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OMB Approval # 1218-xxxx; Expires: 00-00-0000

The Occupational Safety and Health Administration (OSHA)
and [<Alliance Participant>]
[<Date of Report>]

  1. Alliance Background

    1. Date Signed


    2. Dates Renewed

      NOTE [Renewal date. If Alliance has been renewed more than once, use a bulleted list. If alliance has not been renewed yet, you may delete this section.]
    3. Evaluation Period

      [<Opening date – Closing date>]

    4. Alliance Overview and Goals

      [<Brief summary of the purpose and scope of the Alliance – from the Alliance agreement.>]

  2. Implementation Team Meetings

    • [<Date>]
    • [<Date>]

    In addition to these formal meetings, the Alliance coordinators from both groups maintained regular contact throughout the reporting period to monitor the Alliance's progress and results.

  3. Results of Alliance Activities in Support of Agreement Goals

    Dissemination: Alliance Program participant shared information on agency-developed or OSHA Alliance Program-developed tools and resources, OSHA standards/rulemakings, enforcement, and outreach campaigns.

    These tables are best viewed on tablets, notebooks, or desktop computer screens.

    Dissemination TypeDate DescriptionEmphasis AreasNumber Reached

    Alliance Webpage-OSHA Website

     <TBD by OSHA>

    Alliance Webpage-Participant Website

     <Number of Views or Hits>
    Press Release    
    Social Media    
    Email Blast    
    TOTAL [Total]

    Outreach Events and Training for non-OSHA Staff: Alliance Program participant or OSHA participation in events which includes speeches/presentations, exhibits, roundtables, conferences, informational webinars or other meetings or training in support of the Alliance or an OSHA initiative.

    These tables are best viewed on tablets, notebooks, or desktop computer screens.

    Activity TypeDateEvent NameParticipant Name(s) and Affiliation(s)Title Of Presentation (if applicable)CityStateEmphasis AreasNumber Reached
    <Speaker/ Presentation>        
    TOTAL [Total]

    Training for OSHA Staff: Alliance Program participant provided training or assistance in training OSHA and OSHA-affiliated staff (including state plan and/or On-site Consultation Program representatives).

    These tables are best viewed on tablets, notebooks, or desktop computer screens.

    Training TypeDateName/Title of TrainerTraining TitleAudience: OSHA, State Plan, Onsite CityStateEmphasis AreasNumber Reached
    TOTAL [Total]
  4. Alliance Developed Products

    [List all Alliance products developed by the Alliance Program participants during the timeframe of the reporting period. If none, you may delete this section.]

  5. OSHA Product Reviews

    [List all OSHA products reviewed by the Alliance Program participants during the timeframe of the reporting period. If none, you may delete this section.]

    Report prepared by: [Alliance Coordinator, title, Office, date].

*(Emphasis areas are tied to OSHA's Operating Plan, DOL's Strategic Plan, and agency/departmental initiatives; they are updated annually. Use only Areas listed below. If none apply, leave blank. More than one can be included; please input them in alphabetical order.)

  • Agriculture
  • Beryllium
  • Construction
  • Emergency Response/Recovery
  • Fall Prevention
  • Fall Stand-Down
  • Health Care
  • Heat Illness Prevention
  • Hispanic/Latino Workers
  • Oil and Gas
  • Recordkeeping/Reporting
  • Safety & Health Programs
  • Safe + Sound Week
  • Silica
  • Small Business
  • Temporary Workers
  • Telecommunications Towers
  • Trenching
  • Walking-Working Surfaces
  • Young Workers

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 mandatory. 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 is 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, Alliance Office, Department of Labor, Room N-3662, 200 Constitution Ave., NW, Washington, DC 20210; Attn: Paperwork Reduction Act Comment. (This address is for comments regarding this form only; DO NOT SEND ANY COMPLETED TEMPLATES TO THIS OFFICE IN THIS MANNER.)

OMB Approval # 1218-xxxx; Expires: 00-00-0000

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