VHA Directive 7701 Comprehensive Occupational Safety and Health Program.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7701 Veterans Health Administration Transmittal Sheet Washington, DC 20420 December 12, 2022

COMPREHENSIVE OCCUPATIONAL SAFETY AND HEALTH PROGRAM

1. SUMMARY OF MAJOR CHANGES:

a. Updated referenced directive names and database names, position titles and mail codes to current information.

b. Overhauled responsibilities of Under Secretary for Health and Assistant Under Secretaries for Health (for Health and Operations).

c. Added required Records Management language.

d. Aligned training requirements with publication requirements.

e. Created appendices for supplemental and explanatory language.

2. RELATED ISSUES: VA Directive 7700, Occupational Safety and Health, dated February 11, 2009.

3. POLICY OWNER: The Assistant Under Secretary for Health for Support (19) is responsible for the contents of this directive. Questions may be addressed to the Director, Office of Occupational Safety and Health, Healthcare Environment and Facilities Programs (19HEF) at 202-632-7888.

4. RESCISSIONS: VHA Directive 7701, Comprehensive Occupational Safety and Health Program, dated May 5, 2017, is rescinded.

5. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of December 2027. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded

6. IMPLEMENTATION SCHEDULE: This directive is effective upon publication.

BY THE DIRECTION OF THE OFFICE OF

THE UNDER SECRETARY FOR HEALTH:

/s/ Alfred A. Montoya Jr., MHA, FACHE Acting Assistant Under Secretary for Health for Support

December 12, 2022 VHA DIRECTIVE 7701

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DISTRIBUTION: Emailed to the VHA Publication Distribution List on December 13, 2022.

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

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CONTENTS

COMPREHENSIVE OCCUPATIONAL SAFETY AND HEALTH PROGRAM

1. POLICY

2. RESPONSIBILITIES

3. TRAINING

4. RECORDS MANAGEMENT

5. BACKGROUND

6. REFERENCES

APPENDIX A

VHA SAFETY AND HEALTH LEADERSHIP COUNCIL MEMBERSHIP...................A-1

APPENDIX B

VISN OSH PROGRAM ELEMENTS .........................................................................B-1

APPENDIX C

ANNUAL WORKPLACE EVALUATION REQUIREMENTS ..................................... C-1

APPENDIX D

NETWORK EMPLOYEE SAFETY AND HEALTH LEADERSHIP COMMITTEE

MEMBERSHIP ......................................................................................................... D-1

APPENDIX E

VA MEDICAL FACILITY DIRECTOR ANNUAL WORKPLACE EVALUATION

REQUIREMENTS .....................................................................................................E-1

APPENDIX F

PROCESS FOR REPORTING UNSAFE OR UNHEALTHFUL WORKING

CONDITIONS ............................................................................................................ F-1

COMPREHENSIVE OCCUPATIONAL SAFETY AND HEALTH PROGRAM

1. POLICY

This Veterans Health Administration (VHA) directive establishes procedures and standards for the VHA Occupational Safety and Health (OSH) program to protect personnel providing support to VHA under the direct supervision of VHA staff. It is VHA policy to maintain a safe and healthful work environment for VHA employees, volunteers, and other persons performing work under direct supervision of VHA staff by satisfying OSH requirements, including VA Directive 7700. VHA organizations will develop, implement and maintain a comprehensive OSH program that meets the requirements of 29 CFR 1960 and applies a combination of hazard assessments, safe work practices, engineering and administrative controls, employee training, and personal protective equipment (PPE) to prevent injuries and illnesses. AUTHORITY: 5 U.S.C. § 7902(d) & (e); 29 U.S.C. § 668; 38 U.S.C. § 7301(b). NOTE: This VHA directive applies to all VHA-owned and leased properties, other Department of Veterans Affairs (VA) entities located at VHA facilities, all compensated and non-compensated VHA employees (regardless of location), volunteers, and other persons performing work within a VHA facility who are under direct supervision by VHA staff.

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

c. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

d. Executive Director, VHA Office of Healthcare Environment and Facilities Programs. The Executive Director, Office of Healthcare Environment and Facilities Program is responsible for:

(1) Overseeing the VHA Occupational Safety and Health (OSH) program.

(2) Periodically assessing the VHA Occupational Safety and Health Program and system for continued need, currency and effectiveness.

