OSHA Voluntary Protection Program << Back to OSHA Alliance Program

July 8, 2010

MEMORANDUM FOR: REGIONAL ADMINISTRATORS, DIRECTORATES, AND FREE STANDING OFFICES

FROM:

DAVID MICHAELS, PhD, MPH

SUBJECT:

Revised Alliance Program Participation Criteria

One of the Occupational Safety and Health Administration's (OSHA) objectives under this Administration is to review the efforts of our cooperative programs, including the Alliance Program, to ensure that they are effectively supporting OSHA's mission. The Directorate of Cooperative and State Programs (DCSP) was asked to review the Alliance Program, establish criteria to evaluate Alliances, and evaluate national Alliances. Via an August 24,2009, memorandum from Mike Connors, we asked each Region to review their active Alliances based on the following criteria:

  • Do the Alliance agreement goals address OSHA's Areas of Emphasis? (e.g. diverse workforces, small businesses, high hazard industries)
  • Are the Alliance Program participants actively working to meet the goals of the Alliance agreement and producing tangible results?
  • Do the participating OSHA offices remain committed to meeting the goals of the Alliance agreement?

Your efforts resulted in the conclusion of more than 100 Alliances that either no longer fell within OSHA's emphasis areas or were not producing tangible results. This refocusing of priorities has strengthened the Alliance Program's effectiveness.

I am pleased to announce a formal revision of tbe Alliance Program participation criteria. The revised criteria will further enable OSHA to meet the Department of Labor's strategic goals by ensuring that workers will have a voice in our Alliance efforts, reaching constituencies most in need of OSHA's assistance, and working to increase workers' knowledge of their rights under the Occupational Safety and Health Act. The attached Alliance Program participation criteria and Alliance agreement templates are effective immediately and are posted on tbe Alliance Program Web page (http://www.osha.gov/dcsp/alliances/index.html). In the coming weeks, DCSP will schedule a conference call with Regional Alliance Coordinators, Compliance Assistance Specialists, and other interested individuals to discuss the revised Alliance Program participation criteria and the new templates.

Through the Alliance Program, OSHA works with a variety of organizations to increase awareness of worker rights and employer responsibilities. As we move forward with the revised criteria, I encourage you to maintain or establish Alliances with organizations, including community- and faith- based organizations, that can reach Spanish-speaking and other diverse, at-risk workforces, as well as organizations that represent workers in high hazard industries or who are impacted by OSHA's enforcement initiatives and rulemaking efforts.

Attachments

Criteria for New and Renewed Alliances
  • Alliance Program participants are committed to working closely with OSHA to develop and share information with workers and employers to help prevent injuries, illnesses, and fatalities in the workplace and to educate workers and employers about their rights and responsibilities under the Occupational Safety and Health Act.
     
  • Alliances provide a forum for employers and workers to work together to resolve workplace safety and health issues. To achieve this, Alliances with employers and employer groups (e.g. trade associations) must also include worker representatives. This is accomplished by:
    • Having a union signatory; or
    • Having worker involvement in the Alliance Agreement's development and implementation, including project workgroups.
  • Alliances support the Department's strategic goals of enhancing worker voice and providing safe and secure workplaces. This is accomplished by the Alliance Program participants:
    • Demonstrating the ability and commitment to reaching one or more diverse, at risk workforces through the Alliance.
    • Providing workers with effective training and workplace safety materials.
    • Supporting OSHA enforcement initiatives, such as by sharing information on NEPs and/or developing compliance assistance materials for other specifically targeted hazards/industries.
    • Disseminating information on new and revised OSHA standards, such as by training workers on new standards and developing worker information on new standards.
    • Providing OSHA staff with training opportunities.
    • Providing OSHA with a unique and desired skill or resource.
  • Alliance Program participants possess sufficient knowledge and resources to fulfill the goals of the Alliance agreement.
     
  • Alliance Program participants make the products of the Alliance available to the public for free.
     
