OSHA Voluntary Protection Program

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Purpose and Scope of Review

An onsite review was conducted from Date, at the City, State. The purpose of the evaluation was to determine the site's eligibility or continued eligibility for site-based participation in the Occupational Safety and Health Administration's (OSHA) Voluntary Protection Programs (VPP). NOTE: If C-FOP add the following language "This onsite review was conducted using the Corporate Facility Onsite Process (C-FOP)"The VPP Evaluation Team consisted of:

Name, Title, Office, City, State
Name, Title, Office, City, State
Name, Title, Office, City, State
Name, Title, Office, City, State
Name, Title, Office, City, State
Methods of Data Collection

The information for this report was obtained from the site's VPP Application, documentation reviewed onsite, interviews with employees, annual evaluations, and site walk-throughs of the facility.
Employees at the Worksite

There are XXX employees working on site. In addition, there are XXX contract employees onsite performing maintenance, capital projects, guard services, janitorial services, etc. Employees at the site are represented by the insert union name(s) and local(s). OR Employees at the site are not represented by a collective bargaining agent. Formal interviews were conducted with XX site employees and XX contract employees. Informal interviews were conducted with XXXsite employees and XXX contract employees.
The Worksite

The site is properly classified under North American Industrial Classification System (NAICS) code XXXXXX Provide a description of the site, e.g., size, location, operation, buildings, etc. Describe the site's processes, productions, and applications. Housekeeping at the facility was considered by the OSHA VPP team to be please select one: poor, fair, good or excellent.
Worksite Hazards

The hazards at the site include, but are not limited to . The site use chemicals considered to be highly hazardous and in sufficient quantity to place the site under the Process Safety Management (PSM) Standard.

Injury and Illness Rates

The three year Total Case Incidence Rate (TCIR) and Days Away/Restricted/Transferred Case Incidence Rate (DART) for the period 20XX-20XXare XX and XX, respectively. The site TCIR is XX% above/below, and the DART is XX% above/below the 20XX BLS industry average for NAICS code XXXXXX for 20XX.

Team leader must verify

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

OSHA Activity

There has been no OSHA inspection activity or fatalities at this site within the past XX years. The site maintains an excellent relationship with their local OSHA Area and Regional offices.
Elements of the VPP Review/Program Changes

Bullet summary information of VPP Elements with a reminder that all aspects of the safety and health management system meet the VPP requirements.
- 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

All elements of the site's safety and health management system met the high quality expected of VPP participants (or describe the program requirements that you considered an area of excellence).
Recommendation for Participation

The OSHA VPP Review Team recommends Site name, City, Statebe approved for participation in the OSHA VPP Star or Merit Program.
Goals
- Merit goals (if relevant)
- 1-Year Conditional goals (if relevant)
- Rate-reduction plan (if relevant)

Facility Onsite Process (C-FOP)
or
Compressed Reapproval Process (CRP)
Site Worksheet

Company Name
City, State

Onsite Evaluation Date
Month - Start/End Dates, 20xx

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
A. Written Safety & Health Management System
A1. Is the written safety and health management system at least minimally effective to address the scope and complexity of worksite hazards? If not, please explain. MRØ.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
B.Corporate Leadership & Commitment to Safety and Health
B1. Does management overall demonstrate at least minimally effective, visible leadership with respect to the safety and health management system (as per FRN, VOL. 74, NO. 6, 01/09/09 page 936, IV. A.5. a-h)? Provide examples MRØ.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
C. Planning
C1. For site-based construction sites, is safety included in the planning phase of each project? MRØ.

		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? (Top management acknowledges ultimate responsibility even if some safety and health functions are delegated to others.) If not, please explain. MRØ.

D2. 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.

D3. Are adequate resources (equipment, budget, or experts) dedicated to ensuring workplace safety and health? Provide examples. MRØ.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
E. Contract Employees
E1. Does the site's contractor program cover the prompt correction and control of hazards in the event that the contractor/sub-contractor fails to correct or control such hazards? Provide examples. MRØ.

E2. Based on your answers to the above item, 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. Do employees support the site's participation in the VPP? MRØ.

F2. Do employees feel free to participate in the safety and health management system without fear of discrimination or reprisal? If so, please explain. MRØ.

