Instructions: The purpose of this template is to help
participants and OSHA staff share successes and best practices as a direct
result of participating in OSHA’s Voluntary Protection Programs (VPP) and/or the
OSHA Strategic Partnership Program (OSPP). Once completed, this form should be
submitted to your designated National Office Lead within OSHA’s Office of
Partnerships and Recognition (OPR) and to
Danielle Gibbs
(OPR Outreach Coordinator).
*Note: Any information submitted may be posted to OSHA’s public web page or
used in other outreach activities.
I. General Information: Please check the appropriate boxes and complete
the below table.
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VPP |
|
Partnership |
Date Submitted: ____________________ |
| Submitted By |
Company/Agency Name |
Email |
Phone |
| |
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| NAICS |
|
SIC |
|
#employees
covered |
|
# of employees |
|
Year/Date Entered VPP or Year/Date
OSP was
signed: |
|
|
|
|
Success Story – A story that highlights successes resulting
from participating in the OSHA cooperative program such as reduced TCIR and
DART rates, increased workers’ compensation savings, increased employee
involvement and morale, increased management commitment, increased
productivity, and the overall impact of participating in the OSHA
cooperative program. |
| |
|
|
|
Best Practice – An innovative and effective method or system
for improving worker safety and health resulting in superior outcomes.
(Example: changing work processes to reduce ergonomic injuries resulting in
improved employee morale and reduced workers’ compensation costs.) |
II. Success Story or Best Practice Narrative: Please check the appropriate box
or boxes below that your story includes, followed by your narrative. Each
narrative should include two or three paragraphs (at most). Note: It is possible
that a story may include all three categories.
|
|
Quantitative (ex: reductions in illness and injury rates;
workers compensation savings) |
|
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|
|
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Anecdotal/Human Interest (ex: increased management
commitment; increased employee involvement, morale) |
|
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Quote (quotes from employees, management, corporate
leadership, union officials) |
III. Quantitative Results Data
If you are submitting a success story that includes rate and/or number
reductions, please use the below table to provide data for the most recent three
year period, if possible. If your story is highlighting an increase in the
number of safety training courses offered, please also provide the number of
employees and supervisors trained and the total number of training hours
offered.
Note: You do not need to complete every column – just what
relates to your story.
| |
*TCIR |
**DART |
Number of Fatalities |
Dollar Value of Workers
Compensation Claims |
***Insurance EMR Rate |
| Year 1: |
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| Year 2: |
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| Year 3: |
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3-Year Rate
(Avg.) |
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|
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| BLS Industry National Average for Most Recent
Year (Specific Year) |
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* TCIR: (Total Case Incident Rate) = (# of injuries x 200,000) / total hours
worked
** DART: (Days Away, Restricted, Time away) = (# of lost time injuries x
200,000) / total hours worked
***EMR: Experience Modifier Rate
Thank you for taking the time to help promote the value of
OSHA’s Cooperative Programs!
|
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