Safety Manual for Highway Litter Removal.pdf

Page | 1

Desert Veterans, LLC

Safety Manual for Highway Litter Removal

Revised: January 2025

Page | 2

WELCOME

Working near highway traƯic is inherently dangerous, and incidents involving employees being struck by vehicles or mobile equipment are among the leading causes of fatalities and injuries in work zones. Highway litter removal is critical, but it is not a place to cut corners when it comes to safety.

Your life is on the line, so pay attention, stay alert, and follow the procedures to ensure your safety.

This manual contains:

1. Purpose of OSHA: The Occupational Safety and Health Administration (OSHA) and its enforcement duty under law.

2. High-Visibility Safety Apparel Requirements: Guidelines for proper PPE to keep you visible and safe.

3. Training Requirements: Necessary training for employees working in or around traƯic, streets, and highways.

4. Emergency Planning and Response Procedures: Protocols for handling accidents and emergencies.

INTENDED AUDIENCE

The target audience includes contractors, managers, employees, or employee representatives working in and/or around public or on-site vehicular traƯic. This includes:

State and local highway agencies

Public oƯicials

Insurance industry professionals

Law enforcement agencies

Incident management personnel

Maintenance and construction teams

Academic institutions

Private industries and engineering organizations

Page | 3

OSHA

As part of the Department of Labor (DOL), OSHA's mission is to protect workers' health and safety on the job. OSHA achieves its goals through setting standards, enforcement, providing training, outreach, education, and encouraging improvements in workplace safety.

Due to the ongoing occurrence of work zone crashes and fatalities, OSHA mandates a continued enforcement presence at work zones where operations like highway litter removal are conducted.

OSHA standards regulating work in traƯic are found in 29 CFR 1926 Subpart G. Relevant standards include CFR 1926.200 (g) TraƯic Signs, which outlines the necessity for clear, visible signs in construction zones.

NOTE: All warning garments must meet the ANSI 107 standard for high-visibility safety apparel.

High Visibility Safety Apparel (HVSA)

It is essential that all workers wear high-visibility safety apparel (HVSA). These garments are required to be ANSI-compliant (ANSI 107) and must be worn at all times when working in or near traƯic. The HVSA includes:

Reflective strips: Ensure workers are visible even in low light conditions.

Bright colors: Typically fluorescent yellow-green, orange, or red, these colors maximize visibility.

Personal Protective Equipment (PPE) requirements include hard hats, safety boots, and gloves.

Training Requirements

All workers exposed to highway traƯic whether it is litter removal personnel, or other support roles, must undergo specific safety training. This includes:

Highway Safety Training: Workers should be familiar with how to respond in emergencies, and safe practices for working near traƯic.

COMPETENT PERSON

A Competent Person is an individual who is qualified to identify existing and potential hazards at the worksite. This person has the authority to take immediate corrective actions to eliminate or reduce these hazards. All Desert Veteran Road Generals are be Osha 10 certified and deemed a Competent Person.

Responsibilities of the Competent Person:

Site Inspections: Conduct visual inspections of the jobsite throughout the day.

Page | 4

Safety Training: Provide ongoing safety training for all workers, including new hires, to ensure they understand the hazards associated with their tasks and the safety measures in place.

Hazard Identification: The competent person should identify job-site hazards and clearly explain the safety measures required to mitigate them.

Daily Safety Meetings: Conduct a daily safety meeting prior to the start of work to ensure crew is continually familiarized and updated with the most current safety topics.

Emergency Plans: Provide a briefing on the site’s emergency action plan, including evacuation procedures, first aid protocols, and location of nearest medical facility in the event of a medical emergency.

By ensuring that all workers are well-trained in the use of personal protective equipment, and a familiarization of best safety practices, better safety decisions can be made to protect all individuals working in the area.

MOTOR VEHICLE SAFETY

In road construction work zones, a significant proportion of fatalities are caused by workers being struck by construction equipment or other vehicles. Worker safety within the activity area requires specific measures to ensure that vehicles and equipment are operated safely.

Vehicle and Equipment Safety Requirements:

Vehicle Operators: Equipment shall NOT be left unattended with the vehicle operator within 15 feet of the vehicle at all times. Both the vehicle and trailer are equipped with appropriate lights or reflectors to clearly identify its location. Lights will be left on at all times during operations regardless of the time of day.

