OSHA Voluntary Protection Program > Report and Worksheet Template

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VPP SITE REPORT
Recommending
STAR APPROVAL
for

Company Name
City, State

Month X, 20xx

Report Date
Month X, 20xx

Evaluation Team
Name, Team Leader
Name, Backup Team Leader
Name, Safety Specialist
Name, Hygienist
Name, SGE

Purpose and Scope of Review

Name
Location
Date of evaluation
Purpose of evaluation (Star approval, Merit approval, Demo approval)
VPP Team Members
VPP Volunteers

Methods of Data Collection

Information on which report is based (application, previous reports, walkthrough, on site documentation, etc.)

Employees at the Worksite

Number of employees
Contract employees and/or temporary employees
Collective bargaining agent(s) representing the employees
Number of interviews conducted with different types of employees

The Worksite

NAICS and SIC Codes
Description (one location or many, acreage, age, primary structures, etc.)
Basic description of processes, products, and applications
Housekeeping

Worksite Hazards

Site hazards
Covered under Process Safety Management
- Provide a brief description of how the questions from the PSM application supplement, PSM Questionnaire, and/or the Dynamic Inspection Priority Lists most applicable to the site were asked and verified.

Injury and Illness Rates

Rates - TCIR, DART
Comparisons to BLS industry averages

OSHA Activity

Prior OSHA inspection activity
Relationship with OSHA

Elements of the VPP Review/Program Changes

Bulleted summary of VPP Elements with a reminder that all aspects of the Safety and Health program meet the VPP requirements as set forth in CSP (Refer to the VPP Site Worksheet for specifics).
- Management, Leadership, and Employee Involvement
- Worksite Analysis
- Hazard Prevention and Control
- Safety & Health Training
For Reapproval evaluations, discuss significant program or site changes since the last visit. A bulleted list is acceptable.

Areas of Excellence

Bulleted list and description of best practices (e.g., machine guarding, ergonomics, lockout/tagout, employee involvement)

Recommendation for Participation

Recommendation

Goals

Merit goals (if relevant)
1-Year Conditional goals (if relevant)

A review of the OSHA 300 logs was made. The following are the total incidence and lost workday case rates since 20XX:

Year	Hours	Total # of Cases	TCIR	Number of Cases Involving Days Away from Work, Restricted Activity or Job Transfer	DART Rate
20xx
20xx
20xx
1999
Total
Three-Year Rate (20xx-20xx)
BLS National Average for 20xx (NAICS XXXXXX)
20xx YTD

For the period 20xx-20xx, the site's:

Total Case Incidence Rate (TCIR) is X.X (XX% above/below the 20xx BLS industry averages for NAICS XXXXXX).
The Days Away from Work, Restricted Activity or Job Transfer (DART) case incidence rate is X.X (XX% above/below the 20xx BLS industry averages for NAICS XXXXXX).

The information on the OSHA 300 Logs supports the information provided in the application, and the company's first report of injury forms support the data in the logs. The [Company, Position Title] is responsible for the entries to the OSHA 300 Log and verified the accuracy of the records. The [Position Title] understands the recordkeeping requirements. Based upon interviews conducted with management and employees, the logs accurately reflect the injury and illness experience at this plant.

There [were/were not] temporary employees at the worksite at the time of the team's visit. Injuries or illnesses experienced by temporary employees under the direct supervision of [Company] are recorded on the worksite's OSHA 300 Log. There were X temporary employee injuries recorded on the worksite's OSHA 300 Log for 20xx.

VPP SITE WORKSHEET
Recommending
STAR APPROVAL
for
Company Name
City, State

Evaluation Date
Month x, 20xx

Report Date
Month x, 20xx

Evaluation Team
Name, Team Leader
Name, Backup Team Leader
Name, Safety Specialist
Name, Hygienist
Name, SGE

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
A. Written Safety & Health Management System
A1. Are all the elements (such as Management Leadership and Employee Involvement, Worksite Analysis, Hazard Prevention and Control, and Safety and Health Training) and sub-elements of a basic safety and health management system part of a signed, written document? (For Federal Agencies, include 29 CFR 1960.) If not, please explain.

A2. Have all VPP elements and sub-elements been in place at least 1 year? If not, please identify those elements that have not been in place for at least 1 year.