(3) Coordinating with the Assistant Under Secretary for Health for Operations, Veterans Integrated Services Network (VISN) Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address occupational safety and health performance in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

e. Director, Office of Occupational Safety & Health. The Director, Office of Occupational Safety and Health is responsible for:

(1) Developing a comprehensive OSH Program that conforms to the Safety Management Systems requirements of VHA Directive 7703. NOTE: See also VHA Directive 7702, Industrial Hygiene Program and Exposure Assessment Process, dated July 29, 2021.

(2) Serving as liaison from the Assistant Under Secretary for Health for Operations to the DASHO, through the VA Occupational Safety and Health Office, and to Administration Managers, Assistant Secretaries, and other government agencies.

(3) Establishing initiatives to support the goals and objectives of the OSH program.

(4) Reviewing, updating, and approving a VHA Safety and Health Strategic Plan.

(5) Representing VHA on the VA’s Safety Steering Committee and appointing an alternate representative to attend VHA Safety and Health Leadership Council meetings.

(6) Analyzing and communicating VHA injury, illness, and incident data.

(7) Developing the annual VHA Occupational Safety and Health Summary Report for Facilities.

(8) Administering the OSH Awards program. NOTE: Awards are presented annually to those VHA organizations or individuals that have made outstanding contributions in the development or implementation of the OSH program. The selection criteria, award categories and levels, and the program’s nomination process are developed by the VHA Safety and Health Leadership Council.

(9) Serving as Chair of the VHA Safety and Health Leadership Council (see paragraph 2.g.).

(10) Establishing national training initiatives to address enterprise-wide program trends based on:

(a) Recommendations from the VHA Safety and Health Leadership Council.

(b) Analysis of national accident, injury and illness trends.

(c) Federal and State regulatory requirements.

(d) Recognized best practices.

f. Medical Advisor, Office of Occupational Safety & Health. The Medical Advisor, Office of Occupational Safety & Health, is responsible for:

(1) Providing clinical occupational health and medicine consultation to VHA leadership, Program Offices and VA medical facilities.

(2) Developing and coordinating clinical occupational health policy and guidance regarding safety, industrial hygiene, infection prevention and control, and patient care and nursing services.

(3) Coordinating and providing resources for occupational and environmental health educational programs.

(4) Conducting legislative and regulatory reviews and submitting comments to Federal and State agencies as appropriate, and to the Director, Office of Occupational Safety and Health.

(5) Providing updates on the OSH program to the VHA Safety and Health Leadership Council upon request.

(6) Defining the standards for and managing a recordkeeping system for the VHA Medical Surveillance Program.

(7) Coordinating with the Director, Office of Occupational Safety and Health and the National Program Executive Directors, National Infectious Disease Service (NIDS) when elements of clinical occupational health program intersect with the OSH and NIDS programs. NOTE: Examples include but are not limited to safety training, exposure documentation, injury reporting, medical removal decisions, infection control and control, and PPE.

g. Chair, VHA Safety and Health Leadership Council.

(1) The Chair, VHA Safety and Health Leadership Council, is responsible for:

(a) Providing advice and recommendations to the Director, Office of Occupational Safety and Health on methods and procedures leading to effective occupational safety and health management. NOTE: The VHA Safety and Health Leadership Council is not intended to meet the requirements of 29 CFR 1960.36(b).

(b) Recommending OSH training, program development, implementation, data collection, and technical support.

(2) Submitting nominations for VHA national safety and health awards. NOTE: For more information see Appendix A.

h. Veterans Integrated Services Network Director. Each VISN Director is responsible for:

(1) Ensuring a safe and healthful work environment for all VHA employees, volunteers, and others performing work under direct supervision of VHA management within their respective VISN.

(2) Requesting appropriate and adequate staffing, funding, training, support, and resources for implementing the OSH program.

(3) Ensuring all facilities within the VISN comply with this directive.

(4) Ensuring VISN construction and maintenance programs, designs, and specifications comply with OSH program requirements.

(5) Establishing OSH performance standards for facility Directors.

(6) Developing a written VISN OSH program to implement the national OSH program. (See Appendix B).

(7) Coordinating the Annual Workplace Evaluation (AWE) NOTE: Refer to Appendix E for detailed AWE requirements

(8) Developing a charter for the Network Employee Safety and Health Leadership Committee. The Safety and Health Leadership Committee will meet at least quarterly.

(9) Initiating a Board of Inquiry to investigate any work-related fatality; inpatient hospitalization of one or more employees; overexposure of facility personnel to radiation; and fires resulting in serious injury, death, or damages exceeding $10,000.

(a) Appointing a Chair to oversee each Board of Inquiry upon notification of such an event.

