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Evaluation of the Voluntary Protection Program >  Appendix B VPP Programs
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APPENDIX B: Web Questionnaire

WEB
  Application ID: 3026380
URL: https://gx.gallup.com/oshasafety.gx
FIELD FINAL – FEBRUARY 23, 2005  
(ALL Revisions highlighted in blue)
(2/18 Revisions highlighted in green)
   
PROJECT REGISTRATION #140212
OSHA
City Center: Government
VPP Safety Officers Survey
Simon/Jensen
Edward Purvis, Programmer
December, 2004
N TRANSLATIONS

X INSTRUMENT DESIGN: Deb Brown


n=700
[Deleted Banner]

    The Occupational Safety and Health Administration (OSHA) is working on a project to document the work that the Voluntary Protection Programs (VPP) participants do to promote safety and health. To accomplish this, OSHA is working with The Gallup Organization to collect VPP site injury and illness data and information on mentoring and outreach activities through this online questionnaire. The information we are requesting would ordinarily be included in the success stories portion of your annual submission.

    This online questionnaire will allow OSHA to accurately measure VPP's contributions to workplace safety and health in terms of the mentoring and outreach provided by participants, and in terms of reduced injury and illness rates experienced at sites. This will help OSHA demonstrate VPP benefits and promote program growth. Growth of the VPP will increase the number of employees who go home each day safe and healthy.

    There are three parts to this questionnaire: a) Mentoring Section; b) Outreach Section; and c) Data Collection Section. Before starting this questionnaire, please locate your calendar to retrieve the mentoring and outreach activities that you completed in the last 12 months (2004). You will also be asked questions about the mentoring and outreach activities completed by others at your site during the past 12 months, so you may want to consult with others who perform these activities before starting this questionnaire. Also, please locate the injury and illness logs for your site(s) for the five years prior to joining the VPP.
This online questionnaire allows you to complete what you can, stop, and return to the questionnaire as many times as necessary.
    OSHA will protect information provided in this questionnaire by VPP participants to the greatest extent permitted by law. OSHA, however, will provide the VPP participant with prompt, written notice of a request for disclosure under the Freedom of Information Act and afford the VPP participant a reasonable period of time to object to the disclosure.

    Thank you for participating. If you are ready to begin, please enter the Access Code found on your letter from Acting Assistant Secretary Jonathan Snare.

    Please enter your unique Access Code and click the "Begin Questionnaire" button to continue.

    <Begin Questionnaire>

    (PROGRAMMER NOTE: If incorrect Access Code, display the following error message:)

    The Access Code you have entered is invalid. Please carefully re-enter your Access Code.

    (PROGRAMMER NOTE: If no Access Code is entered, display the following error message:)

    You must enter an Access Code to continue.
 
New Screen
    (PROGRAMMER NOTE: If completed survey found in database for this Access Code, display the following error message:)

    A questionnaire has already been completed with this Access Code. Thank you for your participation.

    If you feel you have received this message in error, please contact galluppoll@gallup.com or call Gallup Client Support at 1-888-297-8999.

New Screen
    (PROGRAMMER NOTE: Display the following at the bottom of each screen:)

    If you need assistance in completing this questionnaire, please contact Gallup Client Support by sending an e-mail to galluppoll@gallup.com or by calling 1-888-297-8999 from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Thursday, or 8:00 a.m. to 6:00 p.m. Eastern Time, on Fridays.

    Do not print, store, or copy this page.

    Copyright © 2004 The Gallup Organization, Princeton, NJ. All rights reserved. Privacy Policy

New Screen
    This first section asks about VPP mentoring activities you and/or others at your site perform with companies or other organizations that are working towards acceptance into the VPP. Mentoring is one-on-one assistance from a VPP participant to a prospective participant from another company or organization (either within your own company or a different company) to help them improve their safety and health management systems, prepare an application for VPP, or prepare for OSHA site visits to be approved for VPP status. Mentoring includes both those activities performed through the VPPPA's mentoring program and mentoring done on your own.

    Mentoring may include (either within your own company or with another company):

    • Conducting mentoring workshops
    • Conducting field visits at potential VPP sites
    • Conducting mock on-site reviews with potential VPP sites
    • Helping potential VPP sites with their application development
    • Helping potential VPP sites analyze problem areas
    • Sharing your knowledge of resources with potential VPP sites
    • Sharing techniques and preparation strategies with potential VPP sites
    • Advising mentees

(There is no question #1)
New Screen
  1. Did you or ANYONE AT YOUR SITE perform any mentoring activities related to the Voluntary Protection Programs (VPP) in the one year period from January 1, 2004, through December 31, 2004, either within or outside your company?