A3. Is the written safety and health management system at least minimally effective to address the scope and complexity of the hazards at the site? (Smaller, less complex sites require a less complex system.) If not, please explain. MRØ.

A4. Have any VPP documentation requirements been waived (as per FRN page 656, paragraph F5a4)? If so, please explain.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
B. Management Commitment & Leadership
B1. Does management overall demonstrate at least minimally effective, visible leadership with respect to the safety and health program (considering FRN items F5 A-H)? Provide examples. MRØ.

B2. How has the site communicated established policies and results-oriented goals and objectives for employee safety to employees?

B3. Do employees understand the goals and objectives for the safety and health program?

B4. Are the safety and health program goals and objectives meaningful and attainable? Provide examples supporting the meaningfulness and attainability (or lack there of if answer is no) of the goal(s). (Attainability can either be unrealistic/realistic goals or poor/good implementation to achieve them.) (See: TED Chapter 3 II C1a)

B5. How does the site measure its progress towards the safety and health program goals and objectives? Provide examples.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
C. Planning
C1. How does the site integrate planning for safety and health with its overall management planning process (for example, budget development, resource allocation, or training)?

C2. Is safety and health effectively integrated into the site's overall management planning process? If not, please explain.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
D. Authority and Line Accountability
D1. Does top management accept ultimate responsibility for safety and health in the organization? (Top management acknowledges ultimate responsibility even if some safety and health functions are delegated to others.) If not, please explain. MRØ.

D2. How is the assignment of authority and responsibility documented and communicated (for example, organization charts, job descriptions)?

D3. Do the individuals assigned responsibility for safety and health have the authority to ensure that hazards are corrected or necessary changes to the safety and health management system are made? If not, please explain. MRØ.

D4. How are managers, supervisors, and employees held accountable for meeting their responsibilities for workplace safety and health? (Annual performance evaluations for managers and supervisors are required.)

D5. Are adequate resources (equipment, budget, or experts) dedicated to ensuring workplace safety and health? Provide examples. MRØ.

D6. Is access to experts (for example, Certified Industrial Hygienists, Certified Safety Professionals, Occupational Nurses, or Engineers), reasonably available to the site, based upon the nature, conditions, complexity, and hazards of the site? If so, under what arrangements and how often are they used?

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
E. Contract Employees
E1. Does the site utilize contractors? Please explain.

E2. Were there contractors onsite at the time of the evaluation?

E3. When selecting onsite contractors, how does the site evaluate the contractor's safety and health programs and performance (including rates)? (See: TED Chapter 3 IV 3-19)

E4. Are contractors and subcontractors at the site to maintain effective safety and health programs and to comply with all applicable OSHA and company safety and health rules and regulations? If so, please provide examples.

E5. Does the site's contractor program cover the prompt correction and control of hazards in the event that the contractor fails to correct or control such hazards? Provide examples. MRØ.

E6. How does the site document and communicate oversight, coordination, and enforcement of safety and health expectations to contractors?

E7. Have the contract provisions specifying penalties for safety and health issues been enforced, when appropriate? If not, please explain.

E8. How does the site monitor the quality of the safety and health protection of its contract employees?

E9. If the contractors' injury and illness rates are above the average for their industries, does the site have procedures that ensure that all employees are provided effective protection on the worksite? If not, please explain.

E10. Do contract provisions for contractors require the periodic review and analysis of injury and illness data? Provide examples.

E11. Based on your answers to the above items, is the contract oversight minimally effective for the nature of the site? (Inadequate oversight is indicated by significant hazards created by the contractor, employees exposed to hazards, or a lack of host audits.) If not, please explain. MRØ.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
F. Employee Involvement
F1. How were employees selected to be interviewed by the VPP team?

F2. How many employees were interviewed formally? How many were interviewed informally

F3. Do employees support the site's participation in the VPP Process? MRØ.

F4. Do employees feel free to participate in the safety and health management system without fear of discrimination or reprisal? If so, please explain. MRØ.

F5. Please describe at least three ways in which employees are meaningfully involved in the problem identification and resolution, or evaluation of the safety and health program (beyond hazard reporting). (See: FRN Chapter 3 Paragraph II.C.1.b)

F6. Are employees knowledgeable about the site's safety and health management system? If not, please explain.