Vehicle Condition: All vehicles must be maintained in good working order:

o Windshield wipers and defrosting devices must be operable for visibility.

o Headlights and brake lights must be functional.

o Audible horns must be in good working condition.

Cab Glass: All vehicle cabs must be equipped with safety glass or equivalent materials to prevent distortion that could interfere with the safe operation of the vehicle.

Seat Belts: All vehicles must have as many seats as there are occupants, and all passengers must wear seat belts. Operators of excavators and backhoes are also required to wear seat belts when seated in the normal operating position.

Desert Veteran Road Generals are required to perform a pre-trip vehicle safety checklist prior to driving the vehicle at the beginning of each workday. Any issues must be reported to the Desert Veterans Fleet Manager immediately and the Fleet Manager will make basic repairs immediately or swap out the vehicle with one of the spare vehicles. See Form 5

Page | 5

Methods of Dealing with Hostile Drivers

Occasionally, drivers may become hostile in work zones. In these cases, workers should:

Walk away from the situation and avoid confrontation.

Be courteous but firm in communication.

Record details of the vehicle (description, driver, and license plate).

Notify the supervisor immediately.

Warn fellow workers about the situation.

COMMITMENT TO SAFETY

Desert Veterans recognizes that our employees are the foundation of our success. To ensure their safety and well-being, we provide comprehensive training, a secure work environment, and procedures prioritizing health and safety. All the work our employees conduct will align with these principles, and no task will ever take precedence over employee safety and health.

We are committed to preventing workplace accidents and maintaining a safe environment for all employees. We value our team members as essential contributors to their families, our business, and the community.

Employees are encouraged to report any unsafe work practices or hazards encountered on the job.

All accidents and incidents, regardless of their severity, must be immediately reported to the on-duty supervisor.

Compliance with federal, state, and local regulations is a key factor in executing this safety policy.

Noncompliance with these policies may result in disciplinary action. Desert Veterans pledges to provide a workplace that is free from recognized hazards by adhering to these core principles:

1. Accident Prevention: All accidents can be prevented through eƯective safety and health controls.

2. Daily Focus on Safety: Safety is a fundamental component of our daily operations.

3. Business Benefits: Accident prevention minimizes human suƯering, promotes better working conditions, and enhances productivity and customer trust.

4. Management Accountability: Management is committed to providing the necessary resources to support this safety policy.

5. Employee Responsibility: Employees must follow safe work practices and report unsafe conditions or hazards.

Page | 6

6. Open Communication: Management will establish clear communication channels to receive safety-related feedback and suggestions from employees.

7. Leadership by Example: Supervisors and managers will demonstrate a strong commitment to safety and monitor the work environment to achieve program goals.

8. Continuous Improvement: The safety program applies to all employees and stakeholders, with a shared goal of improving safety awareness and preventing accidents.

Together, we can create a safe and healthy workplace for all employees.

Employee Safety Responsibilities

Employees of Desert Veterans have the primary responsibility of performing their duties safely to prevent injuries to themselves and others. As conditions of employment, employees must adhere to company safety rules and policies, including:

Learning and observing all safety procedures relevant to their work.

Consulting supervisors before beginning unfamiliar tasks.

Reporting safety concerns or hazards immediately.

Never perform tasks they believe to be unsafe.

General Safety Rules

1. Workplace Conduct: Horseplay, practical jokes, or any behavior that places others at risk is prohibited. Employees must maintain professional behavior.

2. Substance-Free Workplace: Possession or use of illegal drugs or alcohol is strictly forbidden. Employees may not report to work under the influence of these substances.

3. Housekeeping: Keep work areas clean, remove obstructions, and promptly clean spills.

Ensure aisles, fire extinguishers, and electrical panels remain accessible.

4. Injury Reporting: Report all work-related injuries immediately to the supervisor. Failure to do so may aƯect Workers’ Compensation eligibility.

OƯ-Site Safety

Employees must follow these guidelines during oƯ-site work:

Identify emergency exits when indoors.

Avoid tripping or slipping hazards by maintaining awareness of your surroundings.

Use three-point contact (hand on rail, feet on stairs) when using stairs.