    1. Yes
    2. No
    3. Can’t Recall

    (If code 2, 3, or no response in #2, Skip to #3a;
    Otherwise, Continue)
New Screen
  1. How many people at your site, including yourself, performed mentoring activities related to VPP in the one year period from January 1, 2004, through December 31, 2004, either within or outside your company? (Fill in response) (Allow 3 digits)

(Error message:)
    A response is required to continue.


    3a. Since your site was approved for VPP, how many years has your site had at least one person conducting mentoring either within or outside your company? Please only count years where mentoring occurred (do not include decimal places)? (Fill in response) (Allow 2 digits)
(Error message:)
    Please enter numbers only.

    (If code 0 or no response in #3a,
    AND code 2, 3, or no response in #2, Skip to #11;
    If code 0 or no response in #3a,
    AND code 1 in #2, Skip to #6aa;
    Otherwise, Continue)

New Screen
  1. Since your site was approved for VPP, approximately how many facilities has your VPP site mentored either within or outside of your own company? (Fill in response) (Allow 3 digits)

    (If code 0 in #4
    AND code 2, 3, or no response in #2,
    Skip to #11; If code 0 in #4,
    AND code 1 in #2, Skip to #6aa;
    Otherwise, Continue)

(Error message:)
    Please enter numbers only.

New Screen
  1. And of those (response in #4) facilities your site mentored, how many became VPP Sites? (Fill in response) (Allow 2 digits)

    (If code 2, 3, or no response in #2,
    Skip to #11;
    Otherwise, Continue)

New Screen
    6aa. In the one year period from January 1, 2004, through December 31, 2004, please tell us how many facilities either within or outside of your company your site has mentored. Please enter your number here: (Allow 3 digits)

(Error message:)
    A response is required to continue.

New Screen
    In the one year period from January 1, 2004, through December 31, 2004, what were the names or locations of the facilities that your site mentored, both inside and outside your company, and the approximate number of employees at each facility? (PROGRAMMER NOTE: Display 1-3 as a set together) (Allow 100 responses)

    6a1. NAME OR LOCATION: (Fill in response) (Allow 100 characters)

    6a2. NUMBER OF EMPLOYEES: (Fill in response) (Allow 6 digits)

    6a3. Was this facility within your company or an outside company?

    1. Within my company
    2. Outside company
    6b1. NAME OR LOCATION: (Fill in response) (Allow 100 characters)

    6b2. NUMBER OF EMPLOYEES: (Fill in response) (Allow 6 digits)

    6b3. Was this facility within your company or an outside company?

    1. Within my company
    2. Outside company
    6c1. NAME OR LOCATION: (Fill in response) (Allow 100 characters)

    6c2. NUMBER OF EMPLOYEES: (Fill in response) (Allow 6 digits)

    6c3. Was this facility within your company or an outside company?

    1. Within my company
    2. Outside company
    6d1. NAME OR LOCATION: (Fill in response) (Allow 100 characters)

    6d2. NUMBER OF EMPLOYEES: (Fill in response) (Allow 6 digits)

    6d3. Was this facility within your company or an outside company?

    1. Within my company
    2. Outside company
    6e1. NAME OR LOCATION: (Fill in response) (Allow 100 characters)

    6e2. NUMBER OF EMPLOYEES: (Fill in response) (Allow 6 digits)

    6e3. Was this facility within your company or an outside company?

    1. Within my company
    2. Outside company
New Screen
  1. Since your site was approved for VPP, on average, how many facilities does your site mentor every year, OUTSIDE your own company? (Fill in response) (Allow 2 digits)

  2. Since your site was approved for VPP, on average, how many hours PER MONTH does your site spend on mentoring activities with facilities OUTSIDE your own company? (Fill in response) (Allow 3 digits)
New Screen
  1. Since your site was approved for VPP, on average, about how many hours PER MONTH do mentors at your site spend mentoring facilities WITHIN YOUR OWN COMPANY? (Fill in response) (Allow 3 digits)

    15a. Since your site was approved for VPP, on average how many facilities does your site mentor every year WITHIN YOUR OWN COMPANY? (Allow 2 digits)

  2. Does your company REQUIRE you or others at your site to mentor facilities within your company?

    1. Yes
    2. No
    3. I'm not sure
New Screen
  1. Does your site perform any mentoring activities with facilities both within and outside your company that are NOT working towards approval into the VPP, for example, facilities that just want advice on improving the safety and health of their worksites?

    1. Yes
    2. No
    3. Don’t know

    (If code 2, 3, or no response in #9, Skip to #11;
    Otherwise, Continue)
New Screen
  1. Since your site was approved for VPP, on average, how many hours PER YEAR does your site spend mentoring facilities that ARE NOT working towards approval into VPP? (Fill in response) (Allow 3 digits)

New Screen
  1. In the next three years does your site plan to do more, less, or about the same amount of mentoring that you did in the past 12 months for facilities both within and outside your company?

