University of Washington Policy Directory

Print This Page
*Formerly part of the University Handbook
Administrative Policy Statement

Occupational Safety and Health Programs: General Requirements for WISHA Compliance

(Approved by the Executive Director of Health Sciences Administration by authority of Executive Order No. 1)

1.  Overview

The Washington Industrial Safety and Health Act (WISHA), Chapter 49.17 RCW, requires all state employers to maintain work practices and work environments which do not endanger the health or safety of employees. Accident prevention and occupational health and safety training programs are also required by the act. To enforce the act, the Washington State Department of Labor and Industries (L&I) issues standards, inspects work areas, and may issue citations and levy fines if the standards are not met. The policy of the University is to achieve compliance with state standards by instituting occupational safety and health programs in all departments and service units. In addition, employees are required to cooperate by using safe work habits so that accidents and job-related illnesses are prevented. Employee rights and responsibilities under WISHA are outlined in WISHA posters which, by law, are located on a number of bulletin boards on campus.

2.  Compliance Responsibility

A.   Management

WISHA requires that management establish, supervise, and effectively enforce the following practices:

  • A safe and healthful working environment.

  • An accident prevention program as required by the standard.

  • Training programs to improve the skill and competency of all employees in the field of occupational safety and health.

  • Accident investigation procedures for accidents that cause serious injuries and have immediate symptoms.

  • Procedures for reporting fatalities or multiple hospitalization accidents to L&I within 24 hours.

  • A system for maintaining and recording employee injury/illness experience.

  • Posting of required employee job safety and health notices.

For the purposes of compliance with WISHA standards and to provide a safe and healthful working environment for employees, the University has assigned responsibility for occupational health and safety as follows:

  1) Vice Presidents and Deans—These individuals are responsible for directing all units within their respective areas to establish and administer occupational safety and health programs. Assistance in the grouping of work areas into organizational units for the purpose of establishing safety programs is provided by the Environmental Health and Safety Department (EH&S).

  2) Deans, Directors, Chairs, and Supervisors—Each of these individuals is responsible for safety performance in their respective units (as referenced in the Executive Order No. 55).

  3) Department Heads—These individuals are advised to designate one person, plus an alternate, to act as a department coordinator for health and safety. This individual is to be responsible for implementing department safety and health programs and for acting as liaison between the department and EH&S.

  4) Assistant Vice President for Facilities Services—Under the authority of the Senior Vice President for Finance and Facilities, this individual is responsible for ensuring that structures, associated utilities, and grounds meet applicable standards.

B.   Employees

University safety policy states that faculty and staff are responsible for using required safety equipment, for following safe work practices, and for the safety of other employees and students under their supervision.

WISHA standards require that employees:

  • Coordinate and cooperate with all other employees in an attempt to eliminate accidents.

  • Study and observe all safe practices governing their work.

  • Offer safety suggestions which may contribute to a safer work environment.

  • Apply the principles of accident prevention in their daily work and use proper safety devices and protective equipment as required by their employment or employer.

  • Properly care for all personal protective equipment.

  • Promptly report to their immediate supervisor each work-related injury or illness, regardless of the degree of severity.

C.   The Environmental Health and Safety Department

EH&S assists departments in identifying safety hazards, developing occupational safety and health programs, reporting fatalities and multiple injuries to L&I, conducting safety inspections and accident investigations, and correcting conditions of noncompliance. It also advises employee groups as to their responsibilities and rights under WISHA. EH&S has been designated as the University's representative in dealing with L&I on matters concerning the act. Questions concerning the act or its implementation should be directed to EH&S, 206-543-7262. See Administrative Policy Statement 10.1, for a description of EH&S services.