F7. Are employees knowledgeable about the VPP program? If not, please explain.

F8. Are the employees knowledgeable about OSHA rights and responsibilities? If not, please explain.

F9. Do employees have access to results of self-inspection, accident investigation, appropriate medical records, and personal sampling data upon request? If not, please explain.

Section I: Management Leadership & Employee Involvement

Merit Goals: (Include cross- reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations (optional):

1.

2.

Documents Referenced, Programs Reviewed (optional):

1.

2.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
A. Baseline Hazard Analysis
A1. Has the site been at least minimally effective at identifying and documenting the common safety and health hazards associated with the site (such as those found in OSHA regulations, building standards, etc., and for which existing controls are well known)? If not, please explain. MRØ.

A2. What methods are used in the baseline hazard analysis to identify health hazards? (Please include examples of instances when initial screening and full-shift sampling were used. See FRN page 45657, F5.B.2.b )

A3. Does the site have a documented sampling strategy used to identify health hazards and assess employees' exposure (including duration, route, and frequency of exposure), and the number of exposed employees? If not, please explain.

A4. Do sampling, testing, and analysis follow nationally recognized procedures? If not, please explain.

A5. Does the site compare sampling results to the minimum exposure limits or are more restrictive exposure limits (PELs, TLVs, etc.) used? Please explain.

A6. Does the baseline hazard analysis adequately identify hazards (including health) that need further analysis? If not, please explain.

A7. Do industrial hygiene sampling data, such as initial screening or full shift sampling data, indicate that records are being kept in logical order and include all sampling information (for example, sampling time, date, employee, job title, concentrated measures, and calculations)? If not, please explain the deficiencies and how they are being addressed.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
B. Hazard Analysis of Significant Changes
B1. When purchasing new materials or equipment, or implementing new processes, what types of analyses are performed to determine their impact on safety and health? Is it adequate?

B2. When implementing/introducing non-routine tasks, materials or equipment, or modifying processes, what types of analyses are performed to determine their impact on safety and health? Is it adequate?

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
C. Hazard Analysis of Routine Activities
C1. Is there at least a minimally effective hazard analysis system in place for routine operations and activities? MRØ.

C2. Does hazard identification and analysis address both safety and health hazards, if appropriate? If not, please explain.

C3. What hazard analysis technique(s) are employed for routine operations and activities (e.g., job hazard analysis, HAZ-OPS, fault trees)? Are they adequate?

C4. Are the results of the hazard analysis of routine activities adequately documented? If not, please explain.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
D. Routine Inspections
D1. Does the site have a minimally effective system for performing safety and health inspections (i.e., a minimally effective system identifies hazards associated with normal operations)? If not, please explain. MRØ.

D2. Are routine safety and health inspections conducted monthly, with the entire site covered at least quarterly (for construction: entire site weekly)?

D3. How do inspections use information discovered through the baseline hazards analysis, job hazard analysis, accident/incident analysis, employee concerns, sampling results, etc.?

D4. Are those personnel conducting inspections adequately trained in hazard identification? If not, please explain.

D5. Is the routine inspection system written, including documentation of results? If not, please explain.

D6. Do the written routine inspection reports clearly indicate what needs to be corrected, by whom, and by when? If not, please explain.

D7. Did the VPP team find hazards that should have been found through self-inspection? If so, please explain.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
E. Hazard Reporting
E1. Does the site have a reliable system for employees to notify appropriate management personnel in writing about safety and health concerns? Please describe.

E2. Do the employees agree that they have an effective system for reporting safety and health concerns? If not, please explain.

E3. Is there a minimally effective means for employees to report hazards and have them addressed? If not, please explain. MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
F. Hazard Tracking
F1. Does the hazard tracking system address hazards found by employees, hazard analysis of routine and non-routine activities, inspections, and accident or incident investigations? If not, please explain.

F2. Does the tracking system result in hazards being corrected and provide feedback to employees for hazards they have reported. If not, please explain.

F3. Does the tracking system result in timely correction of hazards with interim protection established when needed? Please describe.