    1. More
    2. Less
    3. Same
    4. Don’t know

    (If code 1 in #11, Continue;
    If code 2 in #11, Skip to #12b,
    Otherwise, Skip to text before #17)
New Screen
    12a. (If code 1 in #11:) How many hours PER MONTH would your site be willing to mentor other facilities both within and outside your company in the future? (Fill in response) (Allow 2 digits)

    (All in #12a, Skip to text before #17)

New Screen
    12b. (If code 2 in #11:) Why would mentors at your site prefer to provide less mentoring services than you did in the past 12 months both within and outside your company? (Click all that apply)

    1. We're already spending as much time on mentoring as we can
    2. Our company restricts the amount of time we spend on mentoring
    3. Our company is leaving VPP
    4. Mentoring did not benefit our careers or positions in our company
    5. Some other reason (Fill in response)
(Question #13 deleted)

(There is no question #14)

(Questions #15-#16 moved to after #8)
New Screen
    The next questions are about outreach activities you, and/or others at your site, have conducted. Outreach includes assistance and information provided to prospective VPP applicants such as conducting VPP workshops and training, holding community safety days, and serving as an advocate for the VPP. Outreach also includes assistance and information provided to internal or external corporate entities to promote safety and health principles and practices, including OSHA’s Strategic Partnerships and Alliances, making presentations on safety and health at conferences, or conducting training workshops. Outreach includes those activities conducted at the request of OSHA, (i.e., OSHA outreach) or at the request of other organizations (non-OSHA outreach).

    Outreach activities may include:

    • Providing training in support of the VPP
    • Participating in community safety days/outreach days
    • Serving as an advocate in the business community for the VPP
    • Conducting Strengthening Star Quality Workshops (VPPPA)
    • Conducting safety and health workshops
    • Participation in OSHA Strategic Partnerships and Alliances
    • Making presentations on safety and health issues at conferences
    • Conducting VPP application workshops (VPPPA)
    • Some other activity (Fill in response)
New Screen
  1. Since your site was approved for VPP, how many years has your site had at least one person conducting outreach activities either at the request of OSHA or at the request of other organizations? Please only count years when outreach occurred (do not count decimal places)? (Allow 2 responses)

  2. Did you or ANYONE AT YOUR SITE perform outreach activities at the request of OSHA in the one year period January 1, 2004, through December 31, 2004?

    1. Yes - (Continue)
    2. No
    3. Can’t Recall

    (If code 2, 3, or no response in #18, Skip to #21;
    Otherwise, Continue)
New Screen
    18a. How many people at your site, including yourself, performed outreach activities at the request of OSHA in the one year period January 1, 2004, through December 31, 2004? (Fill in response) (Allow 2 digits)

    [Deleted Note]

New Screen
  1. In the one year period January 1, 2004, through December 31, 2004, using the list of activities below, please indicate which outreach activities your site participated in at the request of OSHA. (Click all that apply)

    1. Providing training in support of the VPP
    2. Participating in community safety days/outreach days
    3. Serving as an advocate in the business community for the VPP
    4. Conducting Strengthening Star Quality Workshops (VPPPA)
    5. Conducting safety and health workshops
    6. Participation in OSHA Strategic Partnerships and Alliances
    7. Making presentations on safety and health issues at conferences
    8. Conducting VPP application workshops (VPPPA)
    9. Some other activity

    (If BLANK to 1-9 in #19, Skip to #21;
    Otherwise, Continue)
New Screen
    (PROGRAMMER NOTE: For each code 1-9 selected in #19, Display #20, #20a, #20b, and #20c as a set together for each occurrence)

  1. (For each code 1-9 selected in #19:) How many times in the one year period January 1, 2004, through December 31, 2004, did you and others at your site: (display A-I, as appropriate)? (Allow up to 20 occurrences for each A-I for each occurrence)

    1. (If code 1 in #19:) Provide training in support of the VPP (Fill in response) (Allow 3 digits)

    2. (If code 2 in #19:) Participate in community safety days/outreach days (Fill in response) (Allow 3 digits)

    3. (If code 3 in #19:) Serve as an advocate in the business community for the VPP (Fill in response) (Allow 3 digits)

    4. (If code 4 in #19:) Conduct Strengthening Star Quality Workshops (VPPPA) (Fill in response) (Allow 3 digits)

    5. (If code 5 in #19:) Conduct safety and health workshops (Fill in response) (Allow 3 digits)

    6. (If code 6 in #19:) Participate in OSHA Strategic Partnerships and Alliances (Fill in response) (Allow 3 digits)

    7. (If code 7 in #19:) Make presentations on safety and health issues at conferences (Fill in response) (Allow 3 digits)

    8. (If code 8 in #19:) Conduct VPP application workshops (VPPPA) (Fill in response) (Allow 3 digits)

    9. (If code 9 in #19:) (Response in #19) (Fill in response) (Allow 3 digits)
(Error message:)
    A response is required to continue.