  • Alliance Program participants have a demonstrated track record of meeting Alliance Agreement goals and Program expectations. (for renewals)

Template for Drafting a National Alliance

(approved 7/8/10)

AGREEMENT ESTABLISHING AN ALLIANCE
BETWEEN
THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
U.S. DEPARTMENT OF LABOR
AND

<ORGANIZATION NAME(S)>


[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) and <organization Name(s)> recognize the value of establishing a collaborative relationship to foster safer and more healthful American workplaces. To that end, OSHA and <organization Name (s)> hereby form an Alliance to provide <organization(s)> members and others with information, guidance, and access to training resources that will help them protect the health and safety of workers, particularly 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). In developing this Alliance, OSHA and <organization Name(s)> recognize that OSHA's State Plan and On-site Consultation Project partners are an integral part of the OSHA national effort.

[The goals and objectives listed below are broken out by standard goal types (raising awareness of OSHA's rulemaking and enforcement initiatives; training and education; and outreach and communication). In addition, they may be customized to fit the circumstances. Delete any that do not apply.]

Raising Awareness of OSHA's Rulemaking and Enforcement Initiatives

The Participants intend to work together to achieve the following goal <s> related to raising awareness of OSHA's rulemaking and enforcement initiatives:

[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 standards or topics/hazards to be addressed.]
  • To share information on OSHA's National Emphasis Programs, Regulatory Agenda, and opportunities to participate in the rulemaking process.
     
  • To share information on occupational safety and health laws and standards, including the rights and responsibilities of workers and employers.
     
  • To 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.
     
  • To encourage worker participation in workplace safety and health by <specify efforts to be undertaken>.
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 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.
     
  • To 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.
     
  • To deliver or arrange for the delivery of <specify> courses.
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 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 OSHA's and the <Organization's> Web sites) to employers and workers in the industry.
     
  • To speak, exhibit, or appear at OSHA's or <Organization(s)> conferences, local meetings, or other <specify> events.
     
  • To 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) developed by the participants.
     
  • To work with other Alliance participants on specific issues and projects on <specify issue, industry, or audience> that are addressed and developed through the Alliance Program.
     
  • To develop and disseminate case studies on <Insert topic/hazard> and publicize their results.
     
  • To encourage <Organization(s) chapters/worksites> to build relationships with OSHA's Regional and Area Offices to address health and safety issues, including <specify>.
OSHA's Alliances provide parties an opportunity to participate in a voluntary cooperative relationship with OSHA for purposes such as raising awareness of OSHA's rulemaking and enforcement initiatives, training and education, and outreach and communication. These Alliances have proved to be valuable tools for both OSHA and its Alliance participants. By entering into an Alliance with a party, OSHA is not endorsing or promoting, nor does it intend to endorse or promote, any of that party's products or services.

An implementation team made up of representatives of each organization will meet to develop a plan of action, determine working procedures, and identify the roles and responsibilities of the participants. In addition, they will meet at least three 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 Directorate of Cooperative and State Programs [, <other National Office Directorate>, (if applicable)] and any other appropriate offices. OSHA will encourage State Plan States' and OSHA On-site Consultation Projects' 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>.




 
<Name>
Assistant Secretary of Labor for
Occupational Safety and Health


 
Date


 
<Name>
<Title>
<Organization Name>


 
Date


Template for Renewing a National Alliance
(approved 7/8/10)

AGREEMENT RENEWING AN ALLIANCE
BETWEEN
THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
U.S. DEPARTMENT OF LABOR
AND

<ORGANIZATION NAME(S)>


[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) and <Organization Name(s)> continue to recognize the value of maintaining a collaborative relationship to foster safer and more healthful American workplaces. To that end, OSHA and <Organization Name(s)> hereby renew [Include the phrase "in part" whenever changes to the goals and/or emphasis areas are occuring] the Alliance signed <Month DD, YYYY,> [and renewed <Month DD, YYYY,> (if applicable)], with a continued emphasis on <specify>. Specifically, <specify: both/each> organization(s) are committed to providing <Organization Name(s)> members and others with information, guidance, and access to training resources that will help them protect the health and safety of workers and understand the rights of workers and the responsibilities of employers under the Occupational Safety and Health Act (OSH Act). Through the Alliance, the organizations will continue to address <specific hazards and/or <specific issues>. In renewing this Alliance, OSHA and <Organization Name(s)> recognize that OSHA's State Plan and On-site Consultation Project partners are an integral part of the OSHA national effort.

[The goals and objectives listed below are broken out by standard goal types (raising awareness of OSHA's rulemaking and enforcement initives; training and education; and outreach and communication). In addition, they may be customized to fit the circumstances. Delete any that do not apply.]

