OMB No. 1218-0274
Exp. Date: 02/28/2023
OSHA 12-10.5

ARRANGEMENT ESTABLISHING AN ALLIANCE
BETWEEN
THE U.S. DEPARTMENT OF LABOR’S
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
<SPECIFY OFFICE(S)>
AND
THE CONSULATE OF MEXICO IN <LOCATION NAME(S)>

The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) <Specific Office(s)> and the Consulate of Mexico in <Location Name(s)>(the Consulate), hereinafter referred to collectively as “the Participants;”

RECOGNIZING the joint commitment to protect workers’ rights for Mexican workers in the United States; 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 Mexican Nationals in <insert location or consular circumscription> and others information, guidance, and access to education and training resources to promote workers’ rights in protecting their occupational safety and health, and to help them understand U.S. domestic law on the rights of workers and the responsibilities of employers under the Occupational Safety and Health Act (OSH Act).

Training and Education

The Participants intend to work together to achieve the following training and education goals:

  • To develop training and education programs for Mexican workers and Mexican employers in <specify location or consular circumscription > regarding workplace safety and health.

  • To develop training and education programs for Mexican workers and Mexican employers in <specify location or consular circumscription > to promote understanding of workers’ rights and responsibilities of employers under the OSH Act, including the use of the OSHA complaint process.

Outreach and Communication

The Participants intend to work together to achieve the following outreach and communication goals:

  • 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 Mexican Nationals working in <specify location or consular circumscription > 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.

Promotion of a National Dialogue

The Participants intend to work together to achieve the following goals related to promoting a joint dialogue on workplace safety and health:

  • 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 issues affecting Mexican Nationals working in <specify location or consular circumscription > 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.

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 may continue for two (2) years from the date of signing. A Participant should endeavor to provide thirty (30) days advanced written notice of its intent to discontinue the 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>, in the English and Spanish languages.

FOR THE U.S. DEPARTMENT OF LABOR’S
OCCUPATIONAL SAFETY AND
HEALTH ADMINISTRATION
<SPECIFIY> OFFICE(S):

FOR THE CONSULATE OF MEXICO IN <specify location>:

 

 


<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 Mexican Consulate. 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