Challenge Administrators Application

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Overview

Overview
1 - Administrator Criteria
2 - Statement of Commitment
3 - Administrator Info Form
4A - Coordinator Info Form - 1
4B - Coordinator Info Form - 2
4C - Coordinator Info Form - 3
4D - Coordinator Info Form - 4
4E - Coordinator Info Form - 5
4F - Coordinator Info Form - 6
4G - Coordinator Info Form - 7
4H - Coordinator Info Form - 8
4I - Coordinator Info Form - 9
4J - Coordinator Info Form - 10

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Sheet 1: Overview

Challenge Pilot
Administrator Application Package Instructions
Included in this spreadsheet are:
Tab 1. Administrator Criteria
Tab 2. Administrator Statement of Commitment
Tab 3. Administrator Information Form
Tab 4A. Coordinator Information Form - Coordinator 1
Tab 4B. Coordinator Information Form - Coordinator 2
Tab 4C. Coordinator Information Form - Coordinator 3
Tab 4D. Coordinator Information Form - Coordinator 4
Tab 4E. Coordinator Information Form - Coordinator 5
Tab 4F. Coordinator Information Form - Coordinator 6
Tab 4G. Coordinator Information Form - Coordinator 7
Tab 4H. Coordinator Information Form - Coordinator 8
Tab 4I. Coordinator Information Form - Coordinator 9
Tab 4J. Coordinator Information Form - Coordinator 10
To access these documents, please click on the tabs at the bottom of this form.
Please complete and return the Statement of Commitment, Administrator Information
Form, and Coordinator Information Forms (one per Coordinator) to:
		OSHA Challenge Program Coordinator
		Directorate of Cooperative and State Programs
		Occupational Safety and Health Administration, Room N3700
		U.S. Department of Labor
		200 Constitution Ave., NW
		Washington, DC 20210
You may submit this package electronically to Jim Boom via e-mail boom.lloyd @dol.gov
You will also need to submit candidate packages (see Candidate Application Package
Spreadsheet), for all organizations that will be participating with you.
Once your Administrator's Package is received, it will be reviewed by OSHA. You will be
contacted if any missing information needs to be provided. Confirmation of your acceptance
as an Challenge Pilot Administrator will be provided by mail. Please allow a 45-day window
for OSHA to complete the review process.
OMB# 1218 – 0239 Expires xx-xx-xxxx Public reporting burden for this collection of information is voluntary and is estimated to average 5 hours per response, including time for reviewing instructions, 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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Sheet 2: 1 - Administrator Criteria

Challenge Pilot
Administrator Criteria
Eligibility:	The role of a Challenge Pilot Administrator is available to any private corporation, federal agency or non-profit association that meets the eligibility criteria outlined below and meets OSHA’s selection process. Eligibility does not extend to private safety and health consultants or for-profit associations at this time.
Role of Challenge Pilot Administrators:	Challenge Pilot Administrator refers to the organization as a whole, such as a federal agency, corporation, or an association. Administrators can administer the program to either their own worksites or members of other companies.
Role of Challenge Pilot Coordinator:	Coordinators are appointed by the Administrator to manage the program implementation for the Challenge Pilot Candidates.
Challenge Pilot Administrator Criteria:	An Administrator must possess the following characteristics in order to be considered:
	Knowledge and Experience: Demonstrated knowledge and experience in safety and health management systems. Experience may include involvement in other OSHA Cooperative Programs such as, VPP or Strategic Partnerships; and/or experience administering corporate-wide safety and health policies at the facility-level.
	Resources: Administrators must confirm the availability of resources including time, personnel and expertise to administer OSHA Challenge to its Candidate facilities or members.
	Commitment: Administrators must be committed to the Challenge Pilot and sponsor a minimum of ten (10) Challenge Pilot Candidates.
Challenge Pilot Individual Coordinator Criteria:	Criteria for individual coordinators include:
	Knowledge and Experience: Knowledgeable safety and health professionals with experience in implementing and evaluating safety and health management systems.
	Training: Ideally, Challenge Pilot Coordinators will have completed the OSHA Special Government Employees (SGE) training or equivalent (i.e., corporate safety and health audit training).
	Evaluation Experience: Ideally, Challenge Pilot Coordinators should have performed site safety and health management system reviews or VPP type onsite evaluations.

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Sheet 3: 2 - Statement of Commitment

Challenge Pilot
Administrator Statement of Commitment
Sample Letter Only
Cathy Oliver, Director
Office of Partnerships and Recognition
Directorate of Cooperative and State Programs
U.S. Department of Labor, OSHA
200 Constitution Avenue, North West
Room N3700
Washington, DC 20210
Attention: Cathy C. Oliver
Dear Ms. Oliver:
I am writing to inform you of [insert name of company, association, or federal agency’s] intent to participate in the Challenge Pilot Program as a Challenge Pilot Administrator. We have reviewed the program and believe [insert name of company, association, or federal agency’s] meets the Administrator criteria you are seeking.
I can assure you that [insert name of company, association, or federal agency] is committed to assisting our potential candidates in progressing through the Challenge Pilot stages towards health and safety excellence. Initially we agree to have a minimum of ten (10) Candidates in the Challenge Pilot.
Attached please find our: (if submitting at this time).
	Administrator Information Sheet
	Coordinator Information Sheet
	Candidate Package(s)
Should you have any questions or need additional information, please contact:
	Name
	Title
	Address
	Phone
	E-mail
[Insert name of company, association, or federal agency] looks forward to working together to bring the principles and benefits of VPP to more facilities throughout the country.
Sincerely,

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Sheet 4: 3 - Administrator Info Form

Challenge Pilot
Administrator Information Form
Section 1. Administrator Information
Name
Site Address
Type of Administrator	Private Company
Section 2. Administrator Contact Information
Administrator Contact Name
Administrator Contact Title
Administrator Contact Phone Number
Administrator Contact Fax Number
Administrator Contact E-mail Address
Section 3. Knowledge and Experience
Please describe your organization’s knowledge and experience in safety and health management systems. Experience may include involvement in other OSHA Cooperative Programs such as, VPP or Strategic Partnerships; and/or experience in administering corporate-wide safety and health policies at the facility-level. [250 words or less]
Section 4. Resources
Please confirm the availability of resources including time and personnel to administer the Challenge Pilot to the Candidate facilities or members. [100 words or less]
Section 5. Process
Please provide a description of your organization’s internal processes to collect baseline and quarterly/annual data for each Challenge Pilot Candidate and ensure its accuracy. (See Candidate’s Package for baseline data requirements and the following Evaluation Report Template for quarterly/annual requirements) [250 words or less]

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Sheet 5: 4A - Coordinator Info Form - 1

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 6: 4B - Coordinator Info Form - 2

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 7: 4C - Coordinator Info Form - 3

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 8: 4D - Coordinator Info Form - 4

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 9: 4E - Coordinator Info Form - 5

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 10: 4F - Coordinator Info Form - 6

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 11: 4G - Coordinator Info Form - 7

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 12: 4H - Coordinator Info Form - 8

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 13: 4I - Coordinator Info Form - 9

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]

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Sheet 14: 4J - Coordinator Info Form - 10

Challenge Pilot
Coordinator Information Form
(Please complete forms for each Coordinator)
Section 1. Coordinator Information
Company Name
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Administrator Name
Section 2. Knowledge and Experience
Please describe your knowledge and experience in safety and health program management. [200 words or less]
Section 3. Training
Please describe any relevant safety and health training you have completed. [150 words or less]
Section 4. Evaluation Experience
Please describe all relevant experience you have in evaluating safety and health management systems. [200 words or less]