New Screen
    20a. (For each code 1-9 selected in #19, ask:) How many hours, including preparation time, did you and others at your site: (display A-I, as appropriate)?

    1. (If code 1 in #19:) Provide training in support of the VPP (Fill in response) (Allow 3 digits)

    2. (If code 2 in #19:) Participate in community safety days/outreach days (Fill in response) (Allow 3 digits)

    3. (If code 3 in #19:) Serve as an advocate in the business community for the VPP (Fill in response) (Allow 3 digits)

    4. (If code 4 in #19:) Conduct Strengthening Star Quality Workshops (VPPPA) (Fill in response) (Allow 3 digits)

    5. (If code 5 in #19:) Conduct safety and health workshops (Fill in response) (Allow 3 digits)

    6. (If code 6 in #19:) Participate in OSHA Strategic Partnerships and Alliances (Fill in response) (Allow 3 digits)

    7. (If code 7 in #19:) Make presentations on safety and health issues at conferences (Fill in response) (Allow 3 digits)

    8. (If code 8 in #19:) Conduct VPP application workshops (VPPPA) (Fill in response) (Allow 3 digits)

    9. (If code 9 in #19:) (Response in #19) (Fill in response) (Allow 3 digits)

    20b. (For each code 1-9 selected in #19:) (Display A-I, as appropriate)

    1. (If code 1 in #19:) Was this within your own company?

      1. Yes
      2. No
    2. (If code 2 in #19:) Was this within your own company?

      1. Yes
      2. No
    3. (If code 3 in #19:) Was this within your own company?

      1. Yes
      2. No
    4. (If code 4 in #19:) Was this within your own company?

      1. Yes
      2. No
    5. (If code 5 in #19:) Was this within your own company?

      1. Yes
      2. No
    6. (If code 6 in #19:) Was this within your own company?

      1. Yes
      2. No
    7. (If code 7 in #19:) Was this within your own company?

      1. Yes
      2. No
    8. (If code 8 in #19:) Was this within your own company?

      1. Yes
      2. No
    9. (If code 9 in #19:) Was this within your own company?

      1. Yes
      2. No

    20c. (For each code 1-9 selected in #19, ask:) (Display A-I, as appropriate)

    1. (If code 1 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    2. (If code 2 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    3. (If code 3 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    4. (If code 4 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    5. (If code 5 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    6. (If code 6 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    7. (If code 7 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    8. (If code 8 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    9. (If code 9 in #19:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)
New Screen
  1. In the next three years, does your site plan to do more, less, or about the same amount of outreach activities at the request of OSHA as you did in the last 12 months?

    1. More
    2. Less
    3. Same
    4. Don’t know

    (If code 1 in #21, Continue;
    If code 2 in #21, Skip to #21b,
    If code 3, 4, or NO RESPONSE in #21, Skip to #22)

New Screen
    21a. (If code 1 in #21:) On average, how many hours PER MONTH would your site be willing to provide related outreach activities at the request of OSHA in the future? (Fill in response) (Allow 3 digits)

(Error message:)
    Please enter numbers only.

    (All in #21a, Skip to #22)

New Screen
    21b. (If code 2 in #21:) Why would your site plan to provide less outreach activities at the request of OSHA than you did in the last year? (Click all that apply)

    1. We're already spending as much time on outreach as we can
    2. Our company restricts the amount of time we spend on outreach activities
    3. Our company is leaving VPP
    4. Outreach activities did not benefit our career or positions in our company
    5. Some other reason (Fill in response)
New Screen
  1. Did you or anyone else at your site perform outreach activities at the request of OTHER ORGANIZATIONS in the one year period January 1, 2004, through December 31, 2004?