(b) Designating members and directing the work of the Board of Inquiry. NOTE:

Facilities may conduct Boards of Inquiry for serious occupational safety and health events which do not meet the VISN notification requirements,

(c) Ensuring that the Board submits an investigative report, including all elements required in 29 CFR § 1960.29, to the VISN Director, the VA medical facility Director, the facility union representative, and the Assistant Under Secretary for Health for Operations within 30 calendar days of the event.

(d) Requesting an extension of time for submitting the report from the Director, Office of Occupational Safety and Health, if more than 30 calendar days is needed.

(e) Ensuring that the report is made available to the DASHO no later than 15 calendar days after receipt of the report by the Assistant Under Secretary for Health for Operations.

(f) Coordinating the collection of facility information for the Annual Safety and Health Report, as required by 29 CFR § 1960.78(b).

(g) Establishing the VISN OSH Awards Program. NOTE: The VISN OSH Awards Program may be a subpart of another awards program, but it must be able to demonstrate that worthy employees are recognized and awarded for their contributions.

(h) Appointing the Chair, Network Employee Safety and Health Leadership Committee.

i. Chair, Network Employee Safety and Health Leadership Committee. The Network Employee Safety and Health Leadership Committee serves as an advisory group for VISN management and assists in the evaluation of the VISN OSH program.

The Chair of the VISN Safety and Health Leadership Committee is responsible for:

(1) Ensuring that meetings occur at regularly scheduled intervals, at least quarterly.

NOTE: The VISN Safety and Health Leadership Committee is not intended to meet the ‘Agency’s certified committee’ requirements of 29 CFR 1960.36(b).

(2) Appointing committee members as specified in Appendix D.

(3) Developing a report to the Executive Leadership Council or Board no less than annually in collaboration with the VISN Safety and Occupational Health Manager.

(4) Providing recommendations for VISN safety and health plans that implement the OSH program goals and policies. Examples must consider:

(a) Analysis of safety and health trends within the VISN.

(b) Annually establishing three program goals for the VISN, based upon trend analysis, that align with the VHA Safety and Health Strategic Plan.

(5) Monitoring progress toward elements assigned to the VISN and facilities for implementing the VHA Safety and Health Strategic Plan.

(6) Monitoring progress towards attaining the three VISN goals.

(7) Reviewing needs and recommending OSH training.

(8) Discussing local issues that have VISN-wide impact.

(9) Analyzing OSH program information and data.

j. VA Medical Facility Director. Each VA medical facility Director is responsible for:

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(1) Ensuring a safe and healthful work environment for all employees, volunteers, and others who perform work under direct supervision of VHA management.

(2) Ensuring adequate Occupational Safety and Health staff, training and resources to implement effective OSH programs. NOTE: OSH staff will provide support and advice for carrying out the Facility Director’s responsibilities to provide a safe work environment.

(3) Informing Network leadership when barriers to compliance are identified.

(4) Developing and implementing a written facility OSH program that conforms to the Safety Management System requirements of VHA Directive 7703 and includes a plan to achieve OSH policies and goals established in the VISN OSH program. (See Appendix B.)

(5) Establishing a facility Safety and Health Leadership Committee. NOTE: Refer to section m. below for committee functions.

(6) Establishing OSH performance standards for the annual evaluation of Service Chiefs, managers, supervisors, and employees.

(7) Ensuring facility construction and maintenance projects, designs, and specifications comply with OSHA, VA, VHA, and VISN OSH requirements.

(8) Developing plans to achieve the OSH policies and goals established by the VISN Director.

(9) Ensuring effective investigation of injuries and illnesses and submittal of employee Incident Reports by supervisory personnel within five calendar days of notification of the incident.

(10) Notifying the VISN Director immediately of any work-related employee fatality, amputation, loss of an eye, or inpatient hospitalization of one or more VHA staff or contract employees. This notification shall be made prior to official OSHA notification.

(11) Notifying the VISN Director and Assistant Under Secretary for Health for Operations when OSHA initiates an inspection. The report must include a copy of the OSHA Notices of Unsafe and Unhealthful Working Conditions or other violation notice that was issued by another regulatory agency.

(12) Following discovery of an event which may warrant a VISN Board of Inquiry, the VHA Medical Facility Director must notify the Assistant Under Secretary for Health for Operations, the VISN Director, union representatives, and appropriate regulatory agencies. Events which must be reported to the VISN include, but are not limited to:

(a) Work-related fatalities,

(b) Incidents resulting in amputation, loss of an eye or inpatient hospitalization of one or more persons,

(c) Fires resulting in death or injury to VHA staff or contract employees, or costs exceeding $10,000 in damages, or

(d) Known or suspected overexposure to ionizing or nonionizing radiation.

