Corporate VPP Facility Application

VPP Corporate Pilot
Corporate-Facility Application Process

Voluntary Protection Programs
Directorate of Cooperative and State Programs
Occupational Safety & Health Administration
U.S. Department of Labor

July 2005

Form Approved
OMB# 1218 – 0239

Expires 4 -30- 2008

Public reporting burden for this collection of information is voluntary and is estimated to average 80 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.

Table of Contents

Section

Page

I. Introduction

1

II. Corporate-Facility Application Process

1

III. C-FAP- Application Contents
A. General Information and Facility Map

2

B. Written Assurances

3

C. Union Information

3

D. Inspection History

3

E. Injury and Illness Rate Information

4

F. Significant Changes or Events

6

G. Facility-Specific Programs

6

H. Evaluation of Safety and Health Management System

6

I. Success Stories

8

Appendices
A. Written Statement of Assurances

A-1

B. Sample Statement of Union Support

B-1

C. Instructions for Calculating Illness and Injury Rates

C-1

C-FAP
VPP Corporate Pilot

i

VPP Corporate Pilot
Corporate-Facility Application Process
I. Introduction
The Voluntary Protection Programs (VPP) Corporate Pilot seeks to establish a more efficient
process for Corporations with effective safety and health management systems uniformly
implemented at its corporate facilities to participate in VPP. The processes under the VPP
Corporate Pilot requires the Corporation to submit a detailed application that describes all
standardized policies, programs, and systems that are implemented at each corporate facility.
Additionally, the Corporation must prescreen each of its facilities prior to the facility submitting
an application to OSHA. An onsite corporate program evaluation is conducted at the Corporate
Office/Headquarters to verify the contents of the corporate application and ensure that topmanagement is committed to VPP. Once the Corporation is accepted into the VPP Corporate
Pilot, all eligible corporate facilities that have been successfully prescreened may apply for VPP
membership using a streamlined application process known as Corporate-Facility Application
Process (C-FAP).

II. Corporate-Facility Application Process
The Corporate-Facility Application Process (C-FAP) is designed to capture facility-specific
information on the implementation of VPP elements at the facility. The intent of C-FAP is for
the facility application to complement the corporate application and describe facility
implementation of corporate policies without duplicating corporate-level information. The
facility and Corporate Office must properly coordinate to ensure this duplication of information
is prevented. This will be ensured by the Corporation through a prescreening of all facility
applications prior to submission to OSHA. The prescreening of facility applications will help to
expedite the application review process conducted by OSHA and allow OSHA to conduct an
onsite evaluation of the facility under the Corporate-Facility Onsite Process (C-FOP) that focuses
on facility implementation of the standardized corporate safety and health policies and
procedures, and any worksite-specific elements of the facility’s program. See the CorporateFacility Onsite Process for more details. The C-FAP and C-FOP are designed to improve
efficiency in VPP processes and conserve resources for both OSHA and the Corporation.

III. C-FAP - Application Contents
Under C-FAP, the primary content of the VPP application is the facility’s most recent annual
evaluation that describes a thorough assessment of the facility safety and health management
system. Additionally, the application must include general facility information, assurances from
management and the Union(s), injury and illness rates, and a description of any programs/
policies that differ from corporate policies. Each of these elements of the facility application are
discuss in the following sections

C-FAP
VPP Corporate Pilot

Page 1

A. General Information and Facility Map
Complete the information below and provide a copy of a map of the facility for use by the Onsite
Evaluation Team.
Point of Contact:

Corporation Name/Address:

Phone:

Facility (Site) Information

Address:

Phone:
Facility Manager

Facility (Site) VPP Contact

FAX

Email

SIC

NAICS

VPP Status

# Applicable Contractors*

# Site Employees*

Total

Site Injury & Illness Rate*
(Last Yr)
Site 3-yr. Injury& Illness
Rate**

TCIR:

DART:

TCIR:

DART:

Applicable

TCIR:

DART:

Type of Work Performed and Products Produced. Provide a
description of the work performed at this facility, the types of
products produced, and the major hazards typically associated
with your industry.

Total Hours Worked

Standard
Industrial
Classification
(SIC) Code:

North American
Industry
Classification
System
(NAICS) Code:

* Enter average employment figure as recorded in worksite’s own records.
** Obtain from tables below.

