OSHA 12-10.7 Biannual Alliance Data Reporting Form

OMB No. 1218-XXXX

Exp. Date: xx/xx/2022

Instructions

Please complete this form biannually (twice per year) and submit to your Alliance Coordinator. In the first column, please select the item from the drop-down menu that most appropriately describes the activity. In the Emphasis Areas column, please specify the applicable Area(s) of Emphasis, using ONLY those Areas listed at the end of this form. Add additional rows as needed. If you have any questions, please contact your Alliance Coordinator.

Report Due Dates:

• April 15 (for Q1&2)

• October 15 (for Q3&4)

Alliance Name:

Reporting Period: ☐Q1&2: October 1-March 31 ☐Q3&4: April 1-September 30 Fiscal Year:

Emerging Safety and Health Trends in the Industry? ☐Yes ☐No

If yes, please describe:

Dissemination

Please list instances when an Alliance Program participant shared information on agency-developed or OSHA Alliance Program-developed tools and resources, OSHA standards/rulemakings, enforcement, and outreach campaigns. Webpage hits should only be reported in the second biannual reporting form for the FY (due October 15).

Dissemination Type	Date	Description	Emphasis Area(s)*	Number Reached (input numeric value only)	Additional Information (Optional)
	10/1/17- 9/30/18	Alliance Webpage-Participant Website		[Enter in October with total for FY]

Outreach Events and Training for non-OSHA Staff

Please list instances when an Alliance Program participant or OSHA representative participated in an event such as a roundtable, conference, informational webinar, stand-down, meeting, or training in support of the Alliance or an OSHA initiative. This includes speeches/presentations and exhibit booths.

Activity Type	Date	Event Name	Representative Name(s) and Affiliation(s)	Title of Presentation (if applicable)	City	State	Emphasis Area(s)*	Number Reached (input numeric value only)	Additional Information (Optional)

Training for OSHA Staff

Please list instances when an Alliance Program participant provided training or assistance in training OSHA and/or OSHA-affiliated staff (e.g., State Plan and/or On-Site Consultation Program representatives).

Training Type	Date	Name/Title of Trainer	Training Title	Audience: OSHA/ State Plan/ Consultation	City	State	Emphasis Area(s)*	Number Reached (input numeric value only)	Additional Information (Optional)

*Please Select From The Following Emphasis Areas: (Emphasis areas are tied to OSHA’s Operating Plan, DOL’s Strategic Plan, and agency/departmental initiatives; they are updated annually. Use only Areas listed below. If none apply, leave blank. More than one can be included; please input them in alphabetical order.)

• Agriculture

• Beryllium

• Construction

• Emergency Response/ Recovery

• Fall Prevention

• Fall Stand-Down

• Healthcare

• Heat Illness Prevention

• Oil and Gas

• Recordkeeping/Reporting

• Safety & Health Programs

• Safe + Sound Week

• Silica

• Small Business

• Temporary Workers

• Telecommunications Towers

• Trenching

• Walking-Working Surfaces

• Young Workers

PAPERWORK REDUCTION ACT STATEMENT

OSHA’s Alliance Program requires completion of this form by its national Alliance participants twice a year for submission to OSHA. Under the Paperwork Reduction Act, a Federal agency generally cannot conduct or sponsor, and the public is generally not required to respond to, an information collection, unless it is approved by OMB and displays a valid OMB Control Number. Use of this form is voluntary. The template ensures that national Alliance participants provide required information about Alliance activities to OSHA. OSHA estimates employer burden for the completion of this collection of information ranges from 6 to 10 hours, with an average of 8 hours. This estimate includes the 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 [email protected] or to OSHA’s Alliance Office, Directorate of Cooperative and State Programs, Department of Labor, Room N-3662, 200 Constitution Ave., NW, Washington, DC 20210; Attn: Paperwork Reduction Act Comment. 1218-XXXX (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED TEMPLATES TO THIS OFFICE IN THIS MANNER.)

OMB Approval# 1218-xxxx; Expires: 00-00-0000

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OSHA 12-10.7