(13) Facilitating employee representatives in OSH program administration by providing designated local facility safety and health union representatives with timely notification of, and official time granted to attend or participate in, the following activities:

(a) Scheduled workplace OSH inspections,

(b) Unscheduled safety and health inspections conducted by VISN or regulatory agencies,

(c) Union safety conference calls, and Safety Committee meetings.

(14) Encouraging the participation of staff and union representatives in local Federal Safety and Health Councils.

(15) Coordinating facility OSH personnel and Contracting Officer’s Representatives (CORs) to ensure safe contractor work practices and OSHA compliance within projects.

(16) Ensuring preoccupancy inspections occur for any newly constructed, renovated, (including change of occupancy classification, change of use, or modification) or leased spaces prior to occupancy by VHA employees or patients.

(17) Establishing a workplace hazard evaluation process to ensure compliance with applicable Federal standards, Executive Orders, and VA and VHA policies. The evaluations must be performed in accordance with VHA Directives 7702 and 7703 in all patient and non-patient care areas of the facility by personnel trained and qualified in the recognition of occupational safety and health hazards and unsafe work practices NOTE: This process is separate and different from the AWE and environmental rounds processes:

(a) Evaluations must be supported by a written record with the identified hazards.

(b) Evaluated sites and frequency of reevaluation are based on the potential hazards, Agency policy, and regulatory requirements.

(c) OSH personnel who develop or review and approve resulting abatement and sampling plans shall consider input from supervisors, employees, and Union representatives.

(18) Participating in the facility AWE by attending the opening and closing conferences; reviewing the AWE report; approving and certifying initial abatement plans; and confirming closure of deficiencies cited during the AWE. NOTE: Refer to Appendix E.

(19) Ensuring that a member of senior management is selected as the Chair of the Accident Review Board (ARB). NOTE: Senior management is defined as a management official with the independent authority to make programmatic and resource decisions across the entire VA Medical Facility.

(20) Ensuring that the Accident Review Board includes representatives from occupational safety and health, employee occupational health, workers’ compensation, and employee representatives.

(21) Completing the facility Safety and Health Management training program.

(22) Posting and updating VA Form 2180, Occupational Safety and Health Protection for VA Employees, at appropriate locations throughout the facility.

(23) Establishing the ARB and ensuring the members are trained in the requirements of the Privacy Act.

(24) Certifying the Annual Summary of Injuries and Illnesses (OSHA Form 300-A) and ensuring that the Summary is posted in the facility from February 1 to April 30 of the following year. NOTE: This information must be retained for a minimum of five years.

(25) Ensuring implementation of the process for reporting unsafe or unhealthful working conditions required by Appendix F.

k. VA Medical Facility Manager/Chief Engineer. The VA medical facility Manager/Chief Engineer is responsible for:

(1) Reviewing specifications for facility design proposals, including new projects or workspace reconfigurations, and including OSH in those reviews.

(2) Ensuring that Project Engineers provide designs and specifications for VHA projects to the VISN Director or appropriate VISN personnel to review for compliance with NFPA and OSH program requirements.

(3) Ensuring the Project Engineer maintains contract submittals related to OSH programs, including contractor safety programs, chemical and product inventories, performance tests and certifications, and Safety Data Sheets for hazardous chemicals.

(4) Ensuring the Project Engineer informs contractors of existing policies and potential hazards they may encounter in the VHA work environment.

(5) Notifying OSH staff before work is being performed involving hazardous materials.

(6) Ensuring that Project Engineers notify OSH personnel when newly constructed and remodeled spaces are ready for a pre-occupancy inspection.

(7) Ensuring preoccupancy inspections occur for any newly constructed, renovated, (including change of occupancy classification, change of use, or modification) or leased spaces prior to occupancy by VHA employees or patients.

(8) Establishing and maintaining a preventive maintenance program for engineering control systems that are established to protect employees from occupational hazards.

(9) Collaborating with OSH personnel to prioritize corrective actions associated with safety and occupational health.

l. Service Line Managers and Supervisors. Service line managers and supervisors are responsible for:

(1) Complying with VHA’s OSH program requirements.

(2) Completing VHA’s Occupational Safety and Health Training for Supervisors (TMS course ID VA 32068) course and ensuring the completion of all required training by employees under their supervision. A portion of the training will address site-specific policies and procedures, in addition to an overview of VHA’s safety program.