Page | 7

Follow all customer-specific safety rules and seek permission before operating equipment on their property.

Safety Orientation and Training

Desert Veterans is committed to educating all employees on safety procedures and best practices through comprehensive training programs. Training topics include:

1. Accident and incident data specific to the company.

2. Work area hazards.

3. Job-specific hazards.

4. Vehicle operation.

5. Personal protective equipment (PPE).

6. Emergency response procedures.

7. Accident reporting requirements.

8. OSHA compliance training.

Periodic Inspections

Workplaces and jobsites will be subject to periodic inspections by Desert Veterans Management to ensure compliance with safety policies. Managers and supervisors are responsible for correcting deficiencies identified during inspections.

OHSA and Regulatory Inspections

Jobsites may be visited by outside agencies to verify safety compliance. In the event of an outside agency inspection, Desert Veteran’s Road Generals must comply with any and all requests from any oƯicial outside agency. Desert Veteran’s Road Generals must contact the Field manager on duty to communicate that an outside agency is conducting an inspection of the crew. The field manager will reach out to ADOT to inform of the inspection. The Desert Veteran’s field manager will notify ADOT when any actions are settled, or corrective actions are implemented

Incident Reporting

1. Report all work-related injuries or suspected injuries immediately to the Field Manager or Safety Compliance OƯicer.

Page | 8

2. Field Manager or Safety Compliance OƯicer will complete an Accident Investigation Form for every incident. See Form 1

3. Employees must return to work under light-duty arrangements, if applicable, once medically cleared.

Accident Investigation

4. An accident investigation will be conducted to determine the root cause of the accident.

The injured employee will be asked to participate in the investigation.

The safety compliance oƯicer or field manager will report all recordable injuries to ADOT upon the completion of an investigation. Any fatal Injuries will be reported to ADOT and OHSA immediately.

Any incidents involving the public will be communicated to ADOT upon the completion of the investigation.

Return to Work Program

At Desert Veterans, our goal is to prevent work-related injuries and ensure the safety of all employees. We are committed to providing prompt medical treatment for injured employees to facilitate their recovery and the earliest possible return to work. Work-related absences can be costly for both Desert Veterans and our employees, which is why we have a workers’ compensation program to support employees who experience work-related injuries or illnesses.

The program’s administrator will determine eligibility for wage loss or medical expense benefits. In addition, Desert Veterans has implemented a Return-to-Work Program, oƯering transitional or light-duty work for employees who are temporarily unable to perform their regular duties. This program is temporary, and will not exceed three months.

Employee Procedures

Reporting Injuries: All work-related injuries must be reported to your supervisor immediately, and no later than the end of the shift during which the injury occurs.

Post-Accident Drug Screen: If a post-accident drug screen is not performed on the same day as the injury, employees will be paid for up to one hour while taking time to complete the screening.

Injury Report Form: Employees must complete and sign a Report of Injury or Illness form.

See Form 2

Medical Treatment: When seeking medical treatment, employees must inform their supervisor and obtain a Return-to-Work Evaluation form. Regardless of the physician chosen, the Return-to-Work Evaluation form must be completed at each practitioner’s visit. General notes stating that the employee is oƯ work will not be accepted. See Form 3

Page | 9

Light-Duty Work: Temporary light-duty work is available for up to 60 days, with progress reviewed every 30 days. Extensions up to a maximum of three months will be considered on a case-by-case basis.

Requirement to Return: Employees capable of performing transitional duties must return to light-duty work. Failure to do so may result in ineligibility for full disability benefits under the workers’ compensation program, disqualification from other benefits, and possible termination.

Weekly Updates: Employees unable to return to work must provide weekly updates on their status. Failure to comply may result in reduced benefits or disciplinary action, up to termination.

FMLA Requirements: Employees unable to return to work must apply for leave under the Family Medical Leave Act (FMLA) by completing a Family Medical Leave Request form.

They must also submit a Return-to-Work Evaluation form and a Physician’s Authorization form. See Form 4

Non-FMLA Eligibility: Employees not eligible for FMLA must return to available work, either regular or light-duty. If unable to return, their position may be filled after a reasonable time.

Updates on medical status must be provided regularly, and return to work will be contingent upon the availability of a suitable position.

