Voluntary Protection Program, Special Government Employee

Compressed Reapproval Process (CRP)

or

Corporate Facility Onsite Process (C-FOP)

Evaluation Report

Company Name

City, State

Onsite Evaluation Date

Month – Start/End Dates, 20XX

VPP Evaluation Team

Name, Title

Name, Title

Name, Title

Name, Title

Name, Title

EXECUTIVE SUMMARY

I. Purpose and Scope of Review

An onsite review was conducted from <Date>, at the <Organization> in <City, State>. The purpose of the evaluation was to determine the site’s <eligibility or continued eligibility> for site-based participation in the Occupational Safety and Health Administration’s (OSHA) Voluntary Protection Programs (VPP). <NOTE: If C-FOP add the following language “This onsite review was conducted using the Corporate Facility Onsite Process (C-FOP)”.> The VPP Evaluation Team consisted of:

Name, Title/Special Government Employee (SGE), Office, City, State

Name, Title/Special Government Employee (SGE), Office, City, State

Name, Title/Special Government Employee (SGE), Office, City, State

Name, Title/Special Government Employee (SGE), Office, City, State

Name, Title/Special Government Employee (SGE), Office, City, State

II. Methods of Data Collection

The information for this report was obtained from the site's VPP application, documentation reviewed onsite, interviews with employees, annual evaluations, and site walk-throughs of the facility.

III. Employees at the Worksite

There are <XXX> employees working on site. In addition, there are <XXX> contract employees onsite performing maintenance, capital projects, guard services, janitorial services, etc. Employees at the site are represented by the <insert union name(s) and local(s)>. OR <Employees at the site are not represented by a collective bargaining agent.> Formal interviews were conducted with <XX >site employees and <XX> contract employees. Informal interviews were conducted with <XXX> site employees and <XXX> contract employees.

IV. The Worksite

The site is properly classified under North American Industrial Classification System (NAICS) code <XXXXXX>. Provide a description of the site, e.g., size, location, operation, buildings, etc. Describe the site’s processes, productions, and applications. Housekeeping at the facility was considered by the VPP Evaluation Team to be <please select one: poor, fair, good or excellent>.

V. Worksite Hazards

The hazards at the site include, but are not limited to <state hazards>. The site <does or does not> use chemicals considered to be highly hazardous and in sufficient quantity to place the site under the Process Safety Management (PSM) Standard.

VI. Injury and Illness Rates

The three‑year Total Case Incidence Rate (TCIR) and Days Away/Restricted/Transferred Case Incidence (DART) rate for the period <20XX-20XX> are <XX> and <XX>, respectively. The site TCIR is <XX%> <above/below>, and the DART rate is <XX%> <above/below> the 20XX Bureau of Labor Statistics (BLS) industry average for NAICS code <XXXXXX> for 20XX.

Team leader must verify that a comparison has been conducted against the site’s injury and illness rates reviewed during the evaluation and the site’s injury and illness rates reported in its annual self evaluation.

Year	Hours	Total # of Cases	TCIR Rate	Number of Cases Involving Days Away from Work, Restricted Activity or Job Transfer	DART Rate
20xx
20xx
20xx 1999
Total
Three-Year Rate (20xx-20xx)
BLS National Average for 20xx (NAICS XXXXXX)
20xx YTD

VII. OSHA Activity

There has been no OSHA inspection activity or fatalities at this site within the past <XX> years. The site maintains an excellent relationship with its local OSHA Area and Regional offices.

VIII. Elements of the VPP Review/Program Changes

The VPP Evaluation Team has examined each of the required elements of the site’s safety and health management programs. All VPP requirements have been met and all OSHA standards are appropriately covered.

Bullet summary information of VPP Elements.

• Management Leadership and Employee Involvement

• Worksite Analysis

• Hazard Prevention and Control

• Safety and Health Training

<For Reapproval evaluations>, discuss significant program or site changes since the last visit. A bulleted list is acceptable. [For Star reapproval evaluations recommending One-Year Conditional, add the following sentence: Refer to Section XI for discussion of safety and health management program corrections.]

<Incentive Programs>The site utilizes an incentive program which meets the requirements of Memorandum #5: Further Improvements to the Voluntary Protection Programs (VPP) dated 6/29/11. OR The site does not utilize an incentive program.

IX. Areas of Excellence

All elements of the site’s safety and health management programs met the high quality expected of VPP participants (or describe the program requirements that you considered an area of excellence). NOTE: Do not characterize the safety and health management programs as meeting the high quality expected of VPP participants if the team is recommending One-Year Conditional reapproval.

X. Recommendation for Participation

The VPP Evaluation Team recommends <Site name, City, State> be approved for participation in the OSHA VPP <Star or Merit> Program (add if relevant but placed on One-Year Conditional status or but required to develop an agreed upon Two-Year Rate Reduction Plan).

