Download this fillable template for a model Injury and Illness Prevention Program for Employers with Seasonal or Intermittent Workers that the employer must complete.
Instructions in red font enclosed in brackets indicate where you must enter your worksite-specific information.
Instructions in red font enclosed in brackets indicate where you must enter your worksite-specific information.
Every California employer must establish, implement and maintain a written Injury and Illness Prevention (IIP) Program and a copy must be maintained at each workplace or at a central worksite if the employer has non-fixed worksites.
The requirements for establishing, implementing and maintaining an effective written Injury and Illness Prevention Program are contained in Title 8 of the California Code of Regulations, Section 3203 (T8 CCR 3203) and consist of the following elements:
• Responsibility
• Compliance
• Communication
• Hazard Assessment
• Accident/Exposure Investigation
• Hazard Correction
• Training and Instruction
• Employee access to the IIP Program
• Recordkeeping
This model program has been prepared for use by employers in industries that have been determined by Cal/OSHA to historically utilize intermittent or seasonal workers. Intermittent or seasonal employment refers to controlling, directing, or directly supervising any worker other than permanent workers.
Proper use of this model program requires the IIP Program administrator of your establishment to carefully review the requirements for each of the IIP Program elements found in this model program, fill in the appropriate blank spaces and check those items that are applicable to your workplace.
The recordkeeping section requires that the IIP Program administrator select and implement the category appropriate for your establishment. Sample forms for hazard assessment and correction, accident/exposure investigation, and worker training and instruction are provided with this model program.
Proper use of this model program requires the IIP Program administrator of your establishment to carefully review the requirements for each of the IIP Program elements found in this model program, fill in the appropriate blank spaces and check those items that are applicable to your workplace.
The recordkeeping section requires that the IIP Program administrator select and implement the category appropriate for your establishment. Sample forms for hazard assessment and correction, accident/exposure investigation, and worker training and instruction are provided with this model program.
This model program must be maintained by the employer in order to be effective.
Download the PDF form to your computer, open it with Adobe Reader, and complete it.
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