(3) Providing Safety Data Sheets (SDS) and approved PPE for hazardous work processes.

(4) Identifying and correcting unsafe and unhealthful workplace conditions.

(5) Evaluating hazards of each job in their assigned work area through the completion of a job hazard analysis (JHA).

(6) Maintaining established hazard controls within their area of responsibility.

(7) Ensuring employees receive training in safe work practices, recognition of workplace hazards, and the proper selection, use and maintenance of PPE, and making suggestions to improve OSH.

(8) Encouraging employees to use safe work practices and to make suggestions for improving the OSH program.

(9) Correcting employees demonstrating unsafe work practices and initiating re-training.

(10) Enforcing OSH policy and standards within their assigned work area.

(11) Releasing employees for scheduled medical surveillance, respirator fit testing, attend required safety and health training, and other safety-related activities within the medical center such as committee meetings.

(12) Ensuring employees are aware of their responsibility to:

(a) Follow safe work practices and use engineering controls (including elimination and substitution), administrative, and PPE properly.

(b) Report unsafe or unhealthful workplace conditions to supervisors, the safety office, or a union representative, and initiate corrective action where appropriate.

(c) Report work-related injuries and illnesses to supervisors.

(d) Complete assigned medical surveillance and training requirements.

(13) Completing incident reports using Employees’ Compensation Operations & Management Portal (ECOMP) within 5 business days of notice of injury or illness of an employee or other personnel performing work under the direct supervision of VHA management.

(14) Facilitating employees’ receipt of prompt and appropriate medical attention when injuries occur.

(15) Investigating all work-related injuries, illnesses, and accidents.

(16) Notifying Executive Leadership and Safety of any employee fatality, any inpatient hospitalization of one or more employees, amputation, or loss of an eye including contractors’ employees. Notification must be provided as soon as possible, but no later than 30 minutes after the discovery of the incident by any employee.

m. Chair, VA Medical Facility Safety and Health Leadership Committee. The Chair, VA medical facility Safety and Health Leadership Committee is responsible for:

(1) Assisting and supporting all the VA medical facility staff with implementation of the facility OSH program.

(2) Ensuring that membership includes a chairperson, facility OSH personnel, union representatives, supervisors, and other employees with input or oversight of employee health and safety concerns that are not official union representatives. NOTE: The Chair must be a management official with authority to make programmatic and resource decisions across the entire VA medical facility.

(3) Serving as the focal point for facility-wide safety and health management issues.

(4) Providing a report directly to the Executive Leadership Committee every 6 months. NOTE: The report may pass directly from the Environment of Care (EOC) Committee to the Executive Leadership Committee at facilities when the EOC Committee meets all requirements of, and serves as, the Safety and Health Leadership Committee. NOTE: The facility Safety and Health Leadership Committee is not intended to meet the “Agency’s certified committee” requirements of 29 CFR § 1960.36(b).

(5) Ensuring OSH-related problems and deficiencies are tracked to resolution.

(6) Holding monthly Committee meetings.

(7) Monitoring the facility OSH Program, and coordinating between services to ensure that OSH program elements are implemented effectively and efficiently.

(8) Providing meeting minutes to committee members and service chiefs. NOTE:

Employees are provided copies upon request.

(9) Recognizing safety and health accomplishments at the facility; presenting appropriate awards annually to facility groups and individuals who have made outstanding contributions to the development or implementation of the OSH Program.

(10) Monitoring progress towards achieving VISN Safety and Health goals.

n. Chair, Accident Review Board. The Chair, Accident Review Board (ARB) is responsible for:

(1) Ensuring all ARB members are trained in privacy requirements, including at a minimum, the following:

(a) Overview of existing Federal privacy laws, and regulations, including:

1. The Privacy Act of 1974. NOTE: All personally identifiable information discussed in the ARB falls under the Privacy Act of 1974.

2. 38 U.S.C. §§ 5701 and 7332.

3. VA and VHA privacy policies, including but not limited to VHA Directive 1080, Access to Personally Identifiable Information in Information Technology Systems, dated January 6, 2017; VHA Directive 1605, VHA Privacy Program, dated September 1, 2017;

VHA Directive 1605.01, Privacy and Release of Information, dated August 21, 2016;

VHA Directive 1605.02, Minimum Necessary Standard for Access, Use, Disclosure, and Requests for Protected Health Information, dated April 4, 2019;

and VHA Directive 1605.04, Notice of Privacy Practices, dated October 7, 2015.

NOTE: Information provided to an ARB member, in reviewing individual incidents of occupational injury and illness, is provided as a routine use under the provisions of the Privacy Act.

