OSHA Challenge Program - Annual Evaluations

Challenge Pilot
Administrator's Annual Report
Administrator Name

Report Period

CY 2004
Section 1. Administrator Information Update
(If there were any changes)
Name
Site Address

Section 2. Administrator Contact Information Update
(If there were any changes)
Administrator Contact Name
Administrator Contact Title
Administrator Contact Phone Number
Administrator Contact Fax Number
Administrator Contact E-mail Address
Section 3. Coordinator Contact Information Update
(If there were any changes)
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Section 4. Candidate Information Update
Please list any Candidates who have dropped out or have been added since the last progress report.
You must submit a Candidate Package for all new Candidates.

Challenge Pilot
Administrator's Annual Report - Part A

Challenge Pilot
Administrator's Annual Report
Section 5. Significant Achievements and Milestones
Please describe any significant achievements/milestones accomplished by your
Challenge Pilot Participants during the past year.

Section 6. Roadblocks and Barriers
Please describe any issues that have prevented your Challenge Pilot Participants from making
progress.

Section 7. Additional Comments/Suggestions
Please provide any additional comments or suggestions to improve the Challenge Pilot Program.

Expires: 04-30-2008

Form Approved OMB No. 1218-0239
Public reporting burden for this collection of information is voluntary and is estimated to average 20
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
Administrator's Annual Report - Part A