Full Duty Clearance: Employees must provide a Return-to-Work form indicating their readiness to resume full duties. Permanent restrictions will be assessed on a case-by-case basis concerning essential job functions. No permanent light-duty positions will be created.

Cooperation: Employees must cooperate with the third-party administrator and provide accurate information promptly to receive entitled benefits. Concerns should be addressed with a supervisor or Human Resources.

Page | 10

Emergency Action Plan

General Emergency Guidelines

Stay calm and think through your actions.

Know emergency numbers:

o Fire/Police/Ambulance: 911 o See East Valley ADOT Routes: Emergency Contacts o Internal Emergency Number:

o David Garcia (Field Manager): 602-489-0960 o Noah Rivera (Field Manager): 480-634-0531 o Jacob Tilley (Safety Compliance OƯicer): 602-696-7566 o 24 hr. Hotline: 602-884-4175

Do not hesitate to alert others or call for help in an emergency. Acting in good faith will not result in reprimand, even if it turns out to be a false alarm.

First aid supplies and emergency equipment are available in every vehicle and at every Desert Veterans oƯice. All Desert Veteran’s Road Generals and Managers are trained in basic first aid and can identify when a higher level of care is required.

Fire Safety

Fire Extinguishers are located in every Desert Veterans Vehicle and at every Desert Veterans oƯice.

Alert individuals in the immediate area of a fire hazard.

Activate the fire alarm or notify the appropriate personnel.

If trained, use a fire extinguisher:

o P = Pull the pin.

o A = Aim the nozzle at the fire’s base.

o S = Squeeze the handle.

o S = Sweep side-to-side at the base of the fire.

Always position yourself between the fire and an exit. Stay low and back away when the fire is extinguished. Evacuate immediately if the fire becomes unmanageable.

Notify the incident commander of the fire’s location for communication with the fire department.

Notify the Desert Veterans Safety Compliance OƯicer or Field Manager of the incident as soon as possible.

Page | 11

Smoking

Smoking, electronic cigarettes, vaping is prohibited in and within 20 feet of all public areas and places of employment in Arizona. Additionally, Desert Veterans and its employees must ensure that smoke does not enter the enclosed area and that customers do not have to breathe the smoke when using entrances. Smoking or vaping is not permitted in any Company buildings, facilities, or in vehicles.

Employees wishing to smoke or vape should do so during their break times, outside Company buildings and vehicles, near the outside passenger side of the vehicle when working on site, and in accordance with local ordinances. Employees must be mindful of current fire restrictions issued by local and state oƯicials. When fire restrictions are deemed “very high” or “extreme” the state of Arizona does not allow smoking outside. During these conditions, Desert Veterans does not allow employees to smoke on site.

Environmental Safety Precautions Heat-Related Illnesses

1. Wear loose, light-colored clothing and a hat to reflect heat and allow for air circulation.

2. Gradually adapt to working in hot conditions, avoiding overexertion during peak temperature times.

3. Stay hydrated by drinking water frequently, at least 8 ounces every 20-30 minutes. Avoid caƯeine, as it increases urination and dehydrates the body.

4. Watch for signs of heat-related illnesses:

o Heat cramps: Severe muscle spasms caused by the loss of body salt and water due to heavy sweating.

o Heat exhaustion: Symptoms include heavy sweating, cool or pale skin, nausea, headache, weakness, vomiting, and fast pulse.

o Heat stroke: Severe illness with high body temperature, minimal sweating, red and dry skin, rapid breathing and pulse, confusion, or unconsciousness.

5. Treat heat illnesses immediately:

o Heat cramps: Move to a cooler area, hydrate with 6 ounces of water every 15 minutes, and seek medical examination.

o Heat exhaustion: Move to a cooler area, lie down with elevated legs, cool the body with fans or cool towels, and drink water. Seek medical attention.

o Heat stroke: Call 9-1-1 immediately. Move to a cooler area, remove outer clothing, cool the body with wet towels or water, and do not drink liquids.

Page | 12

Cold Weather Illnesses

1. Exposed skin freezes quickly in extreme cold, especially in high winds. Cold-related injuries can occur even above freezing temperatures when wet.

2. Watch for signs of cold-related illnesses:

o Uncontrollable shivering, slurred speech, clumsy movements, fatigue, and confused behavior.

