OMB No. 1218-0274
Exp. Date: 02/28/2023
OSHA 12-10.2a


[The opening paragraph 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) <Specify Office(s)> and <Organization Name(s)> recognize the value of establishing a collaborative relationship to foster safety and health practices and programs to improve American workplaces. To that end, OSHA and <Organization Name (s)> hereby form an Alliance to provide <Organization(s)> members and the public with information, guidance, and access to training resources that will help them protect workers by reducing and preventing exposure to <specify> hazards <and/or> addressing <specify> issues, and understand the rights of workers and the responsibilities of employers under the Occupational Safety and Health Act (OSH Act).

This agreement provides a framework and objectives for the Alliance's activities. Alliance participants also agree to meet the "Fundamental Requirements for OSHA Alliance Program Participants" and the "Guidelines for OSHA's Alliance Program Participants: Alliance Products and Other Alliance Projects."

Through the Alliance, the organizations will use available injury, illness, and hazard exposure data, when appropriate, to help identify areas of emphasis for Alliance awareness, outreach, and communication activities. The Alliance will also explore and implement selected options, including but not limited to member surveys, to evaluate the Alliance and measure the impact on improving workplace safety and health. In developing this Alliance, OSHA and <Organization Name(s)> recognize that OSHA’s State Plan and On-Site Consultation Program partners are an integral part of the OSHA national effort, and that information about the products and activities of the Alliance may be shared with these partners for the advancement of common goals.

[The goals and objectives listed below are broken out by standard goal types (Raising Awareness: Outreach and Communication, and Training and Education). The goals and objectives should be customized to reflect the anticipated projects or to otherwise fit the circumstances. Delete any that do not apply.]

Raising Awareness: Outreach and Communication

The Participants intend to work together to achieve the following objective<s>:

[Following are sample objectives for this goal. Delete any that do not apply and add additional objectives consistent with anticipated activities. If one or more Alliance participants are employers or employer groups (e.g., trade associations), the worker participation bullet must be included. To the extent possible, make any applicable objectives listed below more specific by, for example, naming specific conferences to attend or the audience(s) to be reached.]

  • Share information on OSHA’s National/Regional/Local Initiatives (Emphasis Programs, Regulatory Agenda, Outreach), and opportunities to participate in initiatives and the rulemaking process.

  • Share information on occupational safety and health laws and standards, including the rights and responsibilities of workers and employers.

  • Develop information on the recognition and prevention of workplace hazards, and communicate such information (e.g., print and electronic media, electronic assistance tools, and OSHA and the <Organization<s> websites) to employers and workers in the industry.

  • Speak, exhibit, or appear at OSHA and <Organization(s)> conferences, local meetings, or other <specify> events.

  • Convene or participate in forums, roundtable discussions, or stakeholder meetings on <specify topic/hazard> to help forge innovative solutions in the workplace or to provide input on safety and health issues.

  • Share information among OSHA personnel and industry safety and health professionals regarding <specify Organization(s)> good practices or effective approaches through training programs, workshops, seminars, and lectures (or any other applicable forum).

  • Encourage worker participation in workplace safety and health by <specify efforts to be undertaken>. <Note: This bullet is required if one or more participants are employers or employer groups (e.g., trade associations).>

  • Collaborate with other Alliance participants on specific issues and projects on <specify issue, industry, or audience>.

  • Develop and disseminate case studies on <Insert topic/hazard> and publicize their results.

  • Encourage <Organization(s) chapters/worksites> to build relationships with OSHA’s Regional and Area Offices to address health and safety issues, including <specify>.

Training and Education

The Participants intend to work together to achieve the following objective<s>:

[Following are sample objectives for this goal. Delete any that do not apply and add additional objectives consistent with anticipated activities. To the extent possible, make any applicable objectives listed below more specific by, for example, naming the type of course to be developed or the course content or updating the language to reflect specific projects.]

  • Develop effective training and education programs for <specify audience> regarding <specify hazard(s) or issue area(s)>, and to communicate such information to constituent employers and workers.

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

  • Develop effective training and education programs for <specify audience> to promote understanding of workers’ rights, including the use of the OSHA complaint process, and the responsibilities of employers and to communicate such information to workers and employers.

OSHA’s Alliances provide organizations an opportunity to participate in a voluntary cooperative relationship with OSHA for purposes such as raising awareness of OSHA’s initiatives, outreach, communications, training, and education. These Alliances have proven to be valuable tools for both OSHA and Alliance participants. By entering into an Alliance with an organization, OSHA is not endorsing or promoting, nor does it intend to endorse or promote, any of that organization’s products or services.

An implementation team made up of representatives of each organization will meet one to two times per year to track and share information on activities and results in achieving the goals of the Alliance. OSHA team members will include representatives of the <list each OSHA Office that is a signatory to the Alliance agreement> and any other appropriate offices. OSHA will encourage State Plans' and OSHA On-Site Consultation program' participation on the team.

This agreement will remain in effect for <specify: two years/other period not to exceed two years>. <specify: Either/Any> signatory may terminate it for any reason at any time, provided they give 30 days’ written notice. This agreement may be modified at any time with the written concurrence of <specify: both/all> signatories.

Signed this <date> day of <month>, <year>.



Occupational Safety and
Health Administration

<Organization Name>





OSHA’s Alliance Program provides the following agreement template to assist organizations preparing an initial, regional Alliance agreement. 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 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