		How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No	Interview	Observation	Doc Review
G. Safety and Health Management System Evaluation
G1. Does the annual evaluation cover the aspects of the safety and health management system, including the elements described in the Federal Register? If not, please explain. MRØ.

Section I: Management Leadership and 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: (Delete this section for final transmittal to National Office)

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. 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. MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
B. Hazard Analysis of Routine Activities
B1. Is there at least a minimally effective hazard analysis system in place for routine operations and activities? MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
C. Routine Inspections
C1. 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.

C2. Are routine safety and health inspections conducted monthly, with the entire site covered at least quarterly ( construction sites: entire site weekly)? MRØ.

C3. For site-based construction sites, are employees required to conduct inspections as often as necessary, but not less than weekly, of their workplace/area and of equipment? MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
D. Hazard Reporting
D1. 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
E. Hazard Tracking
E1. Does a minimally effective hazard tracking system exist that result in hazards being controlled? If not, please explain. MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
F. Accident/Incident Investigations
F1. Is there a minimally effective system for conducting accident/incident investigations, including near-misses? If not, please explain. MRØ.

		How Assessed
Section II: Worksite Analysis	Yes or No	Interview	Observation	Doc Review
G. Trend Analysis
G1. Does the site have a minimally effective means for identifying and assessing trends? MRØ.

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. Does the site have minimally effective written procedures for emergencies MRØ.

A3. Is the site covered by the Process Safety Management standard (29 CFR 1910.119)? If yes, please answer questions A4-A7 below. Additionally, please complete either the onsite evaluation supplement A or B, and onsite evaluation supplement C. If not, skip to section B. MRØ.

A4. Which chemicals that trigger the Process Safety Management (PSM) standard are present? MRØ.

A5. 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.

A6. 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.

A7. Is the PSM program adequate in that it addresses the elements of the PSM standard and the PSM directive? Please explain. MRØ.

		How Assessed
Section III: Hazard Prevention and Control	Yes or No	Interview	Observation	Doc Review
B. Recordkeeping
B1. Are OSHA required recordkeeping forms being maintained properly in terms of accuracy, form completion, etc.? If not, please explain. MRØ.

B2. Is the recordkeeper knowledgeable of 29 CFR 1904, OSHA's recordkeeping standard? MRØ.

B3. Do the injury and illness rates accurately reflect work performed by contractors/sub-contractors at the site evaluated? MRØ.

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. Does the training provided to managers, supervisors, and non-supervisory employees (including contract employees) adequately address safety and health hazards? MRØ.

A2. Does the site provide minimally effective training to educate supervisors and employees (including contract employees) regarding the known hazards of the site and their controls? If not, please explain. MRØ.

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 Participant and Onsite Evaluation Team Data Sheet

VPP Participant Information:
Name of Company:
Site Address:
Mailing Address:
Site Manager Name:
Site Manager Phone:			Site Manager E-mail Address:
Small Employer (<250 employees onsite AND <500 employees corporate-wide: Yes_____ No_______
NAICS Code:	No. of site employees:				No. of site contract employees:
Union Information
Union Name & Local No.:
Site Representative:
Mailing Address:
Telephone Number:
Union Information
Union Name & Local No.:
Site Representative:
Mailing Address:
Telephone Number:
Onsite Evaluation Team Information:
Evaluation Start Date:			Evaluation End Date:
Type of Visit: Initial Approval: _________ Reevaluation: _________			Participation: Site-based: __________________ Mobile Workforce: ___________ Corporate: __________________
MAO Requested: Yes_____ No____ If Yes, Date:		MAO Rec'd Before Onsite: Yes_____ No_______		Date MAO Rec'd:
90/30 Day Items: Yes_____ No_______			Date 90/30 Day Items Completed:
Team Members			Discipline of Members
Team Leader (TL): Back-Up Team Leader: Team Member 2: Team Member 3: Team Member 4: Team Member 5:			Team Leader: Back-Up Team Leader: Team Member 2/SGE: Team Member 3/SGE: Team Member 4/SGE: Team Member 5/SGE:

PARTICIPANT AREAS OF EXCELLENCE/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)


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