(b) Penalties for unlawful disclosure of records covered by the Privacy Act.

(2) Ensuring the ARB carries out the following:

(a) Reviewing records of occupational injury and illness incidents using OSH management information system data to evaluate contributory events and potential causes. NOTE: All personal identifiers must be redacted from records prior to submission to the ARB for review.

(b) Reviewing, at a minimum, all OSHA recordable injuries, the sharps injury log, incidents of occupational injury and illness that result in medical expense, job transfers, restrictions, days away from work, or in lost time beyond the day of incident.

(c) Tracking and trending all illnesses and injuries to provide information for improving the safety and health program.

(d) Reviewing incidents of elevated frequencies of reportable incidents by groupings (e.g., type or source of incident, type of injury, location of incident, job category; and severity of injuries, illnesses, and incidents) and costs (e.g., medical, continuation of pay, wages, and associated costs).

o. VHA Employees. VHA employees are responsible for:

(1) Following safety and health rules and regulations established by their facility and VHA management.

(2) Addressing safety and health hazards at the most appropriate and lowest level in the organization.

(3) Reporting unsafe and unhealthful working conditions to their supervisors when they cannot personally address them.

(4) Reporting work-related injuries and illnesses to supervisors.

(5) Completing assigned medical surveillance and training requirements

3. TRAINING

a. The following training is required for all supervisors and managers:

(1) Occupational Safety and Health Training for Supervisors, available in the Talent Management System (TMS) as course number 32068.

b. The following training is recommended for all new (to VHA) or newly assigned Safety and Occupational Health staff:

(1) VHA Facility Safety Program, available in TMS as course number VHA-027.

(2) NOTE: VHA-027, VHA Facility Safety Program, is available to all employees and union representatives as desired.

(3) NOTE: Additional training requirements are identified by the VISN or local medical facility training needs assessment and 29 CFR 1960 Subpart H.

4. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive shall be managed as required by the National Archives and Records

Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

5. BACKGROUND

The objectives of the OSH program are to:

a. Provide a safe and healthful work environment for all VHA employees and volunteers.

b. Ensure compliance with Federal statutes and regulations, Executive Orders and VA and VHA policies.

c. Establish Safety and Health Leadership Committees at VISN and facility levels.

d. Ensure that all VA medical facilities and other VHA locations establish, implement, and maintain Safety Management Systems (SMS) as an element of the comprehensive OSH program. NOTE: For a detailed discussion of SMS and related responsibilities, see VHA Directive 7703, Occupational Safety Management Systems in VHA, dated March 10, 2021.

e. Consistently strive to eliminate work-related injuries and illnesses, and to reduce or minimize the severity of injuries and illnesses that do occur.

f. Establish VHA national, VISN, and facility-level OSH awards programs to acknowledge outstanding achievements.

g. Identify a formal process for Veterans Integrated Service Network (VISN) staff to provide OSH services and technical support to:

(1) VA Administrations and offices located in the VISN, and

(2) VHA offices physically located within the VISN, but outside the administrative authority of the VISN Director. These include, but are not limited to:

(a) Consolidated Mail Outpatient Pharmacies (CMOPs),

(b) Veterans Canteen Service (VCS),

(c) Consolidated Patient Account Centers,

(d) Service Area Officer (SAO),

(e) Office of Integrated Veteran Care (IVC),

(f) Health Resource Center (HRC), and

(g) Health Eligibility Center.

6. REFERENCES

a. P.L. 91-596, the Occupational Safety and Health Act of 1970, Section 19, Federal Agency Safety Programs and Responsibilities.

b. 29 C.F.R. part 1960, Basic Program Elements for Federal Employee Occupational Safety and Health Programs and Related Matters.

c. VA Directive 7700, Occupational Safety and Health Program, dated February 11, 2009.

d. VHA Directive 7702, Industrial Hygiene Program and Exposure Assessment Process, dated July 29, 2021.

e. VHA Directive 7703, Occupational Safety Management Systems in VHA, dated March 10, 2021.

f. VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017.

g. Executive Order 12196, Occupational Safety and Health Programs for Federal Employees, https://www.archives.gov/federal-register/codification/executive-order/12196.html.

h. OSHA Form 300, Log of Work-Related Injuries and Illnesses, https://www.osha.gov/recordkeeping/forms.

i. OSHA Form 300-A, Summary of Work-Related Injuries and Illnesses, https://www.osha.gov/recordkeeping/forms.

j. OSHA Form 301, Injury and Illness Incident Report, https://www.osha.gov/recordkeeping/forms.

k. OSHA Instruction CPL 02-00-124, Multiemployer Citation Policy, dated December 10, 1999.

l. OSHA Standard Interpretation, Definition of Multi-Employer Worksites, dated July 7, 2012.

