OMB No. 1218-0274
Exp. Date: 02/28/2023
OSHA 12-10.6

ARRANGEMENT ESTABLISHING AN ALLIANCE
BETWEEN
THE U.S. DEPARTMENT OF LABOR’S
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
<SPECIFY OFFICE(S) (e.g., XXX Regional Office)>
AND
<ORGANIZATION NAME(S) (e.g., Consulate General of XXX) >

[The opening paragraphs and overall goals may be modified to reflect the specifics of the Alliance, but in general should fit this model.]

The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) <Specific Office(s) (e.g., xxx Regional Office> and <Organization Name(s) (e.g., Consulate General of xxx)>, hereinafter referred to collectively as “the Participants;”

[In the event the Alliance is with one or more Consulates that are party to a Letter of Arrangement with OSHA (Currently this includes Costa Rica, Dominican Republic, El Salvador, Guatemala, and Nicaragua), please complete and include the paragraph below.]

Recognizing the joint commitment to protect workers’ rights for <insert name (e.g. Philippine)> workers acknowledged in the Letter of Arrangement between the Occupational Safety and Health Administration of the United States of America and the Ministry of Foreign Affairs of <insert formal country name>, signed at Washington, D.C., on <insert date>; and

Recognizing that OSHA’s Alliance Program provides for the establishment of cooperative relationships for purposes such as training and education, outreach and communication, and promoting a national dialogue on workplace safety and health;

Intend to form an Alliance to achieve the following:

Overall Objective

The Participants intend to establish a collaborative relationship to provide <insert constituency (e.g. Dominican Nationals in New York)> and others information, guidance, and access to education and training resources to promote workers’ rights in protecting their occupational safety and health, particularly with regards to <insert hazards and/or issues>, and to help them understand the rights of workers and the responsibilities of employers under the Occupational Safety and Health Act (OSH Act).

[The goals and objectives listed below are broken out by standard goal types (training and education, outreach and communication and promoting a national dialogue on workplace safety and health). To the extent possible, they should contain specifics. Delete any bullets that do not apply.]

Training and Education

The Participants intend to work together to achieve the following training and education goal<s>:

[Following are model objectives for this goal. Delete any that do not apply and to the extent possible, make specific those that do, for example, by naming the type of course to be developed or the course content.]

  • To develop training and education programs for <specify audience (e.g., Honduran Nationals in New York> regarding <specify hazard(s) or issue area(s)>.

  • To develop training and education programs for <specify audience (e.g., Honduran Nationals in New York> to promote understanding of workers’ rights and responsibilities of employers, including the use of the OSHA complaint process.

  • To deliver or arrange for the delivery of <specify> courses.

  • To develop workplace health and safety curricula on <specify>.

Outreach and Communication

The Participants intend to work together to achieve the following outreach and communication goal<s>:

[Following are model objectives for this goal. Delete any bullets that do not apply and to the extent possible, make specific those that do, for example, by naming specific conferences to attend or the audience(s) to be reached.]

  • To develop information on the recognition and prevention of workplace hazards, and to develop ways of communicating such information (e.g., print and electronic media, electronic assistance tools, and links to OSHA’s Web site from the Consulate’s Web site) to <insert constituency (e.g. Ecuadorians in Little Rock )> and their employers.

  • To speak, exhibit, or appear at the Participants’ conferences, local meetings, or other events.

  • To participate in “Mobile Consulate” activities and events.

  • To share information among DOL personnel and safety and health professionals regarding <specify Organization(s)> good practices or effective approaches and publicize results through outreach by <specify Organization(s)> and through materials, training programs, workshops, seminars, and lectures (or any other applicable forum) developed by the participants.

Promotion of a National Dialogue

The Participants intend to work together to achieve the following goal<s> related to promoting a national dialogue on workplace safety and health:

[Following are model objectives for this goal. Delete any bullets that do not apply and to the extent possible, make specific those that do, for example, by naming specific topics/hazards to be addressed.]

  • To raise awareness of and demonstrate commitment to workplace safety and health and workers’ rights under the OSH Act whenever leaders from the Participants address groups.

  • To convene or participate in forums, roundtable discussions, or stakeholder meetings on <specify topic/hazard> to help forge innovative solutions on issues concerning workplace safety and health and understanding of workers’ rights and responsibilities of employers under the OSH Act.

  • To share information on laws and standards, including those relating to workers’ rights and responsibilities of employers <Where appropriate, insert the clause,” which apply in (fill in State name)”>.

An implementation team made up of representatives of each Participant intends to meet to develop a plan of action, determine working procedures, and identify the roles and responsibilities of the Participants. In addition, the Participants intend to meet at least three times per year to track and share information on activities and results in achieving the goals of the Alliance.

Nothing in this Arrangement commits the Participants to the expenditure of any funds.

This Arrangement may commence upon signature by both Participants. This Arrangement is intended to cease two (2) years from the date of signing. A Participant should endeavor to provide thirty (30) days advance written notice of its intent to discontinue its participation in this Arrangement. This Arrangement may be modified in writing at any time by mutual consent of the Participants.

Signed at <insert city, state>, in duplicate, this <insert day of month (e.g. 12th)> day of <insert month, year> <Where appropriate, insert the clause “, in the English and (fill in the blank) languages”>.

For the U.S. Department of Labor’s
Occupational Safety and Health
Administration, <specify> Office:

For the Consulate of <specify>




<Name>
<Title>


<Name>
<Title>


PAPERWORK REDUCTION ACT STATEMENT

OSHA’s Alliance Program provides the following agreement template to assist organizations preparing a Consulate Alliance agreement with a Consulate from a country other than Mexico. 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 template is voluntary. The template ensures that Alliance participants provide required information about potential 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, determining goals, and developing objectives for the agreement. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to OSHAPRA@dol.gov 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. 1218-0274 (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED TEMPLATES TO THIS OFFICE IN THIS MANNER.)

OMB Approval # 1218-0274; Expires: 02-28-2023