3.  General Requirements for WISHA Compliance

All of the University's organizational units are required to plan and implement occupational safety and health programs to ensure that facilities, equipment and supplies, management practices, and operational procedures meet applicable safety and health standards. Note: Department or unit safety and health programs must be documented in a written safety and health plan. Assistance in developing these programs and copies of the state and other occupational safety and health standards can be provided by EH&S. At a minimum, programs should include the following:

A.   Accident Investigations

Accident investigations must be conducted following accidents that cause serious injuries and have immediate symptoms. For serious accidents, investigation must be conducted by EH&S and include the immediate supervisor of the injured employee, witnesses, an employee representative, and any other person with the special expertise required to evaluate the facts relating to the cause of the accident. The findings of the investigation shall be documented by EH&S. Less serious accidents do not require EH&S's involvement in the investigation, but all accidents must be investigated by the supervisor of the employee(s) involved and findings and corrective action reported on the appropriate University incident/accident report form (see Section 4 of this policy statement).

B.   Hazard Identification

Hazard identification is critical to establishing effective employee safety and health programs. Employing departments and supervisors must be aware of and identify the potential hazards in work areas under their control. If employees have the potential to be exposed to workplace hazards, specific programs must be in place. EH&S can assist departments in identifying hazards and implementing the appropriate health and safety programs. Following is a list of occupational safety and health concerns which are regulated by WISHA; however, the list is not necessarily conclusive. Any workplace hazard must be identified and corrected, whether a specific regulation exists or not.

  • Accidents
  • Air Contaminants
  • Asbestos
  • Benzene
  • Bloodborne pathogens
  • Carcinogens
  • CFC (chlorinated
  • Chemical hazards in
  • Chemical hazards,
  • Compressed gas &
       compressed gas equipment
  • Confined spaces
  • Cranes, overhead & gantry
  • Electrical
  • Emergency evacuation
  • Emergency response to
       hazardous materials incidents
  • Ergonomics (repetitive
       motion/cumulative trauma)
  • Excavation, trenching &
  • Falls (from heights)
  • Falls (slip and trip hazards)
  • Fire emergency & fire
  • Fire extinguishers
  • First-aid emergencies
  • Forklift operation
  • Formaldehyde
  • Hand & portable power tools
  • Hazardous energy
  • Hazardous materials
  • Hazardous waste
  • High noise
  • Ladders
  • Lasers
  • Lead
  • Lifting 20 lbs. or more
  • Machinery & machine
  • Materials handling &
       storage, including cranes,
       derricks, rigging
  • Means of egress
  • Personal protective
  • Physical agents
       (illumination, ionizing &
       nonionizing radiation,
       vibration, pressure,
  • Powered platforms
  • Radiation
  • Respiratory hazards
  • Welding
  • Working surfaces, guarding
       floors & wall openings,
       ladders, scaffolds
  • WISHA regulations covering these hazards require a variety of protective measures such as specific safety procedures, equipment, and training; medical surveillance; engineering controls; etc. EH&S can provide information needed to comply with these regulations.

    C.   Self-Evaluation Inspections

    To determine whether work areas meet the General Safety and Health Standards and Occupational Health Standards (Chapters 296-24 and 296-62 WAC) established by L&I, departments must conduct regular, thorough inspections to evaluate work conditions and work practices. These inspections should be held at regular intervals to insure continuing compliance with standards; contact EH&S, 206-543-7388, for assistance.

      1) Conditions Not in Compliance With WISHA—Conditions identified as being out of compliance with WISHA should receive immediate corrective action. EH&S will advise departments on ways to correct specific conditions. Further consultation with L&I is available to departments needing assistance in solving specific problems. State consultants do not issue citations as state inspectors do when areas are below standards, but rather advise and recommend corrective actions. Requests for these services should be made through EH&S. The L&I representative will be received by EH&S, and the consultation will be conducted jointly with an EH&S representative.

      2) Correction of Noncomplying Conditions—If a department is unable to correct a condition which is out of compliance due to budget or personnel limitations, the department must submit a report to the appropriate vice president or dean for resolution. The report should include the recommended corrective action and an estimate of the resources needed to implement it.

    D.   Safety Orientation

    Safety orientation is required for all employees. This requirement is met in part by the University's New Employee Orientation Program and in part by the employing department.

      1) New Employee Orientation Program—The New Employee Orientation Program covers the following information:
    • A description of the University's total safety program.

    • How and when to report injuries and unsafe conditions and practices.

    • Reporting emergencies.