F4. Does a minimally effective tracking system exist that results in hazards being controlled? If not, please explain. MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
G. Accident/Incident Investigations
G1. Is there a minimally effective system for conducting accident/incident investigations, including near-misses? If not, please explain. MRØ.

G2. Are those conducting the investigations trained in accident/incident investigation techniques? If not, please explain.

G3. Describe how investigations discover and document all the contributing factors that led to an accident/incident.

G4. Were any hazards discovered during the investigation previously addressed in any prior hazard analyses (e.g., baseline, self-inspection)? If not, please explain.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
H. Safety and Health Program Evaluation
H1. Briefly describe the system in place for conducting an annual evaluation.

H2. Does the annual evaluation cover the aspects of the safety and health program, including the elements described in the Federal Register? If not, please explain.

H3. Does the annual evaluation include written recommendations in a narrative format? If not, please explain.

H4. Is the annual evaluation an effective tool for assessing the success of the site's safety and health system? Please explain.

H5. What evidence demonstrates that the site responded adequately to the recommendations made in the annual evaluation?

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
I. Trend Analysis
I1. Does the site have a minimally effective means for identifying and assessing trends? MRØ.

I2. Have there been any injury and/or illness trends over the last three years? If so, please explain.

I3. If there have been injury and/or illness trends, what courses of action have been taken? Are they adequate?

I4. Does the site assess trends utilizing data from hazard reports or accident/incident investigations to determine the potential for injuries and illnesses? If not, please explain.

Section II: Worksite Analysis

Merit Goals: (Include cross- reference to section, subsection, and question, e.g., II.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations (optional):

1.

2.

Documents Referenced, Programs Reviewed (optional):

1.

2.

		How Assessed
Section III: Hazard Prevention and Control	Yes or No	Interview	Observation	Doc Review
A. Hazard Prevention and Control
A1. Does the site select at least minimally effective controls to prevent exposing employees to hazards. MRØ.

A2. When the site selects hazard controls, does it follow the preferred hierarchy (engineering controls, administrative controls, work practice controls [e.g., lockout/tagout, bloodborne pathogens, and confined space programs], and personal protective equipment) to eliminate or control hazards? Please provide examples, such as how exposures to health hazards were controlled.

A3. Describe any administrative controls used at the site to limit employee exposure to hazards (for example, job rotation).

A4. Do the work practice controls and administrative controls adequately address those hazards not covered by engineering or administrative controls? If not, please explain.

A5. Are the work practice controls (e.g., lockout/tagout, bloodborn pathogens, and confined space programs) recommended by hazard analyses implemented at the site? If not, please explain.

A6. Are follow-up studies (where appropriate) conducted to ensure that hazard controls were adequate? If not, please explain.

A7. Are hazard controls documented and addressed in appropriate procedures, safety and health rules, inspections, training, etc.? Provide examples.

A8. Are there written employee safety procedures including a disciplinary system? Describe the disciplinary system.

A9. Has the disciplinary system been enforced equally for both management and employees, when appropriate? If not, please explain.

A10. Does the site have minimally effective written procedures for emergencies (TED 3-16 3h)? MRØ.

A11. Are emergency drills held at least annually?

A12. Does the site have a written preventative/predictive maintenance system? If not, please explain.

A13. Did the hazard identification and analysis (including manufacturers' recommendations) identify hazards that could result if equipment is not maintained properly? If not, please explain.

A14. Does the preventive maintenance system adequately detect hazardous failures before they occur? If not, please explain.

A15. How does the site select Personal Protective Equipment (PPE)?

A16. Do employees understand the limitations and uses of PPE? If not, please explain.

A17. Did the team observe employees using, storing, and maintaining PPE properly? If not, please explain.

A18. Is the site covered by the Process Safety Management standard (29 CFR 1910.119)? If yes, please answer questions A19-A21 below. Additionally, please complete either onsite evaluation supplement A or B, and onsite evaluation supplement C. If not, skip to section B. MRØ.

A19. Which chemicals that trigger the Process Safety Management (PSM) standard are present? MRØ.

A20. Which process(es) were followed from beginning to end and used to verify answers to the questions asked in the PSM application supplement, the PSM Questionnaire, and/or the Dynamic Inspection Priority Lists? MRØ.