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APPENDIX A

VHA SAFETY AND HEALTH LEADERSHIP COUNCIL MEMBERSHIP

1. The VHA Safety and Health Leadership Council membership will include, at a minimum:

a. A Chairperson, who is the Director, Office of Occupational Safety and Health,

b. A Safety and Occupational Health Manager, Safety and Occupational Health Specialist, or Industrial Hygienist from the Office of Occupational Safety and Health,

c. The Medical Advisor, Office of Occupational Safety and Health,

d. A representative from Office of Healthcare Engineering,

e. At least one representative from each of the National Unions, to be designated by the Unions,

f. At least one VISN Safety and Occupational Health Manager,

g. At least one VISN Industrial Hygienist,

h. At least one facility Safety and Occupational Health Manager, and

i. At least one facility Industrial Hygienist.

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APPENDIX B

VISN OSH PROGRAM ELEMENTS

1. The VISN OSH program will include a description of the following elements and responsibilities:

a. The VISN Director’s role in the VISN OSH program.

b. Scope of OSH support provided to assigned VHA facilities, including Annual Workplace Evaluation (AWE) surveys.

c. VISN OSH Program Staffing. VISN OSH staff will include, at a minimum, one VISN Safety and Occupational Health Professional and one VISN Industrial Hygienist.

NOTE: VISN Industrial Hygienist refers to assigning someone from the VISN or from a facility to take the lead role for the VISN industrial hygiene program. Collateral duties assigned to VISN Safety and Health staff should be limited and not interfere with their primary responsibilities to the VISN OSH Program.

d. Training needs of assigned VHA facility safety and health staff.

2. The VISN OSH Program will be reviewed at least annually; a report will be submitted to the Assistant Under Secretary for Health for Support for approval.

3. Changes to scope or staffing of the VISN OSH program must be approved by the Assistant Under Secretary for Health for Operations prior to implementation.

4. The VISN OSH program will ensure the rights of employees to file reports of unsafe or unhealthful working conditions at the VISN level. In addition to elements required by 29 CFR § 1960.28, the program must:

a. Protect the right of employees to file anonymous reports.

b. Prohibit reprisal actions.

c. Provide for investigation of employee reports of unsafe or unhealthful working conditions. NOTE: A member of VISN OSH staff will investigate reports of unsafe or unhealthful working conditions that cannot be resolved at the facility level.

5. The VISN OSH Office will maintain a list of reports investigated and action taken to resolve the employee concern

NOTE: Program standardization comes from a combination of OSHA regulations and VHA Directive 7702, Industrial Hygiene Program and Exposure Assessment Process and VHA Directive 7703, Occupational Safety Management Systems in VHA.

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=11279

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APPENDIX C

ANNUAL WORKPLACE EVALUATION REQUIREMENTS

VISN Director AWE requirements include at a minimum:

a. Ensuring a qualified VISN team, consisting of at least one VISN Safety and Occupational Health Manager and one VISN Industrial Hygienist, conducts an annual OSH compliance inspection and program evaluation for all assigned VA medical facilities. Safety and industrial hygiene evaluations may be conducted concurrently or separately.

b. Ancillary facilities may be evaluated by one qualified VISN Safety and Occupational Health Manager or VISN Industrial Hygienist, or they may be assigned to qualified medical center safety staff. VISN OSH personnel must review and track completions of annual evaluations of ancillary facilities and pre-occupancy inspections conducted by VHA facility staff. NOTE: Ancillary facilities include VHA facilities that are assigned to a medical center or a VISN and are not located within the VA Medical Center campus. Examples include but are not limited to CBOCs and Health Care Centers.

c. The primary focus of the AWE is occupational safety and health compliance. If the facility requires a survey of other programs in addition to occupational safety and health, that second survey cannot interfere with the purpose and conduct of the occupational safety and health compliance evaluation.

d. The AWE evaluation report must be reviewed and signed by the VISN Director.

e. The VA medical facility Director must receive the AWE report with the VA Form 2165, Safety, Occupational Health and Fire Protection Evaluation, within 15 business days after the closing conference for safety violations and 30 business days after the closing conference for occupational health violations.

f. The Safety Automated Facility Evaluation (SAFE, or its designated replacement system) Technical Deficiencies List must be used to report all deficiencies.