    • A description of the University's Hazard Communication Program.

    • A description of the University's Health and Safety Committee Plan.
      2) Employing Department—The employing department provides the following information:
    • Location of first-aid kits, Material Safety Data Sheets (MSDS), and other safety and health information.

    • Emergency evacuation routes and procedures.

    • Use and care of required personal protective equipment.

    • Identification of hazardous gases, chemicals, or materials, along with instructions on safe use and emergency actions following exposure (specific hazard communication training).

    • On-the-job review of the safety practices.

    • Required safety and health training.

    Note: Temporary and hourly employees do not attend the University's New Employee Orientation Program, so employing departments must provide comprehensive safety orientation within the department at the time of their initial assignment; call EH&S, 206-543-7201, for a New Employee Safety Orientation checklist.

    E.   Safety Education and Training

    To ensure an effective program, employees must be trained in safe work practices. Supervisors are responsible for seeing that these practices are followed. EH&S will assist departments in implementing safety training and education programs upon request.

      1) Training New Employees—New employees should be thoroughly trained in safe operation of equipment, and in safe procedures for performing all duties included in their job assignments before being permitted to perform on their own.

      2) Safety Education Meetings—Safety education meetings should be held periodically in each organizational unit to reinstruct employees in safe work practices and to inform employees of new developments relating to safe operations.

      3) Specific Training—Specific training is required for certain occupations and occupational exposures. Contact EH&S Training, 206-543-7201, for assistance in determining employee safety training requirements.

    F.   First-Aid Training

    In certain workplaces it is a requirement that personnel trained in first aid be present. For example, shops, dispersed work crews, and field trips must have first-aid certified employees present during each shift. EH&S will interpret first-aid requirements for organizational units, and can provide qualifying first-aid training upon request.

    G.   First-Aid Kits

    As specified by WISHA, first-aid kits must be readily accessible and procedures in place to assure that first-aid kit contents are maintained in a serviceable condition; contact EH&S, 206-543-7388, for first-aid kit content requirements.

    H.   Health and Safety Committees

    The University of Washington has implemented an occupational Health and Safety Committee Plan to comply with WISHA regulations and to provide a forum for employee participation in assessing and enhancing workplace health and safety at the University. University health and safety committees are structured along organizational lines and report to the head of the organizational unit. A University-wide health and safety committee, composed of members of the organizational unit committees, provides campuswide consistency and oversight and reports to the director of EH&S. See Administrative Policy Statement 10.11, for a description of the University's Health and Safety Committee Plan.

    I.   Posting Employee Job Safety and Health Notices

    Each University unit or department must have a bulletin board for posting safety notices and safety educational material. The board must be in a location accessible to all employees (hallway, lunchroom, photocopy room, etc.) and at a minimum must display the posters required by L&I and the University Hazard Communication poster; call EH&S, 206-543-7201, to obtain copies of the required posters.

    J.   Record Keeping

    State standards require designated organizational units to maintain records of all safety activities covering the previous twelve months. These records must be made available to L&I noncompliance personnel at their request. Department records should include:

    • Results of self-evaluation inspections.

    • Records of requests for assistance in correcting noted deficiencies.

    • Minutes of safety education-accident prevention meetings.

    • Records of employees requiring medical evaluations including dates of examinations and immunizations.

    • Records of employee safety training, including dates when certificates expire, where applicable.

    4.  Reporting Accidents

    A.   All Accidents, Injuries, and Occupational Illnesses

    Every accident, injury, or occupational illness that requires first aid or medical treatment, or that results in time loss must be reported within 24 hours, as follows:

    • General campus and Health Sciences employees report to EH&S on the Incident/Accident/Quality Improvement Report form.

    • Harborview Medical Center and University of Washington Medical Center employees report to their respective Risk Management Offices on an Incident/Accident/Quality Improvement Report form.

    • School of Dentistry employees report to the School of Dentistry on an Unusual Incident/Accident Report form.

    Records of all occupational accidents, injuries, and illnesses are maintained on the Medical Centers Information Systems.

