-30-09 N/A

Most recent inspection of fume hoods with fire suppressant N/A

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

Science safety Checklist completed? Yes No N/A

 Facilities Safety Review

Building:

Mock-OSHA Review Date Review

Area Completed N/A Recommendations
Art

Dark Room

Wood Shop

Kitchen

Metal Shop

Halls, Gym, etc.

Graphic Arts

Maintenance/Custodial

Transportation

Grounds/Garage

Chemistry/Life
Science

Fire and Life Safety Checklist

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

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

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

CORRIDORS, ENTRANCES, STAIRS

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

X Fire extinguishers serviced, maintained, and tagged every year

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

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

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

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

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

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

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

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

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

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

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

TECHNICAL LAB AREAS

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

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

Program Contact Person(s): Mary Carter

Is the First Aid/CPR program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No
Has the District determined a provider in the event of a medical emergency?
Yes No

The local provider determined travel time was estimated to be within the 4-8
minute limit. Therefore Tracy Ambulance will
be the designated emergency response provider.

The local provider determined travel time was estimated to be in excess of the
4-8 minute limit. Therefore N/A will be the
designated emergency response person located within the district.

Has training been provided for affected staff? Yes No

Note: Training is provided alternative years. One year is dedicated to first-aid

and the next to CPR.

Note: First-aid kits are located in Metals shop, wood shop, ag shop, boiler room
and none at the elementary

Checklist of E/OHS Activities for Hazardous Waste Management

Program Contact Person(s)

Primary Contact Person: Jo Pyle

Secondary Contact Person: Richard Hanson

Is the Hazardous Waste Management program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Did this school generate ten gallons of waste per year? Yes No

Note: In Greater Minnesota, schools generating ten gallons of waste per year or
less do not need a license.

Did this school generate 220 pounds or less per month hazardous waste (about
½ drum or less liquid)? Yes No

Note: Wastes that do not count include antifreeze, cathode ray tubes,
fluorescent lamps, lead acid batteries, pcb ballasts, photo fixer reclaimed on
site, used oil and oil filters.

Training for VSQG’s do not have training requirements however MPCA strongly
recommends persons handling wastes be given training on best handling and
safety risks associated.

Has training been provided for affected persons? Yes No N/A

Date Conducted: N/A
Date Scheduled: N/A

Has annual report and license application sent in? Yes No N/A

Checklist of E/OHS Activities for Hearing Conservation

Program Contact Person: Jo Pyle

Is the Hearing Conservation Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the program been approved by the School Board for the current school
year? Yes No

Has the school been surveyed for noise hazards? Yes No

Have sound level measurements been collected? Yes No

Have the results been documented? Yes No

Location: Activities Manual

Has training been scheduled or completed for affected individuals this school
year? Yes No N/A

Date:

Presenter:

Have regulatory changes occurred that may affect this program? No

Note: Several years of sound testing results indicate this program should be
considered limited. Personal Protective equipment is (ear muffs, foam ear
plugs, etc.) is recommended during certain operations such as lawn mowing.

Checklist of E/OHS Activities for Indoor Air Quality

Program Contact Person: Jo Pyle

Is the IAQ Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has an IAQ Committee been established? Yes No

Have the program and goals been approved by the School Board for the current
school year? Yes No

Has the annual cursory walk-through been conducted? Yes No

Have the districts key building systems been evaluated? Yes No

When was the evaluation completed? Aug, 1999

Who conducted the evaluation? MacNeil Environmental, Inc.

Were occupied areas of the district evaluated using the EPA’s Tools For Schools
check list or equivalent? Yes
• Teachers check list? An information fact sheet was provided all –staff.
# of forms distributed 30 # of Forms returned: 30

• Building maintenance checklist?

• Building ventilation checklist?

Training conducted
(date)

(date)

Has the District determined the mechanical ventilation rate of each occupied
space? Yes No.

Supportive technical services were conducted on: May 15, 2000.

(date)

Results of technical services are located? Activities manual

Comments: The IAQ notification was sent to parents in the Aug. 2009 Spotlight.
LC 9-9-09

IAQ Survey Review Form

Building: Tracy High School

Building Contact: Jo Pyle Program Contact: Jo Pyle

Room Identification Water Ventilation Building failures Cleanliness/ O&M

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

Chemistry Lab Not at this Acceptable Okay Okay Satisfactory

Monica Headlee time
Food Service Not at this Acceptable Okay Okay Satisfactory
time
Wood Shop Not at this Acceptable Okay Okay Satisfactory
Mike Perterraeins time
Library Not at this Acceptable Okay Okay Satisfactory
Laurie Fox time
Ag Shop Not at this Acceptable Okay Okay Satisfactory
John Lanoue time

Notes: Jo conducts frequent surveys of HVAC systems. The filters are

serviced as needed which is usually 4 times per year. All floor drains are
functioning properly and should not present IAQ issues. No water intrusions
were observed.