3. Layer clothing to stay warm:

o Inner layer: Use synthetic materials to wick moisture away from the skin.

o Middle layer: Wool or synthetic fabric retains body heat.

o Outer layer: Choose wind-breaking materials that allow for ventilation.

4. Wear a hat to prevent heat loss—up to 40% of body heat is lost through the head.

5. Use heat packets in gloves, boots, vests, and hats to add extra warmth.

6. Be aware of the eƯects of cold temperatures:

o Reduced dexterity, weaker grip on cold tools, numbed pain sensation, and decreased muscle strength.

Contact with Insects, Rodents, and Other Pests

1. Do not touch rodents, even if they appear dead.

2. Avoid disturbing animals in nests or dens as they may feel threatened and become aggressive.

3. Never approach or corner a snake or other dangerous animals.

4. Wear appropriate repellents for pests and animals in the area.

5. Cover exposed skin by wearing long-sleeved shirts, long pants, boots, and a hat. Ensure no skin is exposed at the neck, wrists, or ankles.

6. Tuck pants into boots and stay alert for any signs of pests.

7. Avoid wearing perfumes or cologne that may attract animals.

8. Manage food and waste responsibly to avoid attracting pests to your work area.

9. If you are allergic to insects, always carry the necessary medication and inform coworkers of your allergy for emergency assistance.

Page | 13

Vehicle Use Policy To: All Drivers of Desert Veterans EƯective: Immediately

This policy applies to all employees authorized to drive vehicles owned and/or insured by Desert Veterans. The following guidelines are established to promote safe vehicle operation and clarify insurance-related matters:

1. Driver’s License Requirements:

o All drivers must possess a valid driver’s license.

o Motor Vehicle Records will be checked periodically. Driving privileges may be suspended or terminated if your record indicates an unacceptable number of accidents or violations. If your record falls within the insurance carrier’s guidelines for an "unacceptable driver," your employment may be terminated.

2. Change in License or Driving Record:

o Notify your supervisor immediately of any changes to your license status or driving record.

3. Use of Personal Vehicles:

o Employees must not operate personal vehicles for any business-related activities for Desert Veterans.

4. Accident Protocol:

o Take necessary steps to protect the lives of yourself and others.

o Follow all police instructions.

o Do not admit or assume fault. Liability and negligence will be determined through a thorough investigation.

o Report the accident to the Field Manager as soon as possible.

By signing below, you confirm that you have read, understood, and agreed to comply with the Vehicle Use Policy.

Employee Signature: ________________________ Date: ______________

Page | 14

Employee Acknowledgement Form At Desert Veterans, we are deeply committed to your safety and well-being. We will take every necessary measure to prevent workplace accidents and ensure a safe working environment for all employees.

Your role in this eƯort is crucial. You are encouraged to report any unsafe practices or hazards you encounter while on the job. All incidents, no matter how small, must be reported immediately to the supervisor.

To ensure the eƯective implementation of our safety policies, compliance with all federal, state, and local safety regulations is mandatory. Failure to comply may result in disciplinary action. Our company is committed to providing a hazard-free environment and follows these guiding principles:

1. Accidents are preventable through the implementation of eƯective safety policies.

2. Safety and health controls are an integral part of our daily work practices.

3. Accident prevention is good business, reducing suƯering, improving working conditions, and boosting productivity.

4. Management is responsible for providing a safe workplace and allocating resources to promote and implement safety programs.

5. Employees are responsible for following safe practices, and company rules, and preventing accidents. Supervisors will create channels open for feedback and concerns related to safety.

6. Management and supervisors will lead by example, fostering a strong commitment to safety.

7. Safety is everyone's responsibility. We must all work together to continuously improve safety awareness, prevent injuries, and ensure a safe workplace.

By signing this document, I acknowledge receipt of Desert Veterans’ employee safety handbook. I have read and understood all the policies, and I agree to comply with these safety protocols.

