APPENDIX H: BLANK WORKSHEETS

This appendix contains blank copies of all the worksheets presented in the Implementation Guide, for your use. The worksheets are identified by the same numbers used in the Guide. For example, Worksheet 6-1 would be the first worksheet found in Module 6.

Worksheet 1-1: Costs and Benefits of Developing and Implementing an IEMS
Costs	Benefits
Contact Person:	Date completed:

Worksheet 1-2: IEMS Responsibilities
IEMS Function	Person	Regular Position
Management Representative

IEMS Coordinator

IEMS Committee

Contact Person:	Date Completed:
Corresponds to RESP-01 of the Company Manual Template.

Worksheet 1-3: IEMS Development Schedule and Resources Worksheet
Module	Participants	Budget	Target Completion
Making the Commitment: Creating a Policy Statement and Determining the Scope
Intermediate steps: (As appropriate)

Planning the Process: Decision Points, Leadership & Participants, Schedule & Plan
Intermediate steps: (As appropriate)
Determining Significant Aspects: Prioritizing Concerns and Setting Objectives
Intermediate steps: (As appropriate)
Developing Operational Controls
Intermediate steps: (As appropriate)
Making Improvements: Evaluating Alternatives and Setting Targets
Intermediate steps: (As appropriate)
Implementation: Building Organizational Support for Your IEMS
Intermediate steps: (As appropriate)

Setting Up Environmental Management Projects; Measuring and Achieving Success
Intermediate steps: (As appropriate)
Establishing Continuing Improvement
Intermediate steps: (As appropriate)
Contact Person:	Date Completed:

Worksheet 1-4: Persons Responsible for IEMS Development

Products
Technologies
Work Practices
Recycle/Reuse
Treatment
Disposal
Contact Person:	Date Completed:
*See Section AE of the Company Manual Template.

1 Take from Worksheet 4-7, Performance Comparison.

2 Take from Worksheet 4-8, Regulatory Cost Comparison.

3 Take from Worksheet 4-9d, Cost Comparison.

4 Take from Worksheet 4-4, Criteria to Determine Environmental Impact.

5 Rank on a scale of low to high to reflect the desirability of each product. This is a judgment call.

Note: For more information on the methodology for comparing alternatives, refer to both the DfE website and the Cleaner Technologies Substitutes Assessment, A Methodology Resource Guide, DfE, U.S. EPA 744-R 95-002, Dec. 1996.

Figure 5-a. Root Cause Diagram

Worksheet 5-1: Environmental Performance Measurement Indicators
Aspect	Objective	Indicator	Date Checked	Who Checked	Result	Corrective Action
Contact Person:	Date Completed:

Worksheet 5-2: Calibration Log
Indicator	Measurement Method	Equipment Used	Equipment calibrated:

date/method
Contact Person:	Date Completed:

Worksheet 5-3:* Corrective Action Notice
Issue Date:	Solution Due Date:
Requested by:

Issued to:
Problem Statement:

Most Likely Causes:
Suggested Solutions:
Action Taken:
Measured Results:
Corrective Action Closed by:	Date:
Contact for Notice:	Date completed:
*Report results on TCA-01 in the Company Manual Template.

Worksheet 6-1:* Operational Control Procedures
Significant Environ-

mental Aspect	Indicator(s)	Associated Job Functions	Existing Operational Control Procedures	Operational Control Procedure Development/ Modification Needed	Responsible for developing	Responsible for checking	Location Posted

Contact Person:	Date Completed:
*Corresponds to OC-01 in the Company Manual Template.

Worksheet 6-2: Operational Control Responsibilities
Significant Aspect	Procedures (list)	Responsible for maintaining controls
Contact Person:	Date Completed:

Worksheet 6-3: Training Plan for Operational Controls
Aspect	Procedures	Person Responsible for Carrying Out	Training Needs	How to Train	When/ Length	Budget	Completion Date	Person Responsible for training
Contact Person:	Date Completed:

Worksheet 7-1: Environmental Review of New Processes, Products and Activities

Area of Company	New Process, Product, or Activity

Environmental Review by

Environmental Effects	Pollution Prevention Opportunities
Manager/Date	Manager/Date
Contact for form:	Date Completed:

Worksheet 7-2:* Compliance Tracking Log
Person Responsible

Regulation	Compliance Check Date	Results and Root Cause	Corrective Action/

Date	Compliance Verified/ Date
Contact Person:	Date Completed:
*Document results on CA-01 in the Company Manual Template.