Walk-through conducted by: _Lee Carlson____ Date: _4/15/09

IAQ Survey Review Form

Building: Tracy Elementary School

Building Contact: Program Contact: Jo Pyle

Room Identification Water Ventilation Building Cleanliness/ O&M
Contact individual Intrusion problems failures Proper Carpets
i.e. foundation storage
or roof
problems
Food Service Not at this Acceptable/food Okay Okay N/A
time odors are
limited to
kitchen area
Food Service/dish Not at this Acceptable/ Okay Okay N/A
washing time excessive
moisture not
present
Halls Not at this Acceptable Okay Okay Satisfactory
time
Library Not at this Acceptable Okay Okay Satisfactory
time
Ag Shop Not at this Acceptable Okay Okay Satisfactory
time
Staff Lounge Problems on Acceptable Possible ground Good Satisfactory
exterior wall water intrusion

Recommendations: The area around the building has been tiled out. This may
reduce past moisture problems.

Walk-through conducted by: _Lee Carlson___ Date: _4/015/09

Checklist of E/OHS Activities for Integrated Pest Management

Program Contact Person: Jo Pyle

Is the IPM Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Has the annual monitoring been conducted to determine location and degree of
infestation? Yes No
A map of the problem area/areas has been developed. Yes No

Has notice been given to parents regarding application activities? Yes No

Location or publication used to notify parents: Spotlight, Aug, 2009.

The Pesticide Notification has been sent to all parents with children. The
Spotlight was the media used. LC 9-9-09

Checklist of E/OHS Activities for Laboratory Standard/Chemical

Hygiene Plan

Program Contact Person: Monica Headlee , CHO

Is the Laboratory Standard/Chemical Hygiene Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Fume hood was tested on _5/08/08______________.

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

Chemical inventory:

Date of most recent survey: fall, 2008

Location of inventory listing: Chemistry lab

Are Material Safety Data Sheets (MSDSs) located with inventory? Yes No N/A

Are the MSDS readily accessible? Yes No N/A

Has the DCFL Science Lab Checklist been completed? Yes No N/A

Is training for affected personnel complete? Yes No N/A

Date(s) of instruction:

Roster signed? Yes No N/A

Lesson plan outline available with roster? Yes No N/A

Status of Emergency Eye Wash/Deluge Shower:

Is flushing conducted weekly? Yes No N/A

Is descriptive signage properly posted? Yes No N/A

Is flushing activity documented? Yes No N/A

Note: the deluge shower is not available.11-06-08

Fume Hood Evaluation

Chemical Hygiene Officer: Monica Headlee

Hood: Location: ROOM 152

FIELD TEST (lf/min)

>100 lf/min >100 lf/min >100 lf/min

>100 lf/min >100 lf/min >100 lf/min

X Pass ‫ ٱ‬Fail (face velocity of 100 lf/min cannot be

achieved)

Sash Height: 24”

Used as Storage? Yes No

Clean? Yes No

Comments: This fume hood operated adequately when sash was in full open
position.

Completed by: Lee Carlson Date: 5/8/08

Fume Hood Evaluation

Chemical Hygiene Officer: Monica Headlee

Hood: #1 Location: ROOM 152

FIELD TEST (lf/min)

>100 lf/min >100 lf/min >100 lf/min

>100 lf/min >100 lf/min >100 lf/min

X Pass ‫ ٱ‬Fail (face velocity of 100 lf/min cannot be

achieved)

Sash Height: Full open

Used as Storage? Yes No

Clean? Yes No

Comments: This fume hood operated adequately when sash was in full open
position.

Completed by: Lee Carlson Date: 11-11-09

Checklist of E/OHS Activities for Lead-in-Water Management

Program Contact Person: Jo Pyle

Is the Lead-in-Water Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

This school completed testing of water supply taps _7/13/2000.

(date)

Is a map of all potable water taps available for review? Yes No N/A
Checklist of E/OHS Activities for Lead-in-Paint Management

Program Contact Person: Jo Pyle

Is the Lead-in-Paint Management Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Testing for lead in paint on playground equipment: Note: All playground

equipment has been replaced with lead free.

Date completed: N/A

Yet to be tested: N/A

Results of evaluation for paint condition in rooms K-1:

Building constructed post-1978; facility not applicable
Building constructed prior to 1978; paint determined to be in
____good__________ condition

Checklist of E/OHS Activities for Lockout/Tagout

Program Contact Person: Jo Pyle

Is the Lockout/Tagout Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Is LO/TO equipment available? Yes No N/A

Is the equipment appropriate for application? Yes No N/A

If available, where is the equipment located? Custodial office

Is the equipment maintained in an orderly and readily usable condition?

