Challenge Participant

CHALLENGE CANDIDATE APPLICATION AND INSTRUCTIONS

1. Complete the Challenge candidate application.

2. Write and sign a Challenge candidate statement of commitment. A sample letter of commitment is at the end of this application.

3. To submit electronically, attach the completed Challenge candidate application and a scanned copy of the signed Challenge participant statement of commitment to an email and send it to your Challenge Administrator.

To submit via hard copy, send the completed Challenge candidate application and the signed Challenge participant statement of commitment to your Challenge Administrator. All Challenge Administrators’ addresses can be found on the OSHA Challenge Web page (http://www.osha.gov/dcsp/vpp/challenge.html) under “Find a Challenge Administrator.”

If you have questions about OSHA Challenge or the Challenge candidate application process, please contact the Office of Partnerships and Recognition (http://www.osha.gov/dcsp/opr/index.html) at 202-693-2213.

OMB Control Number: 1218-0239 Expires 01-31-2018

Public reporting burden for this collection of information 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Cooperative and State Program U.S. Department of Labor, 200 Constitution Ave., Suite N3700 NW, Washington, DC 20210-4537 and reference the OMB Control Number 1218-0239

Challenge Participant Application
Challenge Participant Applicant
Site Address
Site Manager Name
Site Manager Title
Company/Corporate Name (if different from above)
Company/Corporate Address (if different from above)
Challenge Participant Applicant Contact Name
Challenge Participant Applicant Contact Title
Challenge Participant Applicant Contact Phone Number
Challenge Participant Applicant Contact E-mail Address
Union Name and Local #
Union Address (if different from above)
Union Representative’s Name
Union Representative’s Phone Number
Union Representative’s Fax Number
Union Representative’s E-mail Address
Number of Employees
Number of Contract Employees
SIC
NAICS

Baseline Injury and Illness Information

Challenge Participant Applicant OSHA 300 Log Totals for Calendar Year

G

H

I

J

K

L

M:1

M:2

M:3

M:4

M:5

M:6

Total Hours Worked		Total # of Employees
TCIR		DART

To Calculate TCIR:

(Columns H +I + J) x 200,000 = TCIR

Total Hours Worked

To Calculate DART:

(Columns H + I) x 200,000 = DART

Total Hours Worked

Challenge Participant Applicant

Statement of Commitment

<Date>

In our mission to produce high quality products and services, we, <Challenge Participant Applicant>, value our employees as our greatest assets and we are committed to providing a safe workplace for them. We assure you that <Challenge Participant Applicant> is committed to successfully completing OSHA Challenge and developing an effective safety and health management program. We will provide the necessary data and documentation to our challenge Administrator, <organization name>, and keep them informed of our progress. We also will involve our employees in OSHA Challenge. We are excited to be involved in voluntary efforts with OSHA and look forward to reaching our goals.

Attached please find our Challenge participant application. Should you have any questions or need additional information, please contact me at <Challenge Participant Applicant telephone number> or <Challenge Participant Applicant email address>.

Signature

<Challenge Participant Applicant name>

<Challenge Participant Applicant title>

<Challenge Participant Applicant>

OSHA Challenge Participant Application – revised 040213