OSHA 12-10.4 Regional Alliance Annual Report Template

OMB No. 1218-XXXX Exp. Date: xx/xx/2022

ALLIANCE ANNUAL REPORT

Regional/Area Office Alliances

The Occupational Safety and Health Administration (OSHA)

and [Alliance Participant]

[Date of Report]

1. Alliance Background

1.  Date Signed

 [Initial signing date]

2. Dates Renewed

 [Renewal date. If Alliance has been renewed more than once, use a bulleted list. If alliance has not been

renewed yet, you may delete this section.]

3. Evaluation Period

[Opening date – Closing date]

4. Alliance Overview and Goals

[Brief summary of the purpose and scope of the Alliance – from the Alliance agreement.]

II. Implementation Team Meetings

• [Date]

• [Date]

In addition to these formal meetings, the Alliance coordinators from both groups maintained regular contact throughout the reporting period to monitor the Alliance’s progress and results.

III. Results of Alliance Activities in Support of Agreement Goals

Dissemination: Alliance Program participant shared information on OSHA-developed or OSHA Alliance Program-developed tools and resources, OSHA standards/rulemakings, enforcement, or outreach campaigns.

Dissemination Type	Date	Description	Emphasis Area(s)*	Number Reached (numeric value)	Additional Information (Optional)

Outreach Events and Training for non-OSHA Staff: Alliance Program participant or OSHA participation in events which includes speeches/presentations, exhibits, roundtables, conferences, informational webinars or other meetings or training in support of the Alliance or an OSHA initiative.

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

Training for OSHA Staff: Alliance Program participant provided training or assistance in training OSHA and OSHA-affiliated staff (including 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 (numeric value)	Additional Information (Optional)

1. Alliance Developed Products

[List any Alliance products developed by the Alliance Program participants during the timeframe of the reporting period. If none, you may delete this section.]

Report prepared by: [Alliance Coordinator, title, Office, date].

*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 Alliance Annual Reports for Field Alliances. Alliance participants may be required to use this template or to review a completed template, with assistance from OSHA personnel. OSHA uses this report to assess the effectiveness of the individual Alliance, as well as the impact of the overall Alliance Program. 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 report is voluntary. The template ensures that Alliance participants provide required information about Alliance activities to OSHA. OSHA estimates employer burden for the completion of this collection of information ranges from 3 to 5 hours, with an average of 4 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 Directorate of Cooperative and State Programs, Office of Outreach Services and Alliances, 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

OSHA 12-10.4