Challenge Pilot Candidtate Application

Challenge Pilot
Candidate Information Package Instructions

Included in this spreadsheet are:
Tab 1.
Tab 2.
Tab 3.
Tab 4.

Candidate Statement of Commitment
Candidate Information Form
OSHA 300 Baseline Information Form [Must provide at least 1 year of data]
Optional Data (e.g., productivity rate, turnover rate, absenteeism rate)

To access these documents, please click on the tabs at the bottom of this form.

Please complete and return each of these documents to your Challenge Pilot
Administrator.
You may submit this package electronically or via hard copy. However, you
must still fax a signed, original of the Statement of Commitment Letter to your
Challenge Pilot Administrator.
Form Approved
OMB# 1218 – 0239

Expires 04 -30- 2008

Public reporting burden for this collection of information
is voluntary and is estimated to average 10 hours per response,
including the time for reviewing instruction, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding
this burden estimate, or any other aspect of this collection of information
including suggestions for reducing this burden to the Division of Voluntary
Programs, Department of Labor, Room N-3700, 200 Constitution Avenue,
N.W., Washington, DC 20210.

Challenge Pilot
Candidate Information Package - Overview

Challenge Pilot
Candidate Statement of Commitment

Sample Letter Only
(The Administrator must receive a signed Statement of Commitment from each
candidate)

In our quest to produce high quality products and services, we, [insert
Candidate facility’s name, city and state], value our employees as our
greatest assets. Therefore, management is committed to providing a safe and
healthful workplace for our employees. Safety and health are paramount to our
corporate vision and mission. Management hereby states that we will [strive to]
successfully complete the three stages of the Challenge Pilot Program, provide
the necessary data and documentation to our Administrator, [Insert
Administrator name], and keep our Administrator informed of our progress.
We also will involve our employees in the Challenge Pilot process. We are
excited to be involved in voluntary efforts with OSHA and look forward to
reaching our goals.
Sincerely,

Site Manager

Challenge Pilot
Candidate Information Package - Statement of Commitment

Challenge Pilot
Candidate Information Form
Section 1. Candidate Information
Candidate Name
Site Address
Site Manager Name
Site Manager Title
Company/Corporate Name
(If different from above)
Company/Corporate Address
Administrator Name

Section 2. Challenge Candidate Contact Information
Candidate Contact Name
Candidate Contact Title
Candidate Contact Phone Number
Candidate Contact Fax Number
Candidate Contact E-mail Address
Section 3. Collective Bargaining Representative
Union Name and Local #
Agent's Name
Agent's Address
Agent's Phone Number
Agent's Fax Number
Agent's E-mail Address
Section 4. Employees
Number of Employees
Number of Contract Employees
Section 5. Type of Work and Products/Services
Please provide a comprehensive description of the work performed at your site, the type of product
produced, and/or servicesprovided, and the typical hazards associated with your industry. Also provide
your SIC and NAICS.
Description

SIC

Challenge Pilot
Candidate Information Package - Candidate Information Form

NAICS

Challenge Pilot Program
OSHA 300 Baseline Information*
Candidate Name
REQUIRED DATA
Most Recent Complete Calendar Year of Data
G

H

I

J

[Enter Year of Data Here]
K

L

Total Hours Worked

M:1

M:2

TCIR

#VALUE!

M:1

M:2

TCIR

#VALUE!

M:1

M:2

TCIR

#VALUE!

M:3

M:4

M:5

DART

#VALUE!

M:4

M:5

DART

#VALUE!

M:4

M:5

DART

#VALUE!

OPTIONAL DATA
Previous Year's Data
G

H

I

[Enter Year of Data Here]
J

K

L

Total Hours Worked

Data from Two (2) Years Previous
G

H

I

[Enter Year of Data Here]
J

K

Total Hours Worked

3-Year Average

M:3

TCIR

L

#VALUE!

M:3

DART

#VALUE!

* - OSHA will use this information to track the progress of OSHA Challenge Candidates. It will NOT be used for enforcement purposes.

Challenge Pilot
Candidate Information Package - OSHA 300 Baseline Information

Challenge Pilot Program
Optional Data
Please provide data for your most recent calendar year, where possible.

Candidate Name

Year of
Data
Provided
Absenteeism Rate

Turnover Rate

Productivity Rate

Other Data*

Other Data*

Worker's Compensation Data
Fees
Direct Costs
EMR
Loss Run Data

* - Other data provided by Challenge Participant that may be useful for tracking purposes.

Challenge Pilot
Candidate Information Package Optional Information