    B.   Occupational Injuries and Illnesses

    The University's Office of Risk Management maintains a log of all reported occupational injuries and illnesses that result in time loss or medical treatment beyond first aid (Workers' Compensation claims) and prepares an annual summary to meet the requirements of L&I. Copies of this summary are also posted in a number of work areas on campus. For more information on Workers' Compensation claims and benefits, contact the Office of Risk Management, 206-543-0183.

    C.   Serious Injuries and Fatalities

    Accidents or health hazards resulting in the death, probable death, or hospitalization of an employee or student must be reported immediately to EH&S.

    EH&S reports immediately to L&I each accident or health hazard that results in the death of one or more persons, or hospitalization of two or more persons.

    5.  Reporting Unsafe Conditions or Practices

    All employees are instructed to report to their supervisors, to EH&S, or to the appropriate sector or departmental health and safety committee representative any conditions that they feel are unsafe or unhealthful in their work areas. Unsafe conditions or practices requiring immediate correction must be reported to supervisors. Prompt consideration and replies must be given to employee concerns.

    6.  Requesting Variances From State Standards

    A temporary or permanent variance from a standard may be requested by any organizational unit. Variances must provide safeguards for employees that are equivalent to or greater than those specified in the state regulations. Requests should be directed to EH&S for a determination of technical validity. A request that appears technically valid will be forwarded to the Attorney General's Division for a determination of whether a legal basis for the request exists. EH&S will assist the Attorney General's Division in developing any such variance applications that are produced. Affected employees must be informed of any variance application submitted, and of their right to apply for a hearing on the application.

    7.  Compliance Inspections

    A.   Notification

    To enforce state standards L&I conducts compliance inspections, either unscheduled or in response to employee complaints. Advance notice of these inspections is prohibited by law. Compliance inspectors will contact EH&S to identify those activities to be inspected and to obtain an escort. The University departments involved will be notified by EH&S. If an L&I inspector arrives to inspect a department without an EH&S representative, the department should contact EH&S, 206-543-7262, immediately and advise the inspector to await the arrival of the EH&S representative.

    B.   Inspection Participants

    The following persons may accompany an L&I inspector throughout an inspection and during the entrance and exit briefings:

    • A representative of EH&S.

    • A management representative, designated by the organizational unit.

    • An employee representative selected by the employees within the unit. If employees do not elect to designate a representative, the inspector will interview employees at random during the inspection.

    8.  Citations and Corrective Actions

    A.   Posting

    L&I issues citations for noncompliance conditions found during inspections. Citations and fines are received by EH&S and forwarded to the responsible University department. Citations must be posted at the location where a violation was noted.

    B.   Fines and Abatement Periods

    Normally, a citation will specify an abatement period within which the violation must be corrected, and may assess a fine of up to $70,000 for willful or repeat violations. If the violation is not corrected in the specified period, additional fines of up to $7,000 per day may be assessed for as long as the violation continues. In the event of an extreme health or safety hazard, an operation or facility can be shut down immediately.

    C.   Corrective Action

    EH&S will advise departments on ways to correct noncomplying conditions cited by L&I. If a department is unable to correct a condition which is out of compliance due to budget or personnel limitations, a report should be submitted to the appropriate vice president or dean for resolution. The report should include the recommended corrective action and an estimate of the resources needed to implement it.

    D.   Responses to the Department of Labor and Industries

    Responses to L&I by the cited University department must be submitted in accordance with instructions provided by EH&S.

    E.   Payment of Fines

    Expenses that result from citations and fines are allocated to University departments by the appropriate dean or vice president, except when such expenses are directly related to a deficiency in a capital facility. Deficiencies in capital facilities will be referred to either Facilities Services or the Capital Projects Office for correction.

    9.  Appeal of Citation

    A cited University department may request an appeal of a citation. EH&S determines the technical appropriateness of appealing a citation and assists the Attorney General's Division in developing the appeal if it is determined that a valid legal basis exists. Notifications of hearings on appeals will be received and processed by EH&S. Employees may also appeal citations directly to L&I.

    If an appeal is submitted, employees must be informed and provided the opportunity to participate in the hearings.

    October 1998; RC, January 27, 2014.