Raising Awareness of OSHA's Rulemaking and Enforcement Initiatives

The Participants intend to work together to achieve the following goal<s> related to raising awareness of OSHA's rulemaking and enforcement initiatives:

[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 standards or topics/hazards to be addressed.]

 
  • To share information on OSHA's National Emphasis Programs, Regulatory Agenda, and opportunities to participate in the rulemaking process.
     
  • To share information on occupational safety and health laws and standards, including the rights and responsibilities of workers and employers.
     
  • To 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.
     
  • To encourage worker participation in workplace safety and health by <specify efforts to be undertaken>.
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 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.
     
  • To 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.
     
  • To deliver or arrange for the delivery of <specify> courses.
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 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 OSHA's and the <Organization's> Web sites) to employers and workers in the industry.
     
  • To speak, exhibit, or appear at OSHA's or <Organization(s)> conferences, local meetings, or other <specify> events.
     
  • To 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) developed by the participants.
     
  • To work with other Alliance participants on specific issues and projects on <specify issue, industry, or audience> that are addressed and developed through the Alliance Program.
     
  • To develop and disseminate case studies on <Insert topic/hazard> and publicize their results.
     
  • To encourage <Organization(s) chapters/worksites> to build relationships with OSHA's Regional and Area Offices to address health and safety issues, including <specify>.
OSHA's Alliances provide parties an opportunity to participate in a voluntary cooperative relationship with OSHA for purposes such as raising awareness of OSHA's rulemaking and enforcement initiatives, training and education, and outreach and communication. These Alliances have proved to be valuable tools for both OSHA and its Alliance participants. By entering into an Alliance with a party, OSHA is not endorsing or promoting, nor does it intend to endorse or promote, any of that party's products or services.

An implementation team made up of representatives of each organization will meet to develop a plan of action, determine working procedures, and identify the roles and responsibilities of the participants. In addition, they will meet at least three 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 Directorate of Cooperative and State Programs [, <other National Office Directorate>, (if applicable)] and any other appropriate offices. OSHA will encourage State Plan States' and OSHA On-site Consultation Projects' 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>.




 
<Name>
Assistant Secretary of Labor for
Occupational Safety and Health


 
Date


 
<Name>
<Title>
<Organization Name>


 
Date

Template for Drafting a Regional or Area Office Alliance

(approved 7/8/10)

AGREEMENT ESTABLISHING AN ALLIANCE
BETWEEN

 <SPECIFY OFFICE(S)>

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
U.S. DEPARTMENT OF LABOR

AND

<ORGANIZATION NAME(S)>


[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 safer and more healthful American workplaces. To that end, OSHA and <Organization Name (s)> hereby form an Alliance to provide <Organization(s)> members and others with information, guidance, and access to training resources that will help them protect the health and safety of workers, particularly 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). In developing this Alliance, OSHA and <Organization Name(s)> recognize that OSHA's State Plan and On-site Consultation Project partners are an integral part of the OSHA national effort.

[The goals and objectives listed below are broken out by standard goal types (raising awareness of OSHA's rulemaking and enforcement initiatives; training and education; and outreach and communication). In addition, they may be customized to fit the circumstances. Delete any that do not apply.]

Raising Awareness of OSHA's Rulemaking and Enforcement Initiatives

The Participants intend to work together to achieve the following goal<s> related to raising awareness of OSHA's rulemaking and enforcement initiatives:

[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 standards or topics/hazards to be addressed.]
  • To share information on OSHA's National/Regional/Local Emphasis Programs, Regulatory Agenda, and opportunities to participate in the rulemaking process.
     
  • To share information on occupational safety and health laws and standards, including the rights and responsibilities of workers and employers.
     
  • To 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.
     
  • To encourage worker participation in workplace safety and health by <specify efforts to be undertaken>.
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 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.
     
  • To 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.
     
  • To deliver or arrange for the delivery of <specify> courses.
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 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 OSHA's and the <Organization's> Web sites) to employers and workers in the industry.
     
  • To speak, exhibit, or appear at OSHA's or <Organization(s)> conferences, local meetings, or other <specify> events.
     
  • To 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) developed by the participants.
     
  • To work with other Alliance participants on specific issues and projects on <specify issue, industry, or audience> that are addressed and developed through the Alliance Program.
     