g. The VA medical facility Director will receive, review, and sign the Facility Abatement Plan and send a response within 30 calendar days of AWE Report receipt to the VISN Director. Abatement plans for open findings will be updated in the SAFE database (or its designated replacement) until all deficiencies are abated. A copy will be sent to the employee representatives.

h. The VISN Director reviews, approves, and monitors VA medical facility AWE corrective actions and abatement plans

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APPENDIX D

NETWORK EMPLOYEE SAFETY AND HEALTH LEADERSHIP COMMITTEE

MEMBERSHIP

1. Network Employee Safety and Health Leadership Committee membership is appointed by the VISN Director and must include at a minimum:

a. A VA medical facility Director, or a VISN Deputy Director or Associate Director as Chair. The Chair must have the authority to act on behalf of the VISN.

b. A VISN Safety and Occupational Health Manager,

c. A VISN Industrial Hygienist,

d. A VA medical facility Safety and Occupational Health Manager,

e. A facility Research Safety Officer,

f. A facility Health Physicist (if appropriate),

g. A facility Employee Occupational Health representative, and

h. Representatives from the national unions represented within the VISN, to be appointed by the unions.

i. Other personnel invited on an ad hoc basis as determined by the Committee.

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APPENDIX E

VA MEDICAL FACILITY DIRECTOR ANNUAL WORKPLACE EVALUATION

REQUIREMENTS

VA medical facility Director AWE requirements include at a minimum:

a. Ensuring union participation is requested. Upon management’s receipt of the AWE notification, the Director must provide written or electronic notice to all facility local union presidents of the date and ensure that the designated union safety representatives are released from duty to attend all aspects of the evaluation.

(1) If no employee is selected to attend the AWE, the union president may submit a written or electronic notice to the Director.

(2) The Director must provide copies of the AWE report, the abatement plan, and all follow-up reports to union representatives.

b. Ensuring that a notice citing the OSHA deficiencies identified during the AWE is posted at, or near, each place where an unsafe or unhealthful working condition exists or existed, as required by 29 C.F.R. § 1960.26(c)(4)).

(1) If it is not possible to post the notice at or near each location, the notice must be posted in a prominent place where it will be readily observable by all affected employees.

(2) The notice must remain posted until the condition is abated or for three calendar days, whichever is longer.

c. Ensuring the SAFE software program (or its designated replacement) is used to document VA medical facility AWE findings.

d. Ensuring the VISN Director receives an abatement plan signed by the facility Director within 30 calendar days following the evaluation report. NOTE: Follow-up inspection is at the VISN Director’s discretion.

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APPENDIX F

PROCESS FOR REPORTING UNSAFE OR UNHEALTHFUL WORKING

CONDITIONS

1. Notification by an employee of unsafe or unhealthful working conditions. The process for reporting and correcting unsafe or unhealthful working conditions includes the following:

a. For very simple hazards, correct on the spot taking proper safety precautions.

b. For hazards requiring minor assistance, direct verbal or written requests to the supervisor or lowest organization level capable of addressing the hazard. Any request to remain anonymous must to be clearly stated. NOTE: Make immediate notification by the most expeditious means possible for hazards deemed immediately dangerous to life or health (IDLH).

c. For complex hazards requiring more time or a formalized project to correct, submit a written request via email including all pertinent details. Form 2169, Request for Inspection of Workplace, is available for use, but is not required. NOTE: All formal reports of unsafe and unhealthful working conditions must be maintained in the VA medical facility OSH office.

(1) An investigation of the unsafe or unhealthful working condition must be conducted at the lowest level of supervision possible depending on the complexity of the issue. More complex safety issues may require assistance from the Safety and Occupational Health manager.

(2) The investigator will notify the employee or the employee’s representative, in writing within 15 calendar days after the completion of the investigation and actions taken.

(a) For employee reports of imminent danger conditions, an inspection must be conducted immediately upon notification.

(b) For potentially serious conditions, an inspection must be conducted as soon as possible, but within three working days.

(c) For other than serious safety and health conditions, an inspection must be conducted within 10 working days.

(3) If the employee is not satisfied with the timeliness or response of the facility management team, the employee may contact the official responsible for OSH program management at the next higher organizational level, as noted on VA Form 2180, VA Occupational Safety and Health Protection for VA Employees.

(4) Final investigative reports must be made available to the employee within 15 calendar days after the completion of the investigation.

APPENDIX F

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Reprisal against employees who report unsafe or unhealthful working conditions under the OSH program is prohibited.