Employee Signature: _________________________________

Date: _________________________________

Page | 15

Form 1:

ACCIDENT INVESTIGATION REPORT

REPORT #: _______________________

COMPANY: Desert Veterans, LLC ADDRESS: 5610 N. 51st Ave, Glendale, AZ 85301

1. Name of Injured: ___________________________________ S.S. #: ___________________________________

2. Sex: [ ] M [ ] F Age: ___________ Date of Accident: ________________________

3. Time of Accident: [ ] a.m. [ ] p.m.

Day of Accident: ___________________________

4. Employee's Job Title: _________________________________________________

5. Date of Hire: _______________________

6. Address of Location Where the Accident Occurred:

7. Nature of Injury, Injury Type, and Part of the Body AƯected:

8. Describe the Accident and How It Occurred:

9. Cause of the Accident:

10. Was Personal Protective Equipment (PPE) Required?

[ ] Yes [ ] No

Page | 16

11. Was PPE Provided?

12. Was PPE Being Used at the Time of the Accident?

[ ] Yes [ ] No If "No", explain:

13. Was PPE Used as Trained by a Supervisor or Designated Trainer?

[ ] Yes [ ] No If "No", explain:

14. Witness(es):

15. Was Safety Training Provided to the Injured Employee?

If "No", explain:

16. Interim Corrective Actions Taken to Prevent Recurrence:

17. Permanent Corrective Action Recommended to Prevent Recurrence:

Date of Report: ____________________ Prepared by: ___________________________________ Supervisor Date: _____________________________

18. Status and Follow-Up Action Taken by the Safety Coordinator:

Safety Coordinator Date: _______________________

Page | 17

Form 2:

REPORT OF INJURY OR ILLNESS

Employee Information:

Employee Name: ___________________________

Employee ID Number: ______________________

Department: ______________________________

Job Title: ________________________________

Phone Number: ___________________________

Email Address: ___________________________

Injury or Illness Details:

Date of Injury/Illness: _______________________

Time of Injury/Illness: _______________________

Location of Injury/Illness: (Include building, room, or area)

Description of Injury/Illness: (Describe the event, injury, or symptoms)

Injury or Illness Type:

Physical Injury (e.g., sprains, fractures, cuts)

Illness (e.g., respiratory, digestive, etc.)

Other (please specify): ____________________________

Was Medical Treatment Required?

Yes

No

Page | 18

If yes, please provide details of medical treatment received:

Cause of Injury or Illness:

Workplace Accident (e.g., fall, machinery-related)

Occupational Disease (e.g., repetitive strain, exposure to harmful substances)

Pre-existing Condition

Other (please specify): ____________________________

Witness Information (if applicable):

Witness Name: ___________________________

Witness Phone Number: ___________________

Witness Statement: (If applicable, describe what the witness observed)

Employee's Statement:

Describe what happened leading up to the injury/illness and any contributing factors:

Signature of Employee:

Signature: ___________________________

Date: _______________________________

Manager/Supervisor Information:

Name of Supervisor/Manager: _______________________

Page | 19

Date of Report Review: ___________________________

Supervisor's Action Taken:

For HR/Medical Use Only:

HR/Medical Department Review:

Follow-Up Actions (if any):

Further investigation required

Corrective actions recommended

Employee sent home

Worker’s compensation claim filed

Other: ______________________________________

Page | 20

Form 3:

RETURN-TO-WORK EVALUATION FORM

Employee Information:

Employee Name: ___________________________

Employee ID Number: ______________________

Department: ______________________________

Job Title: ________________________________

Phone Number: ___________________________

Email Address: ___________________________

Date of Injury/Illness: ______________________

Date of Last Work Day: ______________________

Medical Provider Information (if applicable):

Provider’s Name: _________________________

Medical Facility/Practice: _________________

Phone Number: ___________________________

Fax Number: _____________________________

Date of Last Visit/Examination: ____________

Return-to-Work Status:

Employee is cleared to return to work without restrictions.

Employee is cleared to return to work with restrictions. (Please specify the restrictions below)

If applicable, list any restrictions or accommodations required:

Page | 21

Employee is not yet cleared to return to work. (Please provide expected date of return or next review date)

Job Capacity and Work Restrictions:

Can the employee perform their normal job duties?

o Yes o No

If no, explain why:

Does the employee require any accommodations to perform their job duties?

o Yes

If yes, describe the accommodations:

Expected Work Schedule:

o Full-time o Modified hours (please specify): ________________________ o Part-time (please specify): ___________________________

Medical Provider’s Notes:

Brief description of the employee’s condition and recovery status:

Any additional medical advice or recommendations:

Page | 22

Employee’s Acknowledgment:

I acknowledge that the information provided in this form is accurate to the best of my knowledge. I agree to abide by any work restrictions or accommodations provided by my healthcare provider and understand that I may be subject to further evaluations or assessments as needed.