C-FAP
VPP Corporate Pilot

Page 2

B. Written Assurances
VPP applicants must assure, that they understand and agree to fulfill program requirements as
participants in the VPP Corporate Pilot related to: OSHA Act compliance, employee support for
VPP application, meeting and maintaining VPP elements, worksite and application prescreening, employee rights, non-discrimination, employee access to records, OSHA access to
documentation, providing annual data, and informing OSHA of organizational and collective
bargaining changes by signing and submitting the form included in Appendix A.
C. Union Information
If employees at the facility are represented by a collective bargaining agent(s), each authorized
collective bargaining agent(s) must either provide a signed statement of support for the facility’s
participation in the VPP, or co-sign the application submitted to OSHA. If a statement of support
is used, it must be on file before the application is considered complete. A sample letter of union
support is provided in Appendix B.
Union Name/ Local***:

Site Representative:

Address:

Phone:

Fax:

Email:
***Attach additional tables for each applicable contractor or union.
D. Inspection History
List all inspection activity involving OSHA over the past five years. Include the type of
inspection (complaint, programmed, referral, accident, fatality, etc.), any citations issued, and
status of any citations at the time this application was submitted. The application will not be
accepted by OSHA if there is any outstanding enforcement action pending including open
inspections, contested cases, etc.

C-FAP
VPP Corporate Pilot

Page 3

E. Injury and Illness Rate Information. Please complete the information and submit tables. Additional guidance on
calculating injury and illness rates can be found in Appendix C.
Table 1: All facility (site) employees including temporary and contract workers who are directly supervised by site management
Table 2: Each applicable contractor’s employees (contractor whose employees worked 1,000 hours or more in any calendar
quarter).
1

Year

Table 1: Site Employee Recordable Non-fatal Injury and Illness Case Incidence Rates
3
4
5
6
7
8

2

Total Work
Hours

Total # of
Injuries

Total # of
Illnesses

Total # of
Injuries &
Illnesses

Total Case
incidence
Rate for
Injuries and
Illnesses
(TCIR)

Total # of
Injuries
Involving
Days Away
from Work,
Restricted
Work
Activity,
and/or Job
Transfer

Total # of
Illnesses
Involving
Days Away
from Work,
Restricted
Work
Activity,
and/or Job
Transfer

9

10

Sum of Injury
& Illness
Cases
Involving
Days Away
from Work,
Restricted
Work
Activity,
and/or/ Job
Transfer

Days Away,
Restricted,
and/or
Transfer
Case
Incidence
Rate (DART
rate)

3 Years Ago
(Annual)
2 Years Ago
(Annual)
Last Year
3 Year Totals
and Rates

BLS rate (from previous 3 yrs) used for comparison
% above or Below National Average

Column 2:
Column 3:
Column 4:
Column 5:

C-FAP
VPP Corporate Pilot

Insert the total person hours worked for the year (not an estimate).
Insert the total number of OSHA recordable injuries for the year.
Insert the total number of OSHA recordable illnesses for the year.
Insert the sum of columns 3and 4.

Page 4

(TCIR) = (total recordable injuries and illnesses ÷ total hours worked) x 200,000
Insert the total number of OSHA recordable injuries involving days away from work,
Insert the total number of OSHA recordable illnesses involving days away from work, restricted work activity, and/or
job transfer
Column 9:
Insert the sum of columns 7 and 8.
Column 10: (DART rate) = (total recordable injuries and illnesses resulting in days away, restricted work activity, and/or job
transfer ÷total hours worked) x 200,000
3-Year Rates: (3-year TCIR) = (column 5 total ÷column 2 total) x 200,000
(3-year DART) = (column 9 total ÷ column 2 total) x 200, 000
BLS Data:
Insert the industry TCIR and DART rate from BLS’s Table of Incidence Rates of Nonfatal Occupational Injuries and
Illnesses by Industry at www.BLS.gov
Comparison: Calculate the percent above or below the BLS national average for your TCIR and DART rate using the formula:
[(Site rate - BLS rate) ÷ BLS rate] x 100
Column 6:
Column 7:
Column 8:

Table 2:
Site Applicable Contractors Recordable Non-fatal Injury and Illness Case Incidence Rates
(Report contractor injury and illness rates for contractors that work 1,000 or more hours in a quarter at your site)
1

