Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of the following concerning the collection of the information on this form.

Authority: The information collected is a registration form to sign up interested parties into the Safety Champions Program that is authorized by the following authority: Section 2(b)(1) of the Occupational Safety and Health Act of 1970 (OSH Act or Act) (29 U.S.C. 651).

Purpose: The primary purpose of collecting this information is to register interested parties in comprehensive safety and health management programs. This will allow OSHA to contact participants with pertinent information about the programs. In addition, the collection of this information is necessary to gauge the effectiveness of the programs, identify the needed improvements, and ensure that resources are being effectively used appropriately while maximizing the practical utility and public benefit of the information in accordance with 44 USC 3507.

Routine Use(s): The Department of Labor routinely uses the information, as follows None, except for the DOL universal routine uses found here: www.dol.gov/general/privacy/sorn#universal.

Consequence of Failure to Provide Information: Completion of this form is voluntary. Failure to provide the information may result in delays activating an employer’s registration profile and implementing tools to participate in the safety and health programs. When this information is missing, the system cannot automatically establish the participant’s account and who is engaging in the safety champions program. Completing the form ensures timely account setup, accurate tracking of interested parties, and uninterrupted access to resources.

Additional information regarding the system of records associated with this can be found in the SORN for DOL/OSHA-6, available at https://www.dol.gov/privacy.