XI. Goals

• Merit Goal(s) (if relevant)

• One-Year Conditional Goal(s) (if relevant)

• Two-Year Rate-Reduction Plan (if relevant)

Corporate Facility Onsite Process (C-FOP)

or

Compressed Reapproval Process (CRP)

Site Worksheet

Company Name

City, State

Onsite Evaluation Date

Month - Start/End Dates, 20xx

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section I: Management Leadership & Employee Involvement
A. Written Safety & Health Management System
A1. Is the written safety and health management system at least minimally effective to address the scope and complexity of worksite hazards? If not, please explain. MRX

		How Assessed
	Yes or No	Interview		Observation	Doc Review
Section I: Management Leadership & Employee Involvement
B. Management Commitment & Leadership
B1. Does management overall demonstrate at least minimally effective, visible leadership with respect to the safety and health management system (as per FRN, VOL. 74, NO. 6, 01/09/09 page 936, IV. A.5. a-h)? Provide examples. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section I: Management Leadership & Employee Involvement
C. Planning
C1. For site-based construction sites, is safety included in the planning phase of each project? MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section I: Management Leadership & Employee Involvement
D. Authority and Line Accountability
D1. Does top management accept ultimate responsibility for safety and health? (Top management acknowledges ultimate responsibility even if some safety and health functions are delegated to others.) If not, please explain. MRX
D2. Do the individuals assigned responsibility for safety and health have the authority to ensure that hazards are corrected or necessary changes to the safety and health management system are made? If not, please explain. MRX
D3. Are adequate resources (equipment, budget, or experts) dedicated to ensuring workplace safety and health? Provide examples. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section I: Management Leadership & Employee Involvement
E. Contract Employees
E1. Does the site’s contractor program cover the prompt correction and control of hazards in the event that the contractor/sub-contractor fails to correct or control such hazards? Provide examples. MRX
E2. Based on your answers to the above item, is the contract oversight minimally effective for the nature of the site? (Inadequate oversight is indicated by significant hazards created by the contractor, employees exposed to hazards, or a lack of host audits.) If not, please explain. MRX

			How Assessed
	Yes or No	Interview		Observation	Doc Review
Section I: Management Leadership & Employee Involvement
F. Employee Involvement
F1. Do employees support the site’s participation in the VPP? MRX
F2. Do employees feel free to participate in the safety and health management system without fear of discrimination or reprisal? If so, please explain. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section I: Management Leadership & Employee Involvement
G. Safety and Health Management System Evaluation
G1. Does the annual evaluation cover the aspects of the safety and health management system, including the elements described in the Federal Register? If not, please explain. MRX

Section I: Management Leadership & Employee Involvement

Merit Goals: (Include cross- reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations (optional)

1.

2.

Documents Referenced, Programs Reviewed (optional):

1.

2.

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section II: Worksite Analysis
A. Baseline Hazard Analysis
A1. Has the site been at least minimally effective at identifying and documenting the common safety and health hazards associated with the site (such as those found in OSHA regulations, building standards, etc., and for which existing controls are well known)? If not, please explain. MRX
A2. Does the site have a documented sampling strategy used to identify health hazards and assess employees’ exposure (including duration, route, and frequency of exposure), and the number of exposed employees? If not, please explain. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section II: Worksite Analysis
B. Hazard Analysis of Routine Activities
B1. Is there at least a minimally effective hazard analysis system in place for routine operations and activities? MRX

		How Assessed
	Yes or No	Interview		Observation	Doc Review
Section II: Worksite Analysis
C. Routine Inspections
C1. Does the site have a minimally effective system for performing safety and health inspections (i.e., a minimally effective system identifies hazards associated with normal operations)? If not, please explain. MRX
C2. Are routine safety and health inspections conducted monthly, with the entire site covered at least quarterly ( construction sites: entire site weekly)? MRX
C3. For site-based construction sites, are employees required to conduct inspections as often as necessary, but not less than weekly, of their workplace/area and of equipment? MRX

			How Assessed
	Yes or No		Interview		Observation		Doc Review
Section II: Worksite Analysis
D. Hazard Reporting
D1. Is there a minimally effective means for employees to report hazards and have them addressed? If not, please explain. MRX

			How Assessed
	Yes or No		Interview		Observation		Doc Review
Section II: Worksite Analysis
E. Hazard Tracking
E1. Does a minimally effective hazard tracking system exist that result in hazards being controlled? If not, please explain. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section II: Worksite Analysis
F. Accident/Incident Investigations
F1. Is there a minimally effective system for conducting accident/incident investigations, including near-misses? If not, please explain. MRX

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section II: Worksite Analysis
G. Trend Analysis
G1. Does the site have a minimally effective means for identifying and assessing trends? MRX

Section II: Worksite Analysis

Merit Goals (Include cross- reference to section, subsection, and question, e.g., II.B2)

1.

2.

90-Day Items (Delete this section for final transmittal to National Office)

1.

2.

Best Practices

1.

2.

Comments including Recommendations (optional)

1.

2.

Documents Referenced, Programs Reviewed (optional)

1.

2.

