Challenge Administrator

Voluntary Protection Program Information

Challenge Administrator Annual Summary Report.xls

Challenge Administrator

OMB: 1218-0239

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1218-0239 can be found here:

Document [xlsx]

Download: xlsx | pdf

Overview

Overview
1 - Admin. Annual Report
2 - Summary of Rates
3 - Participant 1 Info
4 - Participant 2 Info
5 - Participant 3 Info
6 - Participant 4 Info
7 - Participant 5 Info
8 - Participant 6 Info
9 - Participant 7 Info
10 - Participant 8 Info
11 - Participant 9 Info
12 - Participant 10 Info

Sheet 1: Overview

OSHA Challenge
Administrator Annual Report

Included in this spreadsheet are:

Tab 1. Administrator Annual Report
Tab 2. Summary of Participant Injury and Illness Rates - Autofills
Tabs 3 - 12. Individual Participant Information

1.) Some fields in this spreadsheet are programmed to fill these forms automatically.
Do not manually enter data into these fields. All of Tab 2 autofills.
2.) The year has been entered in all applicable boxes.
3.) Each participant is to have their own tab. If you have more than 10 participants, copy the file
of blank annual reports before entering information first. Ensure that you have enough annual
report files for the total number of your participants.
4.) Ensure that all fields are filled in correctly.
5.) Remember to submit an updated OCTPS for each participant along with this summary.
6.) Ensure that the data inputted are consistent and accurate.

*To access these documents, please click on the tabs at the bottom of this form.*

The OSHA Challenge Administrator must prepare the Administrator Annual Report each year along with an OSHA Challenge Tracking Participant Status (OCTPS) form for each participant. Both the annual report and all OCTPS forms must be submitted electronically to your OSHA Challenge Liaison no later than February 15 each year.

Sheet 2: 1 - Admin. Annual Report

OSHA Challenge
Administrator's Annual Report

Administrator Name					Year
					CY2011

Section 1. Administrator Information Update
Name
Site Address
City, State, Zip
Section 2. Administrator Contact Information Update
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
Coordinator Contact Name
Coordinator Contact Title
Coordinator Contact Phone Number
Coordinator Contact Fax Number
Coordinator Contact E-mail Address
Section 4. Participant Information Updates



Section 5. Input from Challenge Administrators
1.) Please provide a couple of examples of significant achievements accomplished by your Challenge participants during the past year.








2.)Do you have any suggestions for improving OSHA Challenge?








OSHA Challenge
Administrator's Annual Report
3.) Additional comments:









Form Approved
OMB# 1218 – 0239 Expires 09-30-2014
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 Office of Partnerships and Recognition,
Department of Labor, Room N-3700, 200 Constitution Avenue, N.W., Washington, DC 20210.

Sheet 3: 2 - Summary of Rates

OSHA Challenge
Summary of Participant Injury and Illness Rates

Administrator					Year
				CY2011

	Injury and Illness Rates
Participant	TCIR			DART
Name	Current	Baseline	%	Current	Baseline	%
[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

[Insert Participant Name Here]	#DIV/0!	0.0	#DIV/0!	#DIV/0!	0.0	#DIV/0!

Sheet 4: 3 - Participant 1 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 5: 4 - Participant 2 Info

OSHA Challenge Participant Information

Participant								OSHA 300 Log Totals for
[Insert Participant Name Here]								Year		CY 2011

G	H	I	J	K	L	M:1	M:2	M:3	M:4	M:5	M:6
0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0	0.0

Total Hours Worked			0.0				Total Employees

Measure				Current
Measure				Year	Baseline	Change
TCIR				#DIV/0!	0.0	#DIV/0!
DART				#DIV/0!	0.0	#DIV/0!

Significant Achievements and Milestones
Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 6: 5 - Participant 3 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 7: 6 - Participant 4 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 8: 7 - Participant 5 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 9: 8 - Participant 6 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 10: 9 - Participant 7 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 11: 10 - Participant 8 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 12: 11 - Participant 9 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

Sheet 13: 12 - Participant 10 Info

OSHA Challenge Participant Information

Participant

OSHA 300 Log Totals for

[Insert Participant Name Here]

Year

CY 2011

M:1

M:2

M:3

M:4

M:5

M:6

0.0

Total Hours Worked

0.0

Total Employees

Measure

Current

Year

Baseline

Change

TCIR

#DIV/0!

0.0

#DIV/0!

DART

#DIV/0!

0.0

#DIV/0!

Significant Achievements and Milestones

Describe any significant achievements/milestones accomplished by your participants during the past year.

File Type	application/vnd.ms-excel
Last Modified By	samanil
File Modified	2012-03-27
File Created	2004-02-03