Employee’s Signature: ___________________________

Date: ________________________

Supervisor/Manager’s Acknowledgment:

I have reviewed the return-to-work evaluation and will ensure that any necessary accommodations are provided to support the employee’s safe return to work. If restrictions are noted, I will work with the employee and HR to ensure compliance.

Supervisor/Manager’s Name: ________________________

Supervisor/Manager’s Signature: _______________________

HR Department Use Only:

HR Representative Name: ________________________

Date of Review: _________________________________

Action Taken:

o Employee cleared for full return to work o Employee placed on modified duties o Further medical assessment required o Other: ________________________

HR Signature: _______________________________

Date: __________________________

Page | 23

Form 4:

FAMILY MEDICAL LEAVE REQUEST FORM

Employee Information:

Employee Name: ___________________________

Employee ID Number: ______________________

Department: ______________________________

Job Title: ________________________________

Phone Number: ___________________________

Email Address: ___________________________

Leave Request Details:

Type of Leave Request:

o Employee’s Serious Health Condition o Family Member’s Serious Health Condition (Relationship to employee:

o Birth of Child (Expected date of birth: ______________________) o Adoption/Foster Care Placement (Expected date of placement:

o Other (please specify): ____________________________

Reason for Leave (Please provide a detailed explanation):

Start Date of Leave: __________________________

End Date of Leave (if known): ___________________

Will the leave be taken intermittently or on a reduced schedule?

o Yes

If yes, please specify the schedule: ________________________

Page | 24

Expected Return to Work Date: _______________________

Certification of Health Care Provider (if applicable):

If you are requesting leave due to your own or a family member’s serious health condition, please provide the following:

I have attached a completed Certification of Health Care Provider form.

I will provide the necessary Certification of Health Care Provider form within the required time frame.

Employee's Acknowledgment and Certification:

I certify that the information provided on this form is true and accurate to the best of my knowledge.

I understand that I may be required to provide additional documentation (such as medical certification) to support my leave request. I also understand that, depending on the nature of my leave, I may be required to comply with company policies regarding paid and unpaid leave during my time away from work.

Employee’s Signature: ___________________________

Supervisor/Manager’s Review:

Manager’s Name: ___________________________

Date Leave Request Received: _______________________

Manager’s Comments: (e.g., impact on work schedule, department, etc.)

Supervisor’s Signature: _________________________

HR Department Use Only:

HR Representative Name: ________________________

Date Leave Request Reviewed: _______________________

Page | 25

Eligibility Determination:

o Employee is eligible for Family Medical Leave o Employee is not eligible for Family Medical Leave o Further information required

Leave Status:

o Approved o Denied o Pending (awaiting additional information)

HR Representative’s Signature: ______________________

Date: _______________________

Important Notes:

This form must be submitted to HR at least 30 days in advance if the leave is foreseeable. If the leave is unforeseeable, it must be submitted as soon as possible.

Employees requesting FMLA leave must meet eligibility requirements, including having worked for the company for at least 12 months and having worked 1,250 hours in the last 12 months.

Additional documentation, such as medical certification or other relevant documents, may be required.

Page | 26

Form 5:

PRE-TRIP VEHICLE SAFETY CHECKLIST

Driver Information:

Driver Name: ___________________________

Vehicle Number/ID: _______________________

Date: _______________________

1. EXTERIOR CHECKS:

Tires:

o Check for proper air pressure (refer to manufacturer recommendations).

o Check for visible damage (cuts, bulges, worn tread).

o Ensure there is a full spare tire and appropriate tools for changing a tire.

Lights:

o Check headlights, brake lights, turn signals, emergency signal lights and emergency flashers to ensure they are working.

Windows and Mirrors:

o Ensure all windows are clean and free from cracks or chips.

o Check side and rearview mirrors for visibility; adjust if necessary.

Windshield Wipers:

o Check for proper wiper function and ensure the wiper blades are in good condition.

o Verify there is enough windshield washer fluid.