A21. Verify that contractor employees who perform maintenance, repair, turnaround, major renovation or specialty work on or adjacent to a covered process have received adequate training and demonstrate appropriate knowledge of hazards associated with PSM, such as non-routine tasks, process hazards, hot work, emergency evacuation procedures, etc.? Please explain. MRØ.

		How Assessed
Section III: Hazard Prevention and Control	Yes or No	Interview	Observation	Doc Review
B. Occupational Health Care Program and Recordkeeping
B1. Describe the occupational health care program (including availability of physician services, first aid, and CPR/AED) and special programs such as audiograms or other medical tests used.

B2. How are licensed occupational health professionals used in the site's hazard identification and analysis, early recognition and treatment of illness and injury, and the system for limiting the severity of harm that might result from workplace illness or injury? Is this use appropriate?

B3. Is the occupational health program adequate for the size and location of the site, as well as the nature of hazards found here? If not, please explain.

Section III: Hazard Prevention and Control

Merit Goals: (Include cross- reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations (optional):

1.

2.

Documents Referenced, Programs Reviewed (optional):

1.

2.

		How Assessed
Section IV: Safety and Health Training	Yes or No	Interview	Observation	Doc Review
A. Safety and Health Training
A1. What are the safety and health training requirements for managers, supervisors, employees, and contractors?

A2. Who delivers the training?

A3. How are the safety and health training needs for employees determined?

A4. Does the site provide minimally effective training to educate employees regarding the known hazards of the site and their controls? If not, please explain. MRØ.

A5. What system is in place to ensure that all employees and contractors have received and understand the appropriate training?

A6. Who is trained in hazard identification and analysis?

A7. Is training in hazard identification and analysis adequate for the conditions and hazards of the site? If not, please explain.

A8. Does management have a thorough understanding of the hazards of the site? Provide examples that demonstrate their understanding.

Section IV: Safety and Health Training

Merit Goals: (Include cross- reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations (optional):

1.

2.

Documents Referenced, Programs Reviewed (optional):

1.

2.

VPP TEAM COMPOSITION DATA SHEET

Name of Company:

Site Address:

Small Employer (<250 employees onsite AND < 500 employees corporate- wide):

Region:

Dates of Onsite: mm/dd/yy - mm/dd/yy

Check One:

Preapproval Visit:

Evaluation Visit:

Report Drafted Onsite:

Yes:

No:

90-Day Items

Date Completed:

06/06/06

TEAM COMPOSITION
NAME	ID	ROLE	SGE
		Team Leader

BEST PRACTICES CHECKLIST

Ergo Program

Confined Space Program

LO/TO Program

PSM

Hazard Analysis

Contractor Program

Medical Program

Self-Inspections

Accountability

Industrial Hygiene

Employee Involvement

Tracking of Hazards

Pre-Job Analysis

Other:

STRATEGIC PLAN

High Hazard Industries

Landscaping – 078

Oil/Gas – 138

Fruits/Vegetables 203

Concrete/Gypsum/Plaster – 327

Blast Furnace/Steel Production – 331

Ship/Boat Building/Repair – 373

Wholesale Storage – 422

Hazards

Ergo

Lead

Silica

Amputations – Construction

Amputations – General Industry

VPP Corporate Tracking

	Application Review	Onsite Prep	Onsite	Report Writing	Total
Team Hours Spent (Est)

Site Information
Company Name:
Legal Name:
Mailing Address:
VPP Contact:
Site Contact Phone:
E-Mail Address:
NAICS Code for the Site: Number of employees at the Site: Number of Contractor employees at the Site: 0
Program Status:
Audit Dates:		Report Date:
Team Leader: Team Member 2: Team Member 3: Team Member 4: Team Member 5:		TL Discipline: TM2 Discipline: TM3 Discipline: TM4 Discipline: TM5 Discipline:
Three years used to calculate Injury/Illness Rates: Year of most current BLS Rates:
Union Information
Union Name:	NA
Local Number:
Site Representative:
Mailing Address:
Telephone Number:
Fax Number:
E-Mail Address:
Union Information
Union Name:	NA
Local Number:
Site Representative:
Mailing Address:
Telephone Number:
Fax Number:
E-Mail Address:

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