Yes No N/A

Have affected personnel been trained as to methods and technique of use?

Yes No N/A

Are written procedures available for affected staff? Yes No N/A

If available, the procedures are located where? Activities Manual

Has the annual audit of energy control procedures been completed? Yes No

Date or dates of completion: 1/10/02

Checklist of E/OHS Activities for Machine Guarding

Program Contact Person: Jo Pyle

Is the Machine Guarding Plan for each affected work area in place? Yes No

Is the plan/plans current? Yes No

Has the Plan been reviewed this school year? Yes No

Has a survey of all district fixed equipment been conducted?

Yes No

When was the evaluation completed? _______________________

 Who conducted the evaluation? _______________________

How are corrections documented? _______________________________

Is all fixed equipment safeguarded to meet OSHA criteria? Yes No

Has the alternative MDE “best practices” criteria used to safeguard equipment?
Yes No

Has equipment determined not in compliance scheduled for repair or

replacement? Yes No

If replaced, was “best practices,” bid specification criteria used for

procurement? Yes No

Identified Fixed Equipment Locations

Location Building/Buildings Staff Affected # of item

Automotive Shop
Wood Shop
Custodial/Maintenanc
e
Welding Shop
Ag Shop
Bus Garage
Art
Scene shop
Science
Contracted technical services to review and recommend?
__________________.

Name of person or contractor conducting survey? ___________________.

(date)

Results of technical services located where? ________________________

Checklist for minimum requirements:

• Power outage protection provided for required equipment
• Emergency stops provided for required equipment
• Safe work practice placards at applicable fixed tool stations
• Proper guards provided and used
• Color coding as prescribed by OSHA standards
• Non-slip surfaces by each piece of equipment
• Fixed equipment secured to prevent “walking” or movement

Has a log of employee accidents and near misses been established and used?
Yes No
Annual training for affected staff is provided? Yes No

Training conducted ____________.

(date)
Training has been scheduled for ____________.
(date)

Checklist of E/OHS Activities for Playground Safety

Program Contact Person: Jo Pyle

Is the Playground Safety program in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Note: The playground is located at the elementary building. The lead

custodian at that facility monitors the condition of the playground.

Surfacing:
 The equipment has adequate protective surfacing under and around it
and the surfacing materials have not deteriorated

Loose-fill surfacing materials have no foreign objects or debris

Loose-fill surfacing materials are not compacted and do not have

reduced depth in heavy use areas such as under swings or at slide exits

General Hazards:

There are no sharp points, corners, or edges on the equipment

There are no missing or damaged protective caps or plugs

There are no hazardous protrusions and projections

There are no potential clothing entanglement hazards, such as open S-

hooks or protruding bolts

There are no pinch, crush, and shearing points or exposed moving parts

There are no trip hazards, such as exposed footings on anchoring

devices and rocks, roots, or any other environmental obstacles in the
play area

Deterioration of the Equipment:

The equipment has no rust, rot, cracks, or splinters, especially where

it comes in contact with the ground

There are no broken or missing components on the equipment (e.g.,

handrails, guardrails, protective barriers, steps, or rungs on ladders)
and there are no damaged fences, benches, or signs on the playground

All equipment is securely anchored

Security of Hardware:

There are no loose fastening devices or worn connections, such as S-

hooks

Moving components, such as swing hangers or merry-go-round bearings,

are not worn

Drainage:
 The entire play area has satisfactory drainage, especially in heavy use
areas such as under swings and at slide exits

Leaded Paint:

The leaded paint used on the playground equipment has not

deteriorated as noted by peeling, cracking, chipping, or chalking

There are no areas of visible leaded paint chips or accumulation of

lead dust

General Upkeep of Playgrounds:

The entire playground is free from miscellaneous debris or litter such

as tree branches, soda cans, bottles, glass, etc.

There are no missing or full trash receptacles

Note: View playground equipment with this link Playground Photos.

Checklist of E/OHS Activities for Personal Protective Equipment

Program Contact Person: Jo Pyle

Is the Personal Protective Equipment Plan in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Has a survey of potential workplace hazards been completed? Yes No N/A

Date(s) activity was conducted:__________________________

Have recommendations been completed for appropriate equipment? Yes No

Has training been completed for the following departments?