  • To develop and disseminate case studies on <Insert topic/hazard> and publicize their results.
OSHA's Alliances provide parties an opportunity to participate in a voluntary cooperative relationship with OSHA for purposes such as raising awareness of OSHA's rulemaking and enforcement initiatives, training and education, and outreach and communication. These Alliances have proved to be valuable tools for both OSHA and its Alliance participants. By entering into an Alliance with a party, OSHA is not endorsing or promoting, nor does it intend to endorse or promote, any of that party's products or services.

An implementation team made up of representatives of each organization will meet to develop a plan of action, determine working procedures, and identify the roles and responsibilities of the participants. In addition, they will meet at least three 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 Plan States' and OSHA On-site Consultation Projects' 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>.




 
<Name>
<Title>

Occupational Safety and
Health Administration


 
Date


 
<Name>
<Title>
<Organization Name>


 
Date

Template for Renewing a Regional or Area Office Alliance

(approved 7/8/10)

AGREEMENT ESTABLISHING AN ALLIANCE
BETWEEN

 <SPECIFY OFFICE(S)>

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
U.S. DEPARTMENT OF LABOR
AND

<ORGANIZATION NAME(S)>


[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)> continue to recognize the value of maintaining a collaborative relationship to foster safer and more healthful American workplaces. To that end, OSHA and <Organization Name(s)> hereby renew [Include the phrase "in part" whenever changes to the goals and/or emphasis areas are occuring] the Alliance signed <Month DD, YYYY,> [and renewed <Month DD, YYYY,> (if applicable)], with a continued emphasis on <specify>. Specifically, <specify: both/each> organization(s) are committed to providing <Organization Name(s)> members and others with information, guidance, and access to training resources that will help them protect the health and safety of workers and understand the rights of workers and the responsibilities of employers under the Occupational Safety and Health Act (OSH Act). Through the Alliance, the organizations will continue to address <specific hazards and/or <specific issues>. In renewing this Alliance, OSHA and <Organization Name(s)> recognize that OSHA's State Plan and On-site Consultation Project partners are an integral part of the OSHA national effort.

[The goals and objectives listed below are broken out by standard goal types (raising awareness of OSHA's rulemaking and enforcement initiatives; training and education; and outreach and communication). In addition, they may be customized to fit the circumstances. Delete any that do not apply.]

Raising Awareness of OSHA's Rulemaking and Enforcement Initiatives

The Participants intend to work together to achieve the following goal<s> related to raising awareness of OSHA's rulemaking and enforcement initiatives:

[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 standards or topics/hazards to be addressed.]
  • To share information on OSHA's National/Regional/Local Emphasis Programs, Regulatory Agenda, and opportunities to participate in the rulemaking process.
     
  • To share information on occupational safety and health laws and standards, including the rights and responsibilities of workers and employers.
     
  • To 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.
     
  • To encourage worker participation in workplace safety and health by <specify efforts to be undertaken>.

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 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.
     
  • To 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.
     
  • To deliver or arrange for the delivery of <specify> courses.
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 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 OSHA's and the <Organization's> Web sites) to employers and workers in the industry.
     
  • To speak, exhibit, or appear at OSHA's or <Organization(s)> conferences, local meetings, or other <specify> events.
     
  • To 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) developed by the participants.
     
  • To work with other Alliance participants on specific issues and projects on <specify issue, industry, or audience> that are addressed and developed through the Alliance Program.
     
  • To develop and disseminate case studies on <Insert topic/hazard> and publicize their results.
OSHA's Alliances provide parties an opportunity to participate in a voluntary cooperative relationship with OSHA for purposes such as raising awareness of OSHA's rulemaking and enforcement initiatives, training and education, and outreach and communication. These Alliances have proved to be valuable tools for both OSHA and its Alliance participants. By entering into an Alliance with a party, OSHA is not endorsing or promoting, nor does it intend to endorse or promote, any of that party's products or services.

An implementation team made up of representatives of each organization will meet to develop a plan of action, determine working procedures, and identify the roles and responsibilities of the participants. In addition, they will meet at least three 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 Plan States' and OSHA On-site Consultation Projects' 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>.




 
<Name>
<Title>

Occupational Safety and
Health Administration


 
Date


 
<Name>
<Title>
<Organization Name>


 
Date