Year

2

Total Work
Hours

3

Total # of
Injuries

4

Total # of
Illnesses

5

Total # of
Injuries &
Illnesses

6
Total Case
incidence
Rate for
Injuries and
Illnesses
(TCIR)

7

8

9

10

Total # of
Injuries
Involving Days
Away from
Work,
Restricted
Work Activity,
and/or Job
Transfer

Total # of
Illnesses
Involving
Days Away
from Work,
Restricted
Work
Activity,
and/or Job
Transfer

Sum of
Injury &
Illness Cases
Involving
Days Away
from Work,
Restricted
Work
Activity,
and/or/ Job
Transfer

Days Away,
Restricted,
and/or
Transfer
Case
Incidence
Rate (DART
rate)

Last Year’s
Totals and
Rates
**** BLS rate from any of the previous 3 yrs used for
comparison.

**** Include SIC and NAICS Codes

C-FAP
VPP Corporate Pilot

Page 5

F. Significant Changes or Events
If applicable, describe the impact of any significant changes (management, corporate buy-outs,
etc.) and events (fatality, catastrophe, accident, complaints, etc.) and steps taken to ensure or
restore worker safety and health.
G. Facility-Specific Programs
If the facility operates safety and health programs, which are not considered uniform Corporate
policies and are not discussed in the VPP Corporate Application, the facility application must describe
the details of these facility-specific programs.
H. Evaluation of Safety and Health Management System
Provide a copy of the facility’s most recent annual evaluation that assesses the effectiveness of each
VPP element and sub-element of the safety and health management system listed below. The annual
evaluation must meet all the requirements listed below:
•

Written narrative evaluation of all VPP elements/sub-elements that includes a summary
description of the facility implementation of the VPP element/sub-element and an assessment
of the effectiveness of that element/sub-element. The assessment must identify the strengths
and weaknesses of the safety and health management system and must contain:
The data/information reviewed to assess the effectiveness of the element/sub-element
Specific findings and recommendations for corrective action or improvement
Time-lines or target dates for completion of corrective actions or improvement items
Identification of responsible party(ies) for completion of corrective action or
improvement items
o Description of measures taken to complete corrective actions/improvement items
o
o
o
o

•
•

To be effective, the evaluation must provide for timely correction of any areas in need of
improvement.
If applicable, describe improvements made since the previous year and completion of the
previous year's recommendations.

1. Management Leadership and Employee Involvement
a.
b.
c.
d.
e.
f.
g.
h.
i.

Management Commitment to Safety and Health Protection and to VPP Participation
Policy
Goals, Objectives, and Planning
Visible Top Management Leadership
Responsibility and Authority
Line Accountability
Resources
Employee Involvement
Contract Worker Coverage

C-FAP
VPP Corporate Pilot

Page 6

j. Annual Evaluation of the Safety and Health Management System
2. Worksite Analysis
a. Baseline Hazard Analysis
b. Hazard Analysis of Routine Jobs, Tasks, and Processes
c. Hazard Analysis of Significant Changes, New Processes, and Non-Routine Tasks
- Including pre-use analysis and new baselines
d.
e.
f.
g.
h.

Routine Self-Inspections
Hazard Reporting System for Employees
Industrial Hygiene Program
Investigation of Accidents and Near-Misses
Trend/ Pattern Analysis

3. Hazard Prevention and Control
a. Certified Professional Resources
b. Hazard Elimination and Control Methods:
c.
d.
e.
f.
g.
h.

Engineering Controls
Administrative Controls
Work Practice Controls and Hazard Control Programs
Safety and Health Rules and Disciplinary System
Personal Protective Equipment

Process Safety Management (if applicable)
Occupational Health Care Program
Preventive/Predictive Maintenance
Tracking of Hazard Correction
Emergency Preparedness
Written Safety and Health Programs:
-

Recordkeeping and Posting
Hazard Communication
Blood borne Pathogens
Employee Exposure Assessment/Industrial Hygiene
Confined Space Entry
Trenching and Excavation
Elevated Work and Fall Protection
Mobile Equipment and Material Handling
Respiratory Protection
Hearing Conservation
Personal Protective Equipment
Asbestos and Lead Management
Fire Prevention and Protection

C-FAP
VPP Corporate Pilot

Page 7

-

-

Hot Work Permitting
Electrical Safe Work Practices
Spill Release and Prevention
Emergency Evacuation Plan
Ergonomic Awareness Program
Process Safety Management
Lockout/Tagout

The above list is not an all-inclusive list of safety and health programs but rather a list of the
most common programs found in the workplace. Please include any other safety and health
programs that apply to your facility.
4. Safety and Health Training
-

Managers
Supervisors
Employees

I. Success Stories
Please describe any success stories related to the implementation of VPP requirements. Include
anecdotal as well as statistical evidence of improvements, non-routine safety and health
activities, outreach, etc.