Brakes:

o Test the brakes to ensure they feel responsive.

o Ensure no unusual sounds or vibrations when applying the brakes.

2. UNDER THE HOOD:

Engine Oil:

o Check oil level and condition (ensure it’s at the proper level and not dirty or low).

Page | 27

Coolant:

o Ensure coolant levels are adequate and there are no signs of leaks.

Battery:

o Check battery terminals for corrosion.

o Ensure the battery is secure and cables are tight.

Belts and Hoses:

o Check for any visible cracks, frays, or wear in the belts and hoses.

Power Steering Fluid:

o Ensure power steering fluid is at the correct level.

3. INTERIOR CHECKS:

Dashboard Indicators:

o Ensure that no warning lights (e.g., engine, ABS, oil pressure) are illuminated on the dashboard.

Seat Belts:

o Ensure all seat belts are functioning properly and not damaged.

Air Conditioning/Heating:

o Check that the air conditioning and heating systems are working properly for comfort and defogging.

Emergency Kit:

o Ensure the vehicle has a fully stocked emergency kit (first aid kit, flashlight, jumper cables, fire extinguisher, etc.).

Fire Extinguisher:

o Ensure that a properly charged fire extinguisher is available in the vehicle.

Driver’s Certification:

I certify that I have completed the pre-trip safety checklist above and that the vehicle is in safe working condition for travel. I will immediately report any issues to my supervisor and take appropriate action before starting the trip.

Driver’s Signature: ___________________________

Date/Time of Check: ___________________________

Page | 28

East Valley ADOT Routes: Emergency Contacts

SR87 & SR587:

Emergency Contact (Non-Emergency): Chandler PD - (480) 782-4000 Mesa PD - (480) 644-2211 Gila River PD - (520) 562-4511

Emergency Room:

SR87: Emergency Room North: Banner Desert 1400 S Dobson Rd, Mesa, AZ 85202

SR87: Emergency Room South: Chandler Regional 1955 W Frye Rd, Chandler, AZ 85224

SR587 Emergency Room: Phoenix ER 3050 S Dobson Rd, Chandler, AZ 85248

SR87: MP 177-218

Emergency Contact (Non-Emergency): Salt River Police Dept.: (480) 850-8200

Emergency Room: 9700 N Saguaro Blvd, Fountain Hills, AZ 85268

US 60: MP 172-218

Emergency Contact (Non-Emergency): Chandler PD - (480) 782-4000 Mesa PD - (480) 644-2211 Tempe PD - 480-350-8311

Emergency Room:

Tempe: Dignity Health E.R. 5125 S Rural Rd, Tempe, AZ 85282

Mesa: Banner Desert 1400 S Dobson Rd, Mesa, AZ 85202

Gilbert: Banner Gateway 1900 N Higley Rd, Gilbert, AZ 85234

Apache Junction / East Mesa: Honor Health 1301 S Crismon Rd, Mesa, AZ 85209

L202 South: MP 30-57

Emergency Contact (Non-Emergency): Chandler PD - (480) 782-4000 Gilbert PD - (480) 503-6500 Mesa PD - (480) 644-2211

Page | 29

Emergency Room: Mercy Gilbert 3555 S Val Vista Dr, Gilbert, AZ 85297 & Chandler Regional 1955 W Frye Rd, Chandler, AZ 85224

SR88: MP 194-220

Emergency Contact (Non-Emergency): Pinal County SheriƯ’s - 520-866-5111 Maricopa County SheriƯ's - (602) 876-1853

Emergency Room: Mountain Vista Medical Center 1301 S Crismon Rd, Mesa, AZ 85209

L202 Red Mountain: MP 6-30

Emergency Contact (Non-Emergency): Chandler PD - (480) 782-4000 Mesa PD - (480) 644-2211 Tempe PD - 480-350-8311

Emergency Room:

East: Honor Health Tempe 1500 S Mill Ave, Tempe, AZ 85281

West: Banner Baywood Medical Center 6644 E Baywood Ave, Mesa, AZ 85206

SR24: MP 0-6

Emergency Contact (Non-Emergency): Pinal County SheriƯ’s - 520-866-5111 Maricopa County SheriƯ's - (602) 876-1853

Emergency Room: East Valley ER and Hospital 5656 S Power Rd, Gilbert, AZ 85295