Special Govt. Employee Eligiblity Information Sheet

Voluntary Protection Programs
(VPP)
Special Government Employee
(SGE)

SGE Application
Revised October 2007

U.S. Department of Labor
Occupational Safety and Health Administration

Table of Contents

Qualifications to Participate .................................................................... 3

Program Information ................................................................................ 4

Application Instructions and Checklist ..................................................... 5

SGE Eligibility Information ................................................................... 6-7

Confidential Financial Disclosure Form ............................................ 8-12

Ethical Conduct for Government Employees .................................... 13-24

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Qualifications to Participate
All SGE applicants must meet the following qualifications:
•
•
•
•
•
•

Experience in applying OSHA regulations
Currently hold, or have held within the past two years, a leadership position(s) in the VPP
activity at their site
Positive interpersonal skills
Sound reading and writing skills
Physically able to perform team members' duties
Management and/or corporate support for participating in the VPP SGE program

Safety and Health Professionals must meet these additional qualifications:
•
•
•

Two or more years experience in the safety and health field
Be employed in a position in which more than 50% of daily duties are dedicated to
conducting or managing worksite or corporate safety or health activities
Be a permanent, full-time employee of a VPP worksite, a current corporate office employee
of a corporation that has one or more VPP worksites, or a current employee of a non-VPP
worksite who was previously an employee at a VPP worksite within the same corporation

Process Safety Management (PSM) Specialist must meet additional
qualifications:
•

Be an employee who has successfully completed the OSHA Training Institute’s (OTI)
Course 3300, Safety and Health in the Chemical Processing Industries and Course 3400,
Hazard Analysis in the Chemical Processing Industries or equivalent training or experience
as demonstrated by education/job classification i.e, Process Safety Manager, Process Safety
Engineer, etc.

Other SGE applicants must have the following qualifications:
•
•

A permanent, full-time employee of a VPP worksite that has worked at a VPP site for a
minimum of two (2) years
Involved in at least three (3) of the following activities (or their equivalent):
9 Chair of safety/health committee
9 Experience working directly with the OSHA VPP on-site review team during the
previous onsite review
9 Experience training others in safety and health procedures
9 Experience writing and reviewing Job Safety Analyses (JSA's) and/or Behavior Job
Analyses (BJA's)
9 Experience coordinating accident investigations
9 Experience coordinating safety and health activities such as wellness days
9 Experience leading worksite hazard inspection teams
9 Other experiences that demonstrate a knowledge of safety and health management
systems
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Program Information
•

SGE applicants must complete and submit an application to participate as an OSHA
volunteer for VPP. Currently serving SGEs must re-apply to participate at the end of their
term of service. A renewal letter will be sent to each SGE prior to their service expiration.

•

Applications to participate as an SGE are processed four times per year. Applications must
be received in the Directorate of Cooperative and State Programs, Office of Partnerships and
Recognition on or before January 15, April 15, July 15 or October 15 of each year. If the
deadline date falls on the weekend or a Federal holiday, applications are due on the first
Federal business day following the applicable deadline date. Late applications will be held
until the next submission deadline.

•

All new applicants must attend training. A new SGE applicant will not be approved to attend
training until his/her application has been approved by the OSHA’s Office of Human
Resources. Successful applicants will be notified by the SGE Coordinator of the date and
location of training.

•

The term of service for SGEs is three years. SGEs serve at the pleasure of the Assistant
Secretary for Occupational Safety and Health Administration. Service is contingent upon the
proper and ethical conduct of SGEs. The term of service for new SGEs begins upon
successful completion of the SGE training course. The term of service for renewing SGEs is
calculated from the approval date of their application.

•

The Director of Cooperative and State Programs or his/her designee will disqualify from
eligibility those applicants for whose employment or financial involvements may present a
conflict of interest or the appearance of impropriety.

•

As a member of a VPP Onsite Evaluation Team, a SGE may review company documents that
describe or verify the worksite’s safety and health program, conduct a walk-through of the
work site to ensure the site’s safety and health program is operating effectively; interview
company and contract employees to determine their level of involvement in and perceptions
of the worksite’s safety and health program and assist in the preparation of a report that
evaluates the worksite’s safety and health program with respect to VPP criteria.