C-FAP
VPP Corporate Pilot

Page 8

Appendix A
Written Assurances

In signing this document, the management of [insert company name], hereby assures that:
We have successfully received a pre-screening evaluation as described in the VPP Corporate
Application.
We will comply with the Occupational Safety and Health Act (OSH Act) and correct, in a timely
manner all hazards discovered through self-inspections, employee notifications, accident
investigations, OSHA onsite reviews, process hazard reviews, annual evaluations, or other
means. (Federal applicants must also agree to comply with Title 29 of the Code of Federal
Regulations (CFR), Part 1960 – Basic Program Elements for Federal Employees).
Within 90 days, we will correct, safety and health deficiencies related to compliance with OSHA
requirements and identified during any OSHA onsite review. We will provide effective interim
protection, as necessary.
Our employees support our application to the VPP.*
Management commits to meeting and maintaining the VPP elements.
Employees including newly hired employees and contract employees will receive orientation on
the VPP, including employee rights under VPP and under the OSH Act or 29 CFR 1960.
We will protect employees given safety and health duties as part of our safety and health
management system from discriminatory actions resulting from their carrying out such duties, as
described in Section 11(c) of the OSH Act and 29 CFR 1960.46(a).
Employees will have access to the results of self-inspections, accident investigations, and other
safety and health data, upon request.*
We will maintain our safety and health management system information and make it available
for OSHA review to determine initial and continued approval to the VPP. This information will
include:
•

Any agreements between management and the collective bargaining agent(s) concerning
safety and health.

•

All documentation enumerated under Section III.J.4 of the July 24, 2000 Federal Register
Notice.

•

Any data necessary to evaluate the achievement of corporate or participating worksite
individual Merit or 1-Year Conditional Star goals.

C-FAP
Appendix A – Written Assurances
VPP Corporate Pilot

A-1

Each year by February 15, we will submit our annual injury incidence and lost work day case
numbers and rates, hours worked, and estimated average employment for the past calendar year
separately for our regular employees and for applicable onsite contract employees as well as a
copy of our annual safety and health program self- evaluation to our designated OSHA Regional
VPP manager.
Whenever significant organizational or ownership changes occur, we will provide OSHA within
60 days a new Statement of Commitment signed by both management and authorized collective
bargaining agents.
Whenever a change occurs in the authorized collective bargaining agent, we will provide OSHA
within 60 days a new signed statement indicating that the new representative supports VPP
participation.
We understand that we may withdraw our participation at any time for any reason should we
deem that desirable.
We, the undersigned, respectfully submit this statement of assurances and request consideration
for participation in the Voluntary Protection Programs.
Signature: __________________________________
Title: ______________________________________
Date: ______________________________________

*At facilities with employees organized into one or more collective bargaining units, the authorized representative
for each collective bargaining unit must either sign the application or submit a signed statement indicating that the
collective bargaining agent(s) supports VPP participation. OSHA must receive concurrence from all such
authorized agents to accept the application. At non-union corporations and worksites, management’s assurance of
employee support will be verified by the OSHA onsite review team during employee interviews.

*At unionized construction sites, this requirement may be met through employee representative access to these
results.

C-FAP
Appendix A – Written Assurances
VPP Corporate Pilot

A-2

Appendix B
Sample Statement of Union Support

Dear ______:
The International Brotherhood of Chemical Workers (IBCW), Local 3-593, is in full support of
this site’s pursuit and participation in the Voluntary Protection Programs (VPP).
We understand that Occupational Safety and Health Administration (OSHA) created VPP to
encourage and recognize excellence in safety and health, and to accomplish OSHA’s mission of
protecting America’s workers through voluntary efforts. We understand the requirements of the
program are based on comprehensive safety and health management systems, with our
represented employees actively and meaningfully involved in the safety and health program.
We, the undersigned, respectfully submit this statement of support for participation in the VPP
and request consideration for membership in VPP.

