Appendix B

Approved Form

OMB Number: 1218-0110

Expiration Date: XX-XX-20XX

Paperwork Reduction Act Notice

Persons are not required to respond to this collection of information unless it displays a valid OMB control number. The Occupational Safety and Health Administration (OSHA) requires State On-Site Consultation program consultants to compile the list of all serious and any imminent danger hazards identified during a consultation visit with the hazard correction due dates mutually agreed upon by the employer and the consultant (see 29 CFR 1908.6(e)(8)). The unedited List of Hazards is the official document that must be posted by the employer at the workplace.

OSHA estimates that it will take the consultant an average of 5 minutes to compile the list. This estimate does not include the time for gathering information about particular workplace hazards and applicable standards, since that is done as a corollary of the On-Site Consultation process.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Office of Small Business Assistance, Occupational Safety and Health Administration, Room N-3660, 200 Constitution Avenue, NW, Washington, DC 20210.

Appendix B

Sample List of Hazards

(Preferred Format)

LIST OF HAZARDS (SERIOUS)

This List of Hazards must be posted, unedited, in a prominent place where it is readily observable by all affected employees for three (3) working days, or until the hazards are corrected, whichever is later.

VISIT NUMBER: 515196904
VISIT DATE(S): 03/16/2020

T & R Eye Center
432 Main Street
Dallas, TX 75003

This notification of serious hazards and any imminent danger hazard(s) identified during the consultation visit is not a citation. The T & R Eye Center is a voluntary participant in the Consultation program and has agreed to correct the hazards on this list within the hazard correction due date(s) specified. The T & R Eye Center has also agreed to make information on other-than-serious hazards as well as corrective actions proposed by the consultant available to employees upon request.

ITEM	0001	STANDARD	1910.0132(d)(01)
INSTANCE	A	CORRECTION DUE DATE:	4/6/2020
DESCRIPTION: The location of the hazard, the description of the hazardous condition, a list of job titles exposed to the hazard, the recommended hazard correction method, and interim protection measures (e.g., any personal protective equipment needed to protect employees from the hazard, use of portable equipment pending repair of faulty equipment).

ITEM	0002	STANDARD	1910.0151(c)
INSTANCE	A	CORRECTION DUE DATE:	4/6/2020
DESCRIPTION: The eyewash station in the Battery Room is placed correctly; however, only hot water can be accessed which would cause further injury to the eye(s). Maintenance personnel work in the Battery Room. An eliminator valve plumbed into the system would eliminate this problem. A portable eyewash station in the Battery Room is recommended pending repairs.

Note: The Occupational Safety and Health Administration (OSHA) requires State On-Site Consultation program consultants to compile the list of all serious, other-than-serious, and imminent danger hazards as well as regulatory violations identified during a consultation visit with the hazard correction due dates mutually agreed upon by the employer and the consultant, when the employer seeks to participate in the Safety and Health Achievement Recognition Program (SHARP) or Pre-SHARP. State Plans that require the verification of hazard correction for all hazard classifications also use this list. In these instances, the heading may reflect: List of Hazards (Serious and Other-than-Serious).