Northern Safety Network Yukon

Build a Safety Manual (Templates)

These updated templates can help you build an effective Health & Safety Managment System (HSMS) for your workplace.


**Customize any samples that you choose to use to suit your  workplace(s).**

See NSNY's Safety Manual Review Form to ensure you have all the required components in place. 

To review the COR and SECOR questions related to each individual section see the COR Harmonized Audit Tool  


Section 1: Safety and Health Policy 

Assignment of Responsibility and Accountability for Health and Safety

Company Safety Policy 

 Example of an Organizational Chart


Section 2: Hazard Assessment, Analysis, and Control 

Critical Task List

Field Level Hazard Assessment 

 Formal Hazard Assessment

Formal Hazard Assessment Template from handbook 

Combined Hazard Assessment & Tailgate form

Hazard Assessment Policy


Pre-Project Hazard Assessment

Task List Example by Area

WSCB Hazard Assesment and Control Handbook 

Sample Formal Hazard Assesment for Office Work 

Sample Formal Hazard Assesment for Vaccumm Truck & Swamper 


Section 3: Safe Work Practices 

Safe Work Practice Policy 

Safe Work Practice Annual Review Sheet

Defective Tools SWP

Fire Extinguisher Use SWP

Use of Cleaning Solvents SWP 


Section 4: Safe Job Procedures 

Safe Job Procedure Policy 

 Job Hazard Analysis (JHA) Column Style (Sample)

 Job Hazard Analysis (JHA) Column Style (Template)

 JHA Narrative Style (Sample)

JHA Narrative Style (Template) 

Sample JHA Cutting sheet wood with a portable hand-held power saw

Safe Job Procedure Annual Review Sheet 

Sample SJP - Backing-Up 

Sample SJP - Set-up-traffic-signs 

Sample SJP Basic-Office-Safety 


Section 5: Workplace Safety Rules 

Company Rules Sample 

Enforcement Policy 

 Employee Warning Report 


Section 6: Personal Protective Equipment 

 PPE Policy

 PPE Maintenance Record 

Info Sheet for Head Protection

Info Sheet for Foot Protection

Info Sheet for Eye and Face Protection

CCOHS Glove Selection Guide 

WSCB Code of Practice: PPE Use in Building Constrcution 


Section 7: Preventative Maintenance Program 

Preventative Maintenance Policy 

 Inventory List 

Maintenance Schedule 

Records of Actions Taken form 

Equipment & Vehicle Inspection Checklist 

Vehicle Repair Log 

PreStart Checklist 

Aerial Lift Inspection 

Scaffold Inspection Checklist 



Section 8: Training and Communication 

Training & Communication Policy 

Employee Orientation form 

Employee Orientation Questionnaire 

On the Job Training Form 

Safety Meeting Template 

Toolbox Meeting Template 

Personal record of Safety Meetings

Combined Tailgate & Hazard Assessment Template 

CODE OF PRACTICE Young and New Workers


Section 9 - Inspections 

Workplace Inspection Policy

Workplace Inspection Form 

Office Inspection Form 

Sample Inspection Checklist for Offices

Sample Inspection Checklist for Outdoor Areas

CCOHS Effective Workplace Inspections Guide 


Section 10 - Incident Investigations and Reporting 

Incident Investigation Policy

Incident Investigation Report

Near Miss Report Form

Investigation Procedure

Investigation checklist

Witness Statement Template 

First Aid Log


Section 11 - Emergency Preparedness 

Emergency Policy Sample 

Fire Preventaion Policy 


Emergency Response Plan template #2

Emergency Phone Number List 

Emergency Evacuation Procedure 

Emergency Evacuation Procedure Sample # 2 

Emergency Prepardness Drills 

Record of Emergency Drill 

Fire Response Procedures 


Section 12 - Statistics, Records, and Document Control 

Record-Keeping Policy  

Employee Training Records Form

Safety Activity Summary Form 

 Injury Summary Sheet 

First Aid Plan

Nature of Injury Summary Sheet 

Year End Injury Summary Sheet 

Company Action Plan Template 

Records and Stats policy (Large companies)


Module 13 - Legislation 

Workplace Legislation

Medical Monitoring 

Right to Refuse Unsafe Work 

3 Worker Rights 


Module 14 - Procurement and Contractor Management (NEW)

scoring related to these questions in the 'V-2023' Audit Document' will not be counted in the final tally during the phase-in period )

Procurement & Contractor Management Policy Sample #1 

Subcontractor Policy Sample #2

Service Provider Pre-Qualification Checklist 

Contractor Safety Orientation 

 Pre- Construction Sub- Contractor Safety Checklist  

Contractor Compliance Declaration 


Section 15 - Territorial Supplement 

15 A - Health and Safety Committee's (HSC) & Worker Health & Safety Rep (WHSR) 


Refer to Sections 36-43 of the WHS Act to determine the requirements for your workplace 

HSC Agenda

HSC Meeting Minutes 

WHSR Policy


15 B - Return to Work (RTW)


RTW Policy 

RTW Policy Sample #2

RTW Protocol 

RTW Plan 

Work related absences flow chart  


15 C - Workplace Violence and Harassment Prevention (WVHP) 



Workplace Violence and Harassment Prevention Guide






Additional Forms and Policies 

Drug and Alcohol Policy 

Environment Policy 

 Ergonomics Policy 

Working Alone Policy 

Working in Extreme Temperatures Policy