Instructions: This form serves as a template to collect and share the Success Stories and Best
Practices of OSHA's cooperative program participants. The form can be completed by OSHA staff or
cooperative program participants. Please note that any information submitted may be posted to OSHA's
public web page or used in other outreach activities. Once completed, this form should be submitted
as follows:
OSHA Staff: Submit electronically to your respective National Office Liaison
Program Participants: E-mail submissions directly to
Danielle Gibbs in OSHA's
Directorate of Cooperative and State Programs.
TO BEGIN, check the appropriate boxes and fill in the yellow highlighted areas.
I. GENERAL INFORMATION: __ VPP __ Partnership Date Submitted:
______________
|
__ |
Success Story – May include such things as reductions
in illness and injury rates, workers compensation savings, TCIR and DART rates. Other stories may
be anecdotal and include employee morale, management commitment, increased productivity, human
interest stories, and the overall impact that VPP has had on the organization. These improvements
must be related to participation in an OSHA cooperative program.
|
|
__ |
Best Practice – An innovative and effective method or
system for improving worker safety and health that has produced superior results. (Example:
Changing work processes to reduce ergonomic injuries, which also have the effect of improving
employee morale and cutting workers' compensation costs.) |
| Submitted By |
Company/Agency Name |
Email |
Phone |
| |
|
|
|
II. Quantitative Results Data - (complete only if submitting a quantitative
success story; i.e. rate reductions)
Provide as much information as possible for the most recent three year period:
| |
*TCIR |
**DART |
Fatalities |
Workers Compensation $ |
Insurance EMR Rate |
| Year 1: |
|
|
|
|
|
| Year 2: |
|
|
|
|
|
| Year 3: |
|
|
|
|
|
| 3-Year Rate (Avg.) |
|
|
|
|
|
| BLS Industry National Average for most recent year |
|
|
|
|
|
|
|
| # employees covered at the site: |
|
|
* TCIR: (Total Case Incident Rate) = (# of injuries x 200,000) / total hours worked
** DART: (Days Away, Restricted, Time away) = (# of lost time injuries x 200,000) / total hours
worked
III. Success Story or Best Practice Narrative
Summarize the Success Story or Best Practice in three to four paragraphs, including as much
information as possible. You may also cut and paste a news story, please include a link (if
possible), the source and date. If submitting a success story, please categorize your story by
checking the appropriate box below, followed by your narrative.
__ Quantitative (ex: reductions in Illness and injury rates; workers compensation savings)
__ Anecdotal/Human Interest (ex: employee morale; mgmt commitment; employee involvement)
__ Quote (quotes from employees, management, corporate leadership, union officials)
|
Back to Top
Printing Instructions