    1. Yes
    2. No
    3. Can’t Recall

    (If code 2, 3, or no response in #22, Skip to #24;
    Otherwise, Continue)

New Screen
  1. In the one year period January 1, 2004, through December 31, 2004, using the list of activities below, please indicate which outreach activities your site participated in at the request of OTHER ORGANIZATIONS: (Click all that apply)

    1. Provided training in support of the VPP
    2. Participated in community safety days/outreach days
    3. Served as an advocate in the business community for the VPP
    4. Conducted Strengthening Star Quality Workshops (VPPPA)
      5. \
    5. Conducted safety and health workshops
    6. Participated in OSHA Strategic Partnerships and Alliances
    7. Made presentations on safety and health issues at conferences
    8. Conducted application workshops (VPPPA)
    9. Some other activity (Fill in response)

    (If none are selected in #23, Skip to #24;
    Otherwise, Continue)

New Screen
    (PROGRAMMER NOTE: For each code 1-9 selected in #23, Display #23a-1, #23a, #23b, and #23c as a set together for each occurrence)

    23a-1. (For each code 1-9 selected in #23:) How many times in the one year period January 1, 2004, through December 31, 2004, did your site: (display A-I, as appropriate)? (Allow up to 20 occurrences for each A-I for each occurrence)

    1. (If code 1 in #23:) Provide training in support of the VPP (Fill in response) (Allow 3 digits)

    2. (If code 2 in #23:) Participate in community safety days/outreach days (Fill in response) (Allow 3 digits)

    3. (If code 3 in #23:) Serve as an advocate in the business community for the VPP (Fill in response) (Allow 3 digits)

    4. (If code 4 in #23:) Conduct Strengthening Star Quality Workshops (VPPPA) (Fill in response) (Allow 3 digits)

    5. (If code 5 in #23:) Conduct safety and health workshops (Fill in response) (Allow 3 digits)

    6. (If code 6 in #23:) Participate in OSHA Strategic Partnerships and Alliances (Fill in response) (Allow 3 digits)

    7. (If code 7 in #23:) Make presentations on safety and health issues at conferences (Fill in response) (Allow 3 digits)

    8. (If code 8 in #23:) Conduct application workshops (VPPPA) (Fill in response) (Allow 3 digits)

    9. (If code 9 in #23:) (Response in #23) (Fill in response) (Allow 3 digits)

    23a. (For each code 1-9 selected in #23, ask:) How many hours, including preparation time, did you and others at your site: (display A-I, as appropriate)?

    1. (If code 1 in #23:) Provide training in support of the VPP (Fill in response) (Allow 3 digits)

    2. (If code 2 in #23:) Participate in community safety days/outreach days (Fill in response) (Allow 3 digits)

    3. (If code 3 in #23:) Serve as an advocate in the business community for the VPP (Fill in response) (Allow 3 digits)

    4. (If code 4 in #23:) Conduct Strengthening Star Quality Workshops (VPPPA) (Fill in response) (Allow 3 digits)

    5. (If code 5 in #23:) Conduct safety and health workshops (Fill in response) (Allow 3 digits)

    6. (If code 6 in #23:) Participate in OSHA Strategic Partnerships and Alliances (Fill in response) (Allow 3 digits)

    7. (If code 7 in #23:) Make presentations on safety and health issues at conferences (Fill in response) (Allow 3 digits)

    8. (If code 8 in #23:) Conduct application workshops (VPPPA) (Fill in response) (Allow 3 digits)

    9. (If code 9 in #23:) (Response in #23) (Fill in response) (Allow 3 digits)

    23b. (For each code 1-9 selected in #23, ask:) (Display A-I, as appropriate)

    1. (If code 1 in #23:) Was this within your own company?

      1. Yes
      2. No
    2. (If code 2 in #23:) Was this within your own company?

      1. Yes
      2. No
    3. (If code 3 in #23:) Was this within your own company?

      1. Yes
      2. No
    4. (If code 4 in #23:) Was this within your own company?

      1. Yes
      2. No
    5. (If code 5 in #23:) Was this within your own company?

      1. Yes
      2. No
    6. (If code 6 in #23:) Was this within your own company?

      1. Yes
      2. No
    7. (If code 7 in #23:) Was this within your own company?

      1. Yes
      2. No
    8. (If code 8 in #23:) Was this within your own company?

      1. Yes
      2. No
    9. (If code 9 in #23:) Was this within your own company?

      1. Yes
      2. No
    23c. (For each code 1-9 selected in #23, ask:) (Display A-I, as appropriate)

    1. (If code 1 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    2. (If code 2 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    3. (If code 3 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    4. (If code 4 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    5. (If code 5 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    6. (If code 6 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    7. (If code 7 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    8. (If code 8 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)

    9. (If code 9 in #23:) Approximately, how many people attended? (Fill in response) (Allow 5 digits)
New Screen
  1. In the next three years, does your site plan to do more, less, or about the same amount of outreach activities at the request of OTHER ORGANIZATIONS as you did in the last 12 months?

    1. More
    2. Less
    3. Same
    4. Don’t know

    (If code 1 in #24, Continue;
    If code 2 in #24, Skip to #25b,
    Otherwise, Skip to #26)

New Screen
    25a. (If code 1 in #24:) On average, how many hours PER MONTH would your site be willing to provide outreach activities at the request of OTHER ORGANIZATIONS in the future? (Fill in response) (Allow 3 digits)

    (All in #25a, Skip to #26)

New Screen
    25b. (If code 2 in #24:) Why would your site plan to provide less outreach activities at the request of OTHER ORGANIZATIONS than you did in the last year? (Click all that apply)

    1. We're already spending as much time on outreach as we can
    2. Our company restricts the amount of time we spend on outreach activities
    3. Our company is leaving VPP
    4. Outreach activities did not benefit our careers or positions in our company
    5. Some other reason (Fill in response)
New Screen
  1. In this third and final section of the OSHA Web questionnaire, we are going to ask for site information about injury and illness rates from the five years prior to being approved into VPP. Please help us by providing this information to the best of your ability. Because we know this data may be difficult to obtain, please feel free to answer what you can now, go off-line to gather additional information, and return to enter the information.

    1. What is your DUN’s number? (Fill in response) (Allow 15 digits)

    2. B. What is your SIC Code? (Fill in response) (Allow 6 digits)

    3. What is your NAICS Code? (Fill in response) (Allow 10 digits)
New Screen
    26E. What, if any, of the following events or activities occurred prior to the time your site started applying for VPP?

    1. Increase in casualty insurance rates
    2. Increase in workers' compensation rates
    3. Changes in management/ownership
    4. OSHA Consultation
    5. OSHA cooperative program (OSHA Alliances; OSHA Strategic Partnerships)
    6. Special Emphasis Program in your industry
    7. OSHA inspection for Fatality
    8. OSHA inspection for Catastrophe
    9. OSHA inspection, other reasons

    26D. On what date was your company first approved in to VPP?
    (PROGRAMMER NOTE: Provide drop down menu for month and year 2004)

(Error message:)
    The date you have entered is not valid.

New Screen
  1. Based on that date, please enter your company’s injury/illness data for the following years as described below:

    We are interested in collecting data from your site for five years prior to the year of your approval into VPP. So, if you were officially approved into VPP on November 15, 2000, the first full year of data we like to collect would be from 1999. We would then like the previous four years of data before that year (1998, 1997, 1996, and 1995 in this example).

    OSHA would like to gather all of this information, which should be easily obtained from your OSHA 200 and/or 300 logs. However, if it is not possible to provide all of the details of the injury and illness data requested, please, at a minimum, complete the highlighted areas (denoted by **) which are critical to OSHA's data analysis efforts.

    (PROGRAMMER NOTE: For each of the year's listed, insert two check boxes at the top of the page that say the following:)

    Not in Business this year
    Data lost/not available this year

    (These will be check boxes that the respondent will be able to use if they choose. If they check one of these boxes, they are STILL ABLE TO FILL OUT THE INFORMATION FOR THAT YEAR IF THEY SO CHOOSE.)
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    ONE YEAR PRIOR TO INITIAL APPROVAL: (PROGRAMMER NOTE: This will automatically be the year PRIOR to the year of their acceptance—the year should automatically come up)

    TWO YEARS PRIOR TO APPROVAL: (PROGRAMMER NOTE: This will automatically be the year TWO YEARS PRIOR to the year of their acceptance—the year should automatically come up)

    THREE YEARS PRIOR TO APPROVAL: (PROGRAMMER NOTE: This will automatically be the year THREE YEARS PRIOR to the year of their acceptance—the year should automatically come up)

    FOUR YEARS PRIOR TO APPROVAL: (PROGRAMMER NOTE: This will automatically be the year FOUR YEARS PRIOR to the year of their acceptance—the year should automatically come up)

    FIVE YEARS PRIOR TO APPROVAL: (PROGRAMMER NOTE: This will automatically be the year FIVE YEARS PRIOR to the year of their acceptance—the year should automatically come up)

    (PROGRAMMER NOTE: There will be two different sets of data to collect. Display years in bold type prior to 2002, use the 200 Log sheets. Display years in bold type for 2002 and subsequent, use the 300 log)

    1. Total number of employees
    2. Total hours worked

    INDEX FOR 200 LOGS: (Display question #s as shown) (Allow 4 digits)

    (PROGRAMMER NOTE: Indicate to respondent that questions labeled ** are CRITICAL QUESTIONS)

      1. Total number of fatalities
      2. **Total number of Checks for injuries involving days away from work or days of restricted work activity or both
      3. Total number of Checks if injury involved days away from work
      4. Total Number of days away from work
      5. Total Number of days of restricted work activity
      6. **Total number of Injuries without lost workdays-check if no entry was made in column 1 or 2 but the injury is recordable as defined above
      7a. Total number of Occupational skin diseases or disorder
      7b. Total number of Dust diseases of the lungs
      7c. Total number of Respiratory conductions due to toxic agents
      7d. Total number of Poisoning (systematic effect of toxic materials)
      7e. Total number of Disorders due to physical agents (other than toxic materials)
      7f. Total number of Disorders associated with repeated trauma
      7g. Total number of All other occupational illnesses
      8. Total number of Illness related deaths
      9. **Total number of Checks for illness that involved days away from work or days of restricted work activity or both
      10. Total number of Checks for illness that involved days away from work
      11. Total Number of days away from work
      12. Total Number of days of restricted work activity
      13. **Total illness without lost workdays-(check if no entry was made in column 8 or 9)

    PLEASE FILL IN THE FOLLOWING INFORMATION FOR THE FIVE YEARS PRIOR TO YOUR APPROVAL INTO VPP INTO THESE SUMMARY LOGS:

    27A. ONE YEAR PRIOR TO INITIAL APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #1:
    4. Response in #2:
    5. Response in #3:
    6. Response in #4:
    7. Response in #5:
    8. Response in #6:
    9. Response in #7a:
    10. Response in #7b:
    11. Response in #7c:
    12. Response in #7d:
    13. Response in #7e:
    14. Response in #7f:
    15. Response in #7g:
    16. Response in #8:
    17. Response in #9:
    18. Response in #10:
    19. Response in #11:
    20. Response in #12:
    21. Response in #13:

    27B. TWO YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #1:
    4. Response in #2:
    5. Response in #3:
    6. Response in #4:
    7. Response in #5:
    8. Response in #6:
    9. Response in #7a:
    10. Response in #7b:
    11. Response in #7c:
    12. Response in #7d:
    13. Response in #7e:
    14. Response in #7f:
    15. Response in #7g:
    16. Response in #8:
    17. Response in #9:
    18. Response in #10:
    19. Response in #11:
    20. Response in #12:
    21. Response in #13:

    27C. THREE YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #1:
    4. Response in #2:
    5. Response in #3:
    6. Response in #4:
    7. Response in #5:
    8. Response in #6:
    9. Response in #7a:
    10. Response in #7b:
    11. Response in #7c:
    12. Response in #7d:
    13. Response in #7e:
    14. Response in #7f:
    15. Response in #7g:
    16. Response in #8:
    17. Response in #9:
    18. Response in #10:
    19. Response in #11:
    20. Response in #12:
    21. Response in #13:

    27D. FOUR YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #1:
    4. Response in #2:
    5. Response in #3:
    6. Response in #4:
    7. Response in #5:
    8. Response in #6:
    9. Response in #7a:
    10. Response in #7b:
    11. Response in #7c:
    12. Response in #7d:
    13. Response in #7e:
    14. Response in #7f:
    15. Response in #7g:
    16. Response in #8:
    17. Response in #9:
    18. Response in #10:
    19. Response in #11:
    20. Response in #12:
    21. Response in #13:

    27E. FIVE YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #1:
    4. Response in #2:
    5. Response in #3:
    6. Response in #4:
    7. Response in #5:
    8. Response in #6:
    9. Response in #7a:
    10. Response in #7b:
    11. Response in #7c:
    12. Response in #7d:
    13. Response in #7e:
    14. Response in #7f:
    15. Response in #7g:
    16. Response in #8:
    17. Response in #9:
    18. Response in #10:
    19. Response in #11:
    20. Response in #12:
    21. Response in #13:

    INDEX FOR 300 LOGS: (Display question #s as shown) (Allow 4 digits)

    (PROGRAMMER NOTE: Indicate to respondent that questions labeled ** are CRITICAL QUESTIONS)

    A. **Total number of employees
    B. **Total hours worked
    G. Total number of Deaths
    H. Total number of Days away from work
    I. **Total number of Job transfer or restriction (Remained at work)
    J. **Total number of Other recordable cases (Remained at work)
    K. Total number of on the job transfer or restriction days (Number of days for injured or illness worker)
    L. Total number of Days away from work (Number of days for injured or ill worker)
    M1. **Total number of Injuries
    M2. Total Skin Disorders
    M3. Total Respiratory Condition
    M4. Total Poisonings
    M5. **Total of All Other Illnesses

    PLEASE FILL IN THE FOLLOWING INFORMATION FOR THE FIVE YEARS PRIOR TO YOUR APPROVAL INTO VPP:

    27F. ONE YEAR PRIOR TO INITIAL APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #G:
    4. Response in #H:
    5. Response in #I:
    6. Response in #J:
    7. Response in #K:
    8. Response in #L:
    9. Response in #M1:
    10. Response in #M2:
    11. Response in #M3:
    12. Response in #M4:
    13. Response in #M5:

    27G. TWO YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #G:
    4. Response in #H:
    5. Response in #I:
    6. Response in #J:
    7. Response in #K:
    8. Response in #L:
    9. Response in #M1:
    10. Response in #M2:
    11. Response in #M3:
    12. Response in #M4:
    13. Response in #M5:

    27H. THREE YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #G:
    4. Response in #H:
    5. Response in #I:
    6. Response in #J:
    7. Response in #K:
    8. Response in #L:
    9. Response in #M1:
    10. Response in #M2:
    11. Response in #M3:
    12. Response in #M4:
    13. Response in #M5:

    27I. FOUR YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #G:
    4. Response in #H:
    5. Response in #I:
    6. Response in #J:
    7. Response in #K:
    8. Response in #L:
    9. Response in #M1:
    10. Response in #M2:
    11. Response in #M3:
    12. Response in #M4:
    13. Response in #M5:

    27J. FIVE YEARS PRIOR TO APPROVAL:

    1. Year:
    2. Total Hours Worked:
    3. Response in #G:
    4. Response in #H:
    5. Response in #I:
    6. Response in #J:
    7. Response in #K:
    8. Response in #L:
    9. Response in #M1:
    10. Response in #M2:
    11. Response in #M3:
    12. Response in #M4:
    13. Response in #M5:
 
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OPTIONAL QUESTION
  1. If you choose, please provide any additional information about successes you have achieved in this past year in the VPP. You may include any other comments you wish about the VPP as well. (Fill in response)
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    (PROGRAMMER NOTE: Right above the "Submit Survey" button, display:)

    Please submit your questionnaire to Gallup by clicking the "Submit Questionnaire" button below. Once you close your browser, you will no longer be able to view the questionnaire or change your responses.

    <Submit Questionnaire>

New Screen
    THANK YOU FOR PARTICIPATING IN THIS QUESTIONNAIRE.

    The information you provided will be very helpful to understanding the positive impacts of the VPP on companies and their employees.

    You may now close your browser or go to another Web page.
 
REVISIONS
 
12/7/04 Revised: Wording in Introduction, Wording in Mentoring Introduction, Wording in questions #2, #3, #4, #5, #6a1-#6e3, #7, #8, #9, #10, #11, #12a, #12b, #13, #15, #16, Wording in Outreach Introduction, Wording in questions #18, #19, #20, #20a, #21, Note after #21, #21a, #21b, #22, #23, #23a-1, #23a, #24, #25a, #25b, #27
 
  Added: #3a, #18a, Critical Question description to Index for 200 Logs - #2, #6, #9, #13, Critical Question description for 300 Logs - A, B, I, J, M1, M5, #28,
 
  Deleted: Names and e-mail address information - #1a-#5c, #6, Outreach participant information #17a1-#17e2,
 
12/20/04 Revised: Wording in Introduction, Wording in #2, Wording in #3, Wording in #4, Wording before #6a1, Wording in #13, Wording in #18-#20, Wording in #22-#23a-1, Skip pattern in #4, Skip pattern in #9, Skip pattern in #13, Skip pattern in #18a, Skip pattern in #22
 
  Deleted: Skip pattern in #3
 
  Added: Skip pattern to #2, Skip pattern to #3a, Skip pattern to #5, Skip pattern to #18
 
12/27/04 Added: Question #6aa
 
  Revised: Note after #3, Wording in #23
 
1/7/05 Deleted: Banner in Introduction,
 
  Revised: Wording in introduction, Date in #2, #3, #6aa, Text before #6a1, #13, #18, #18a, #19, #20, #22, #23, #23a-1, Wording in note after #3a, Wording in #4, Wording in #6aa, Wording in text before #18, Wording in #19, Wording in #26-#27
 
  Added: Error message after #4, error message after #6aa, error message after #20, error message after #21a
 
1/10/05 Revised: Note after #3a, Note after #4
 
1/25/05 Revised: Introduction, Wording in #2, #3a, Note after #3a, Wording in #4, Note after #4, Note after #5, Wording in #6aa, #7, #8, Wording in #15 and #16-also moved to after #8, Wording in #9-#11, Note after #11, Wording in #12, Note after #12, Wording in #12b, Text before #17, Wording in #18-#18a, Wording in #19-#20a, #21-#23a, Wording in #24-#26, #27-#27J, Text in Submit Survey page, Text in Thank you page
 
  Added: Question #15a, #17, #26E,
 
  Deleted: Question #13, Note after #13, Note after #18a
 
2/16/05 Added: Error message after #3a, error message after #26D
  
 
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   Page last updated: 03/15/2007