Safety Champions Program (SCP) Sign Up

OMB Control Number: 1218-0239
Expiration Date: August 31, 2027

The fields indicated with an asterisk (*) are required to complete your registration.

SCP participant worksite:

Worksite street address:

Worksite state:

Worksite city:

Worksite ZIP code:

Worksite manager name:

Worksite manager title:

Company/Corporate name (if different from above):

SCP participant contact name:

SCP participant contact title:

SCP participant contact phone number:

SCP participant contact email address:

Confirm SCP participant contact email address:

Union name and local #:

Union representative's address (if different from above):

Union representative's name:

Union representative's phone number:

Union representative's fax number:

Union representative's email address:

Number of employees:

Number of contract employees:

SIC:

NAICS:

OMB Control Number: 1218-0239 - Expires: 8-31-2027

Public reporting burden for this collection of information is estimated to average 5 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Cooperative and State Programs, U.S. Department of Labor, 200 Constitution Ave., Suite N3700 NW, Washington, DC 20210-4537 and reference the OMB Control Number 1218-0239.