•

Participation as an SGE on a VPP Onsite Evaluation Team should occur within the first 6
months of successfully completing the SGE 3-day training course. Assistance on additional
VPP Onsite Evaluations is strongly encouraged. For SGE Appointment renewal, previous
onsite participation will be considered.

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Application Instructions and Checklist
The following forms must be completed, signed and dated in order for your application to be processed. This
sheet and checklist is for your convenience. If you have any questions regarding the SGE Application, please
contact the SGE Coordinator at (202) 693-2213. Please keep a copy of your application for your files and future
reference.
9 Please complete the SGE Eligibility Information Sheet.
9 Include a copy of your most recently updated resume. Position-specific safety and health experience must
be included either on your resume. Failure to include position-specific safety or health experience may
result in delays in processing your application or disqualification of your application. You must
include your Social Security Number.
9 Please complete the "'Executive Branch Confidential Financial Disclosure Report," (OGE Form 450).
Remember to sign and date the form. The instructions for completing the form are located directly behind
the form in your application packet.
9 Please read "Principles for Ethical Conduct for Government Officers and Employees" and "How to Keep
Out of Trouble: A summary of Ethics Rules for DOL Employees."
____________Eligibility Information Sheet
____________Resume
____________Confidential Financial Disclosure Report
____________Please verify that you have read and understood the Principles of Ethical Conduct for
Government Employees
Please return these forms with a cover letter to:
U.S. Department of Labor – OSHA
SGE Coordinator
Directorate of Cooperative and State Programs
200 Constitution Avenue, NW, Room N-3700
Washington, DC 20210

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SGE Eligibility Information Sheet
SGE Contact Information:

(Check one) _____

Renewing SGE

Your Name and Title: Last,

First

Your Company Name:

___________________________________________________________

Site Address:
City:

Mid Init.

New SGE ______

___________________________________________________________________

_____________________ State:

Phone:

Job Title ___________________________________

_________ Fax:

Social Security Number:

-

___Zip Code:

________________________

_________________ E-mail:
-

Date of Birth (mm/dd/yyyy):

Professional and Practical Experience:

Do you work at an:

Your worksite’s first official VPP approval date:

_______________________
/

/

_____________________

OSHA VPP Site

DOE VPP Site

___ Your starting employment date:

_____

Corporate-level SGE applicants, please provide the site name, address and approval date of the VPP
site you control.

Based on the “Qualifications to Participate” (Page 3), are you applying as a safety or health professional? Yes
__________________________________________________________________________________

No

Field(s) of Expertise (mark all that apply):
Safety Professional
Ergonomics

CSP

Construction

Health Professional
Spanish-Speaking

CIH
Maritime

PSM-Level 1(see qualifications)
Other (specify):

If you are not applying as a safety or health professional, please list at least three of the required
experiences from the “Qualifications to Participate” (Page 3) that you have participated in while working
at your present VPP site.

Waiver of Claims Against the Government

I hereby waive any and all claims against the United States Government or the State in which I perform
services, for any compensation on account of my services as an SGE rendered in connection with an
onsite evaluation of an applicant to OSHA’s VPP Program or a State Plan State’s VPP Program.
Signature of Employee

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Ethical Conduct for Government Employees:
I have read and fully understand the Principles of Ethical Conduct for Government Officers and
Employees and How to Keep out of Trouble: A Summary of Ethics Rules for DOL Employees.
Signature of Employee

Management Contact Information:
Name of Manager/Supervisor:
Corporation:
Address:
City:

__________________________ Title:

________________

___________________________________________________________________
______________________________________________________________________

__________________________ State:

Zip Code:

_______________________

Signature of Manager/Supervisor
(Signature required. Signature implies concurrence with SGE applicant’s qualifications.)

Form Approved
OMB# 1218-0239 Expired 4-31-08
Public reporting burden for this collection of information is voluntary and is estimated to average 8 minutes 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 Office of Partnerships and Recognition,
Department of Labor, Room N-3700, 200 Constitution Avenue., N.W. Washington, DC 20210.

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