Challenge Pilot Candidate

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Overview

Overview
1 - Statement of Commitment
2 - Candidate Information
3 - OSHA 300 Baseline Info
4 - Optional Information

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Sheet 1: Overview

Challenge Pilot
Candidate Information Package Instructions
Included in this spreadsheet are:
Tab 1. Candidate Statement of Commitment
Tab 2. Candidate Information Form
Tab 3. OSHA 300 Baseline Information Form [Must provide at least 1 year of data]
Tab 4. 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.
Once your Administrator receives your Candidate Information Package, it will be
reviewed by OSHA. You will be contacted by your Administrator if any missing
information needs to be provided. Confirmation of your acceptance as an OSHA
Challenge Participant will be provided by mail. Please allow 30 days for 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 10 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 - Statement of Commitment

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

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Sheet 3: 2 - Candidate Information

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	NAICS

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Sheet 4: 3 - OSHA 300 Baseline Info

Challenge Pilot Program

OSHA 300 Baseline Information*

Candidate Name

Candidate 1

2001

Candidate 2

2002

REQUIRED DATA

Candidate 3

2003

Candidate 4

2004

Most Recent Complete Calendar Year of Data

[Enter Year of Data Here]

Candidate 5

2005

Candidate 6

2006

G

H

I

J

K

L

M:1

M:2

M:3

M:4

M:5

Total Hours Worked

TCIR

#VALUE!

DART

#VALUE!

OPTIONAL DATA

Previous Year's Data

[Enter Year of Data Here]

Candidate 5

2005

Candidate 6

2006

G

H

I

J

K

L

M:1

M:2

M:3

M:4

M:5

Total Hours Worked

TCIR

#VALUE!

DART

#VALUE!

Data from Two (2) Years Previous

[Enter Year of Data Here]

Candidate 5

2005

Candidate 6

2006

G

H

I

J

K

L

M:1

M:2

M:3

M:4

M:5

Total Hours Worked

TCIR

#VALUE!

DART

#VALUE!

3-Year Average

TCIR

#VALUE!

DART

#VALUE!

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

* - OSHA will use this information to track the progress of OSHA Challenge Candidates.

It will NOT be used for enforcement purposes.

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Sheet 5: 4 - Optional 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.