| Dissemination |
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| Field |
Instructions |
| Dissemination Type |
Select one from dropdown |
| Start Date |
Enter date for single-day event or start date for multi-day activity |
| End Date |
Enter end date for multi-day activity |
| Description |
Self explanatory |
| Emphasis Areas |
Select at least one or multiple from dropdown. If "Other" is selected, please provide description in "If other, please specify" column. |
| If Other, please specify |
Specify if "Other" is selected as "Emphasis Areas" |
| # Reached |
Enter just a number (no units). Units or other information can be specified in the "Additional Information" column. |
| Additional Information |
Can enter units for number reached. |
| Outreach Events and Training for non-OSHA Staff |
| Field |
Instructions |
| Activity Type |
Select one from dropdown |
| Start Date |
Enter date for single-day event or start date for multi-day activity |
| End Date |
Enter end date for multi-day activity |
| Event Name |
Self explanatory |
| Representative Name |
Self explanatory |
| Representative Affiliation |
Self explanatory |
| Presentation Title |
Self explanatory |
| City |
Self explanatory |
| State |
Select from dropdown |
| Emphasis Areas |
Select at least one or multiple from dropdown. If "Other" is selected, please provide description in "If other, please specify" column. |
| If other, please specify |
Specify if "Other" is selected as "Emphasis Areas" |
| # Reached |
Enter just a number (no units). Units or other information can be specified in the "Additional Information" column. |
| Additional Information |
Can enter units for number reached. |
| Training for OSHA Staff |
| Field |
Instructions |
| Training Type |
Select one from dropdown |
| Start Date |
Enter date for single-day event or start date for multi-day activity |
| End Date |
Enter end date for multi-day activity |
| Trainer Name/Title |
Self explanatory |
| Training Title |
Self explanatory |
| Audience |
Specify groups that received training (OSHA/State Plan/Consultation staff) |
| City |
Self explanatory |
| State |
Select from dropdown |
| Emphasis Areas |
Select at least one or multiple from dropdown. If "Other" is selected, please provide description in "If other, please specify" column. |
| If other, please specify |
Specify if "Other" is selected as "Emphasis Areas" |
| # Reached |
Self explanatory |
| Additional Information |
Self explanatory |
| Biannual Alliance Data Reporting Form |
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| OSHA Form 12-10.7 |
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| Please complete this form biannually (twice per year) and submit to your Alliance Coordinator. |
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| Alliance Name: |
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| Reporting Period: (check one) |
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| Q1&Q2: October 1-March 31 |
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| Q3&Q4: April 1-September 30 |
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| Report Due Dates: |
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| Q1&Q2 report: April 15 |
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| Q3&Q4 report: October 15 |
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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. 1218-0274 (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED TEMPLATES TO THIS OFFICE IN THIS MANNER.)
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| OMB Approval# 1218-0274; Expires: 02-28-2023 |