			How Assessed
	Yes or No				Interview		Observation		Doc Review
Section III: Hazard Prevention and Control
A. Hazard Prevention and Control
A1. Does the site select at least minimally effective controls to prevent exposing employees to hazards? MRX
A2. Does the site have minimally effective written procedures for emergencies? MRX
A3. Is the site covered by the Process Safety Management standard (29 CFR 1910.119)? If yes, please answer questions A4-A7 below. Additionally, please complete either the onsite evaluation supplement A or B, and onsite evaluation supplement C. If not, skip to section B. MRX
A4. Which chemicals that trigger the Process Safety Management (PSM) standard are present? MRX
A5. Which process(es) were followed from beginning to end and used to verify answers to the questions asked in the PSM application supplement, the PSM Questionnaire, and/or the Dynamic Inspection Priority Lists? MRX
A6. Verify that contractor employees who perform maintenance, repair, turnaround, major renovation or specialty work on or adjacent to a covered process have received adequate training and demonstrate appropriate knowledge of hazards associated with PSM, such as non-routine tasks, process hazards, hot work, emergency evacuation procedures, etc.? Please explain. MRX
A7. Is the PSM program adequate in that it addresses the elements of the PSM standard and the PSM directive? Please explain. MRX

		How Assessed
	Yes or No		Interview	Observation	Doc Review
Section III: Hazard Prevention and Control
B. Recordkeeping
B1. Are OSHA required recordkeeping forms being maintained properly in terms of accuracy, form completion, etc.? If not, please explain. MRX
B2. Is the recordkeeper knowledgeable of 29 CFR 1904, OSHA’s recordkeeping standard? MRX
C. Do the injury and illness rates accurately reflect work performed by contractors/sub-contractors at the site evaluated? MRX

Section III: Hazard Prevention and Control

Merit Goals (Include cross reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items (Delete this section for final transmittal to National Office)

1.

2.

Best Practices

1.

2.

Comments including Recommendations (optional)

1.

2.

Documents Referenced, Programs Reviewed (optional)

1.

2.

		How Assessed
	Yes or No	Interview	Observation	Doc Review
Section IV: Safety and Health Training
A. Safety and Health Training
A1. Does the training provided to managers, supervisors, and non-supervisory employees (including contract employees) adequately address safety and health hazards? MRX
A2. Does the site provide minimally effective training to educate supervisors and employees (including contract employees) regarding the known hazards of the site and their controls? If not, please explain. MRX

Section IV: Safety and Health Training

Merit Goals (Include cross reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items (Delete this section for final transmittal to National Office)

1.

2.

Best Practices

1.

2.

Comments including Recommendations (optional)

1.

2.

Documents Referenced, Programs Reviewed (optional)

1.

2.

VPP Participant and Onsite Evaluation Team Data Sheet

VPP Participant Information:
Company Name:
Site Address:
Mailing Address:
Site Manager Name:
Site Manager Phone:			Site Manager E-mail Address:
VPP Contact Name: if same as Site Manager, state “same as above”
VPP Contact Phone:			VPP Contact E-mail Address:
Small Employer (<250 employees onsite AND <500 employees corporate-wide:  Yes_____ No_______
NAICS Code:		No. of site employees:			No. of site contract employees:
Union Information
Union Name & Local No.:
Site Representative:
Mailing Address:
Telephone Number:
Union Information
Union Name & Local No.:
Site Representative:
Mailing Address:
Telephone Number:
Onsite Evaluation Team Information:
Evaluation Start Date:			Evaluation End Date:
Type of Visit: Initial Approval: ____________ Reevaluation: ___________			Participation: Site-based: __________________ Mobile Workforce: ___________ Corporate: __________________
MAO Requested: Yes_____ No_______ If Yes, Date:		MAO Rec’d Before Onsite: Yes_____ No_______		Date MAO Rec’d:
90/30 Day Items: Yes_____ No_______			Date 90/30 Day Items Completed:
Team Members			Discipline of Members
Team Leader (TL): Back-Up Team Leader: Team Member 2: Team Member 3: Team Member 4: Team Member 5:			Team Leader: Back-Up Team Leader: Team Member 2/or indicate if SGE: Team Member 3/or indicate if SGE: Team Member 4/or indicate if SGE: Team Member 5/or indicate if SGE:

PARTICIPANT AREAS OF EXCELLENCE/BEST PRACTICES CHECKLIST
	Ergo Program		Confined Space Program		LO/TO Program
	PSM		Hazard Analysis		Contractor Program
	Medical Program		Self-Inspections		Accountability
	Industrial Hygiene		Employee Involvement		Tracking of Hazards
	Pre-Job Analysis		Other:      
STRATEGIC PLAN
High Hazard Industries
	Landscaping – 078		Oil/Gas – 138		Fruits/Vegetables 203
	Concrete/Gypsum/Plaster – 327		Blast Furnace/Steel Production – 331		Ship/Boat Building/Repair – 373
			Wholesale Storage – 422
Hazards
	Ergo		Lead		Silica
	Amputations – Construction		Amputations – General Industry

VPP CORPORATE TRACKING

	Application Review	Onsite Prep	Onsite	Report Writing	Total
Team Hours Spent (Est)