________________________________________
Joe Smith
Collective Bargaining Agent

Date: ___________________________________

C-FAP
Appendix B - Union Support
VPP Corporate Pilot

B-1

Appendix C
Instructions for Calculating Injury and Illness Rates
I. Definitions
A. Total Case Incidence Rate (TCIR). Total number of recordable injuries and
illness cases per 100 full-time employees that a site has experienced in a given
time frame.
B. Days Away, Restricted, and/or Transfer (DART) Case Incidence Rate.
Number of recordable injuries and illness cases per 100 full-time employees
resulting in days away from work, restricted work activity, and/or job transfer that
a site has experienced in a given time frame.
II.

Review of Rates. New applicants and current participants are required to calculate
annual rates and 3-year rates for the last 3 complete calendar years. Use information
recorded in the OSHA 300 log.
VPP Onsite Evaluation Teams will calculate the site's rates for the previous 3 full
calendar years and year-to-date. When reviewing participating sites, the VPP onsite
teams also will review the rates of each applicable contractor. Note: The 3-year review of
applicable contractors' rates will not begin until 2003. (In the year 2002, 2000 and 2001
data will be reviewed).

III.

Contractor Rates
A. Copies of each applicable contractor's hours worked and injury and illness data
pertaining to the site must be maintained by site management. (Applicable
Contractors are defined as those employers hired to provide services and whose
employees worked a total of 1,000 or more hours in at least 1 calendar quarter at
your worksite.)
B. Injury and illness data for temporary and contractor employees who are regularly
intermingled with the owner's employees and under direct supervision by site
management must be included in the site's rates.

IV.

V.

Construction Sites. Construction applicants must provide TCIR and DART rates. All
workers, including all subcontractors who worked at the site, must be included in the
calculation. The rates must reflect experience from time of site inception until time of
application, but must be at least 12 months. The site's SIC or NAICS code is determined
by the type of construction project, not individual trades.
Rate Calculations
A. Annual rates are calculated by the formula (N/EH) x 200,000 where:
N = Sum of the number of recordable injuries and illnesses in the year.

C-FAP
Appendix C - Guidance for Rate Calculations
VPP Corporate Pilot

C-1

For the TCIR use the total number of injuries plus illnesses.
For the DART rate use injuries and illnesses resulting in days away from work,
restricted work activity, and/or job transfer.
EH = total number of hours worked by all employees in the year.
200,000 = equivalent of 100 full-time workers working 40 hours per week, 50
weeks per year.
B. 3-Year TCIR Calculation. To calculate 3-year TCIR, add the number of all
recordable injuries and illnesses for the past 3 years and divide by total hours
worked for those years. Multiply result by 200,000.
[(#inj + #ill) + (#inj + #ill) + (#inj + #ill)] x 200,000
[hours +hours+hours]
C. 3-year DART Rate Calculation. To calculate 3-year DART rate, use the same
formula as in B. above, except add the number of all recordable injuries and
illnesses resulting in days away from work, restricted work activity, and/or job
transfer for the past 3 years.
[(#DART inj + ill) + (#DART inj + ill) + (#DART inj + ill)] x 200,000
[hours + hours + hours]
D. Rounding Instructions. You must round the rates to the nearest tenth following
traditional mathematical rounding rules. For example, round 5.88 up to 5.9; round
5.82 down to 5.8; round 5.85 up to 5.9.
VI.

Comparison to National Averages. Compare the 3-year TCIR and DART rate to the
most recently published Bureau of Labor Statistics (BLS) national average (available
online at http://www.osha.gov/oshstats/work.html) for the three- or four-digit (if
available) SIC or the NAICS code for the industry in which the applicant is classified.
A. These national averages, currently broken down by SIC code, are found in the
Table of Incidence Rates of Non-fatal Occupational Injuries and Illnesses by
Industry of the BLS Occupational Injuries and Illnesses Bulletin that BLS
publishes each year. When BLS changes from the SIC classification system to the
North American Industry Classification System (NAICS), VPP rates will be
compared to the rates generated under NAICS.
B. To calculate the percent above or below the national average use the following
formula:
Site rate - BLS rate x 100
BLS rate

C-FAP
Appendix C - Guidance for Rate Calculations
VPP Corporate Pilot

C-2