Worksheet 7-3: Pollution Prevention Tracking Log

Area of Company	Pollution Prevention Activity

Date Started

Results

Measurement Method

Person Responsible
Contact:	Date Completed:

Worksheet 7-4: Environmental Emergency Preparedness and Response
Potential Emergency Scenario	Potential Environmental Impact	Action Required	Procedures Needed	Training Needed

Worksheet 8-1: Training Plan
Jobs Affecting Environment	Training Needs	How to Train	When/ Length	Budget	Completion Date	Who is Responsible
Contact Person:	Date Completed:

Worksheet 8-2: Documentation
List Existing Documents	Determine Format: Who/

Date Completed	Develop Prototype (Content): Who/

Date Completed	Assign Writing: Who/ Date	Review Writing/ Compare to Prototype

Who/ Date	Added to Document List/ Date	Who Has Access	Where Located
/	/	/	/	/
/	/	/	/	/
/	/	/	/	/
/	/	/	/	/
List Documents to be Created
/	/	/	/	/
/	/	/	/	/
/	/	/	/	/
/	/	/	/	/
/	/	/	/	/
Contact Person:	Date Completed:
Corresponds to CS–2 of the Company Manual Template.

Worksheet 8-3: Document Control
Document	Who Will Use It	Permanent Location	Periodic Review Schedule/ Who	When Can Be Destroyed
/
/
/
/
/
/
/
/
/
Contact Person:	Date Completed:

Worksheet 8-4:* Working with Stakeholders
Your Stakeholders	Potential Environmental Interest	What You Want to Tell Them	What You Want Them to Tell You	How to Communicate With/ tell Them	When	Person Responsible
Contact Person:	Date Completed:
*Report results on CS-01 in the Company Manual Template.

Worksheet 8-5: Stakeholder Communication Record
Date Communication Received:
Type of Communication:
Received From:
Address/Telephone Number/E-Mail:

Content of Communication

(attach copy if possible):

Will ABC Company Respond?	Y	N
Date of Response:
Person Responding:
Nature of Response

(attach copy if possible):

Are Internal Actions Necessary?	Y	N
(If Yes, fill out a Corrective Action Form.)
Contact Person:	Date Completed:
Corresponds to CS-02 of the Company Manual Template.

Worksheet 9-1: IEMS Program Measurement Criteria

Company Name_____________________________

Measurement

Elements

IEMS Components	Objectives of Component	Activity

Measures	Results

Indicators	Review

Period
Communication Plan
Stakeholders Input
Environmental or IEMS Training
Review of Aspects
Operational Controls
Environmental Review of New Processes and Activities
Setting Objectives & Targets
Environmental Management Project 1
Environmental Management Project 2
Documentation
Regulatory Compliance
Pollution Prevention
Other
Contact person for form:	Date Completed:

Worksheet 9-2: Internal Assessment Checklist
Internal Assessment Team:

Date of Internal Assessment: ___________	Signed: _______________________________
IEMS Procedures:

Check each item assessed, including auditing of records, where applicable (codes in parentheses refer to the Worksheet number ("WS") in this Guide, followed by the document number in the Company Manual Template. ):

__	Environmental policy (Module 2)

__	Environmental objectives (progress; implementation of action plans)

__	IEMS responsibilities (WS 7-2, RESP-01)

__	Identification of Environmental Aspects (WS 1-5, P-EA)

__	Identification of Legal Requirements (WS 1-6, P-LR)

__	Identification of Significant Environmental Aspects (WS 3-3, WS 3-6, P-SEA)

__	Development of Objectives, Targets, and Action Plans (WS 5-1, P-OTP)

__	Conducting an Alternatives Evaluation (WS 4-1 to 4-6, P-AE)

__	Development of Operational Controls (WS 6-1 to 6-3, P-OC)

__	Environmental Training (Awareness and Task-Specific) (WS 8-1, P-ET)

__	Emergency Preparedness (WS 7-5, P-EP)

__	Review of New Products and Processes (WS 7-3, P-NPP)

__	Documentation (WS 8-2, WS 8-3, P-D)

__	Conducting a Compliance Assessment (WS 5-4, P-CA)

__	Conducting an Internal Assessment (WS 9-2, WS 9-3, P-IA)

__	Taking Corrective Action (WS 5-3, P-TCA)

__	Management Review (WS 9-4, P-MR)

IEMS Performance

__	Achieved objective #1

__	Achieved objective #2

__	Achieved objective #3
Contact Person:	Date Completed:
Corresponds to LA-01 of the Company Manual Template.

Worksheet 9-3: Internal Assessment Record
Internal Assessment Team:

Date of Internal Assessment:	_____________	Signed: _____________________
Major Non-Conformities Observed

1.

2.

Minor Non-Conformities Observed

1.

2.

3.

Is ABC Company making progress in meeting its IEMS objectives?
Is ABC Company adhering to the commitments in its environmental policy?
Suggestions for Improving IEMS:

Contact Person:	Date Completed:
Corresponds to IA-02 of the Company Manual Template.

Worksheet 9-4: Management Review Record
Date of review meeting:
Persons present at meeting:

Conclusions:

Actions to be taken/Person(s) responsible:

Signed:_______________________	__________________________

Management Representative	Plant Manager

Worksheet 9-4 corresponds to MR-01 in the Company Manual Template.