Art and Photo Yes No N/A

Custodial Yes No N/A
Grounds keeping/Garage Yes No N/A
Kitchen Yes No N/A
Maintenance Yes No N/A
Science Laboratories Yes No N/A
Technical Education Yes No N/A
Transportation Yes No N/A
 Personal Protective Equipment Assessment
Building: High School_______

Location: Location: Location: Location: Location:

Kitchen Boiler room Maintenance Tech Shop Science
Rooms
Employee: Employee: Employee: Joe Employee: Employee:
Jo Pyle Pyle Paul Monica
Skoglund, Headlee,
Mike Jacob
Peterreins Scandrett
Hot Glove X X X X
Latex
Hand Vinyl X
Leather X X
Neoprene X X
Impact X X X
Splash X X X
Face
Shield
Respirator X
Muffs X X
Ear
Plugs
Neo Apron X X X
Body
Denim X
Steel Toes X
Foot
Metatarsal
Head Hard Hat X
Chemicals, Chemicals, Chemicals, body fluids, body fluids,
scalding scalding electricity, gas chemicals,
Hazard(s) water, water, heat, heat cylinders, open flame,
heat, hot Body fluids, heat, impact
Knives, environment, impact
body fluids
.

Comments on
Availability,
Condition, &
Storage

Completed by __Lee Carlson______________ Date 3-25-2008

Checklist of E/OHS Activities for Respiratory Protection

Program Contact Person: Jo Pyle

Does this school provide respirators for voluntary use? Yes No N/A
If the school allows employees to use respirators voluntarily the following is
mandatory.
1. Read and follow instructions provided by manufacturer.
2. Choose respirators certified for use against contaminants of concern.
3. Do not wear respirators in atmospheres containing contaminants not
designed to protect from those contaminants.
4. Keep track of respirators so that you do not mistakenly wear someone
else’s respirator.

Is the Respiratory Protection program in place? Yes No N/A

Is the Plan current? Yes No N/A

Has the Plan been reviewed this school year? Yes No N/A

Date of review: __2-13-08_____________

Are all employees in this program identified? Yes No N/A

Employee Intended Type of Medical Exam/ Date of Date of

Use Respirator Questionnaire Medical Fit Test
Jo Pyle Misc. ½ mask N/A N/A N/A
voluntary

Fit testing was completed on N/A.

(date)

Type of testing protocol; Irritant Smoke (Stannic Chloride) or

Bitrex (Denatonium Benzoate)
Condition and location of respirators:

Condition: ____new__________

Location(s):__custodial area__________________

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

Verified by: Lee Carlson

Note: The respirators were checked on 3-25-2008 and found to be in like new
condition. The respirators are located in the gray cabinet in the boiler room.
The particulate filters are also located in the same area. LC
Checklist of E/OHS Activities for Underground and Aboveground
Storage Tanks

Program Contact Person: Jo Pyle

Is the Underground and Aboveground Storage Tanks Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Have forms for inventory tracking been provided? Yes No N/A

Do existing records accurately reflect purchase use correlation? Yes No N/A

Are all USTs registered with the Minnesota Pollution Control Agency? Yes No
N/A

Are removals or additions of tanks anticipated in this facility? Yes No N/A

Notes:
 Underground/Aboveground Storage Tank Status

Tank No. Location Size Contents Registered Install date

#1 Bus garage 1000 gal #2 diesel fuel ? 2006

#2 Bus Garage 400 gal gasoline ? 2006

#3 High School 10,000 gal #2 fuel oil Yes 1995?

#4 Elementary 10,000 gal #2 fuel oil Yes 2002

School

Regulated Tanks:Motor fuel tanks larger than 110 gallons

Non-regulated Tanks:Heating oil tanks

Requirements for All USTs: Tank must be registered with MPCA

Requirements for Regulated Tanks:Annual tightness testing and inventory

control Tank must be updated, replaced, or removed by December 22, 1998
• Upgrades:
--Overfill protection
--Corrosion protection STPI approved
--Leak detection

Tightness Testing Results on File:

Dates of past testing:____________________

Records on file:________________________
Checklist of E/OHS Activities for Welding and Brazing Safety

Program Contact Person(s) John Lanoue

Department Contact:

• Metals Shop/Ag. FFA John Lanoue

• Art (jewelry) N/A

• Custodial N/A

Is the Welding and Brazing Plan in place? Yes No

Is the Plan current? Yes No

Has the Plan been reviewed this school year? Yes No

Method or methods used to control airborne particulate matter?

Has training been conducted for affected personnel? Yes No

Type of welding equipment available

• Electric arch…………………. Yes No N/A
• Wire feed/TIG MIG………. Yes No N/A
• Electric spot weld………… Yes No N/A

Personal Protective Equipment: availability and condition

• Gloves………… Yes No N/A

• Goggles………… Yes No N/A
• Welding mask………… Yes No N/A
• Apron………… Yes No N/A
• Steel toed shoes………… Yes No N/A

Describe location of welding activities, example; out-of-doors, booth, floor, all

of the above: