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U.S. Department of Labor | |
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| Occupational Safety & Health Administration | ||||||
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| VPP Corporate Pilot Program > Facility VPP Application Template | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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VPP Corporate Pilot Facility VPP Application Template Voluntary Protection Programs Directorate of Cooperative and State Programs Occupational Safety & Health Administration U.S. Department of Labor March 2004 |
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Form Approved OMB# 1218 – 0239 Expired 10 -31- 2004 Public reporting burden for this collection of information is voluntary and is estimated to average 80 hours per response, including the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate, or any other aspect of this collection of information, including suggestions for reducing this burden to the Division of Voluntary Programs, Department of Labor, Room N-3700, 200 Constitution Avenue, N.W., Washington, DC 20210.
I. Introduction II. Application Form
VPP Corporate Pilot Facility VPP Application Template I. Introduction The Voluntary Protection Programs (VPP) Corporate Pilot seeks to establish a more efficient process for Corporations with effective safety and health management systems uniformly implemented at its corporate facilities to participate in VPP. The VPP Corporate Pilot requires that the Corporation submit a detailed application that describes all standardized policies, programs, and systems that are implemented at each corporate facility. Additionally, the Corporation must pre-screen each of its facilities prior to the facility submitting an application to OSHA. A Program Evaluation is conducted at the Corporate Office/Headquarters to verify the contents of the Corporate Application and ensure that top-management is committed to VPP. Once the Corporation is accepted into the VPP Corporate Pilot, all eligible corporate facilities that have been successfully pre-screened may apply for VPP membership using this streamlined application. The Facility VPP Application is designed to capture facility-specific information on the implementation of VPP elements at the worksite. The information provided in the Corporate Application does not need to be duplicated. The facility and Corporate Office must properly coordinate to ensure this duplication of information is prevented. To ensure that information provided in the Corporate Application is not duplicated by the facility, the Corporate Office should provide the facility a copy the Corporate Application Information Checklist that identifies all the informational areas covered in the Corporate Application. Additionally, all Facility VPP Applications must have been pre-screened by the Corporation prior to submission to OSHA. Pre-screening will help to expedite the application review process conducted by OSHA and allow OSHA to conduct a streamlined onsite evaluation of the facility. As in the traditional VPP process, an OSHA VPP Onsite Evaluation Team will conduct an evaluation of the facility to verify the information described in the application. However, for the VPP Corporate Pilot, onsite evaluation of pre-screened facilities will focus on two VPP elements rather than all four as in traditional VPP. The Onsite Evaluation Team will select the two VPP elements for review; however this information will not be disclosed to the facility prior to the evaluation. Additionally, the review will focus on the facility implementation of the standardized corporate safety and health policies and procedures, and any worksite-specific elements of the facility’s program. The following sections of this application contain the required information Applicant Corporate Facilities must provide, including general facility information, assurances from management and the Union, injury and illness rates, and the facility’s most recent annual evaluation of the safety and health management system including a description of any programs/policies that differ from corporate policies. II. Application Form A. General Information and Facility Map Complete the information below and provide a copy of a map of the facility for use by the Onsite Evaluation Team.
* Enter average employment figure as recorded in worksite’s own records. ** Obtain from tables below. B. Written Assurances VPP applicants must assure, that they understand and agree to fulfill program requirements as participants in the VPP Corporate Pilot related to: OSHA Act compliance, employee support for VPP application, meeting and maintaining VPP elements, worksite and application prescreening, employee rights, non-discrimination, employee access to records, OSHA access to documentation, providing annual data, and informing OSHA of organizational and collective bargaining changes by signing and submitting the form included in Appendix A. C. Union Information If employees at the facility are represented by a collective bargaining agent(s), each authorized collective bargaining agent(s) must either provide a signed statement of support for the facility’s participation in the VPP, or co-sign the application submitted to OSHA. If a statement of support is used, it must be on file before the application is considered complete. A sample letter of union support is provided in Appendix B.
***Attach additional tables for each applicable contractor or union. D. Inspection History List all inspection activity involving OSHA over the past five years. Include the type of inspection (complaint, programmed, referral, accident, fatality, etc.), any citations issued, and status of any citations at the time this application was submitted. The application will not be accepted by OSHA if there is any outstanding enforcement action pending including open inspections, contested cases, etc. E. Injury and Illness Rate Information. Please complete the information and submit tables. Additional guidance on calculating injury and illness rates can be found in Appendix C. Table 1: All facility (site) employees including temporary and contract workers who are directly supervised by site management Table 2: Each applicable contractor’s employees (contractor whose employees worked 1,000 hours or more in any calendar quarter).
**** Include SIC and NAICS Codes F. Significant Changes or Events If applicable, describe the impact of any significant changes (management, corporate buy-outs, etc.) and events (fatality, catastrophe, accident, complaints, etc.) and steps taken to ensure or restore worker safety and health. G. Annual Evaluation of Safety and Health Management System Provide a copy of the facility’s most recent annual evaluation that assesses the effectiveness of each of the elements and sub-elements of the safety and health management system listed below. There is no specified format for the annual evaluation; however, the information for each sub-element must describe:
Please describe any success stories related to the implementation of VPP requirements. Include anecdotal as well as statistical evidence of improvements, non-routine safety and health activities, outreach, etc. Appendix A Written Assurances In signing this document, the management of [insert company name], hereby assures that: We have successfully received a pre-screening evaluation as described in the VPP Corporate Application. We will comply with the Occupational Safety and Health Act (OSH Act) and correct, in a timely manner all hazards discovered through self-inspections, employee notifications, accident investigations, OSHA onsite reviews, process hazard reviews, annual evaluations, or other means. (Federal applicants must also agree to comply with Title 29 of the Code of Federal Regulations (CFR), Part 1960 – Basic Program Elements for Federal Employees). Within 90 days, we will correct, safety and health deficiencies related to compliance with OSHA requirements and identified during any OSHA onsite review. We will provide effective interim protection, as necessary. Our employees support our application to the VPP.* Management commits to meeting and maintaining the VPP elements. Employees including newly hired employees and contract employees will receive orientation on the VPP, including employee rights under VPP and under the OSH Act or 29 CFR 1960. We will protect employees given safety and health duties as part of our safety and health management system from discriminatory actions resulting from their carrying out such duties, as described in Section 11(c) of the OSH Act and 29 CFR 1960.46(a). Employees will have access to the results of self-inspections, accident investigations, and other safety and health data, upon request.* We will maintain our safety and health management system information and make it available for OSHA review to determine initial and continued approval to the VPP. This information will include:
Whenever significant organizational or ownership changes occur, we will provide OSHA within 60 days a new Statement of Commitment signed by both management and authorized collective bargaining agents. Whenever a change occurs in the authorized collective bargaining agent, we will provide OSHA within 60 days a new signed statement indicating that the new representative supports VPP participation. We understand that we may withdraw our participation at any time for any reason should we deem that desirable. We, the undersigned, respectfully submit this statement of assurances and request consideration for participation in the Voluntary Protection Programs. Signature: __________________________________ Title: ______________________________________ Date: ______________________________________ *At facilities with employees organized into one or more collective bargaining units, the authorized representative for each collective bargaining unit must either sign the application or submit a signed statement indicating that the collective bargaining agent(s) supports VPP participation. OSHA must receive concurrence from all such authorized agents to accept the application. At non-union corporations and worksites, management’s assurance of employee support will be verified by the OSHA onsite review team during employee interviews. *At unionized construction sites, this requirement may be met through employee representative access to these results. Appendix B Sample Statement of Union Support Dear ______: The International Brotherhood of Chemical Workers (IBCW), Local 3-593, is in full support of this site’s pursuit and participation in the Voluntary Protection Programs (VPP). We understand that Occupational Safety and Health Administration (OSHA) created VPP to encourage and recognize excellence in safety and health, and to accomplish OSHA’s mission of protecting America’s workers through voluntary efforts. We understand the requirements of the program are based on comprehensive safety and health management systems, with our represented employees actively and meaningfully involved in the safety and health program. We, the undersigned, respectfully submit this statement of support for participation in the VPP and request consideration for membership in VPP. ________________________________________ Joe Smith Collective Bargaining Agent Date: ___________________________________ Appendix C Instructions for Calculating Injury and Illness Rates I. Definitions
VPP Onsite Evaluation Teams will calculate the site's rates for the previous 3 full calendar years and year-to-date. When reviewing participating sites, the VPP onsite teams also will review the rates of each applicable contractor. Note: The 3-year review of applicable contractors' rates will not begin until 2003. (In the year 2002, 2000 and 2001 data will be reviewed). III. Contractor Rates
V. Rate Calculations
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