Form Approved
OMB# 1218 – 0239
Expired 10 -31- 2004
Public reporting burden for this collection of information is voluntary and is estimated to average
120 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.
INTRODUCTION
APPLICATION INFORMATION:
- General Information
- Corporate Eligibility
- Corporate Commitment and Assurances
- Employee Involvement and Contractors
- Corporate Safety and Health Management System
- Renewal
Appendices
Appendix A: Definitions
Appendix B: Statement of Written Assurances
Appendix C: Sample VPP Pre-Screening Process
Appendix D: Corporate VPP Application Checklist
VPP Corporate Pilot
Corporate VPP Application Template
I. Introduction
The Voluntary Protection Programs (VPP) Corporate Pilot seeks to establish a more efficient
process for Corporations to participate in VPP. This pilot is designed to eliminate duplicative
VPP application requirements for Corporations with effective safety and health management
systems uniformly implemented at its corporate facilities. The VPP Corporate Pilot requires
Corporate Applicants to submit a Corporate VPP Application and receive a comprehensive
Corporate Program Evaluation at the Corporate-level and eligible corporate facilities (worksites)
to submit a streamlined application and receive a streamlined onsite evaluation.
The Corporate VPP Application is intended to capture information that describes how corporate
safety and health policies, procedures and systems, consistent with VPP criteria, are uniformly
implemented at all of the Corporation’s facilities. In addition to traditional VPP elements, a
critical component of the VPP Corporate Pilot is for Corporations to have a suitable internal
prescreening process to evaluate their facilities’ level of preparedness for participation in the VPP.
Pre-screening processes are required for evaluating the implementation of the safety and health
management system at the candidate facility and the completeness of the VPP application.
These pre-screening processes must be clearly explained in the Corporate VPP Application. A
sample pre-screening process is provided in Appendix C.
Following the review of the Corporate VPP Application, an OSHA VPP Team will conduct a
Corporate Program Evaluation at the Corporate Office/Headquarters to verify the information
provided in the application. Once the Corporation is accepted into the VPP Corporate Pilot,
individual facilities of the Corporation that have been successfully pre-screened may begin
submitting streamlined applications for VPP membership. This streamlined application requires
only facility-specific information and eliminates the need to repeat information contained in the
Corporate VPP Application. To ensure that information provided in the Corporate VPP
Application is not duplicated by the facility, a checklist is provided in Appendix D for the
Corporation to use to identify all standardized information included in the application. The
facility should be provided a copy of the completed checklist when preparing their application.
The corporate facility will also receive an onsite evaluation from an OSHA VPP Team, which
focuses on the facility implementation of the corporate safety and health policies and procedures,
and any applicable facility-specific programs.
The following sections of this application contain the required information that Corporate
Applicants must submit including general information regarding the Corporation, explanation of
how the Corporation meets the eligibility criteria, and a description of all standardized corporate
policies and programs. Also, Corporate Applicants must provide a written assurance that as
participants in the VPP Corporate Pilot certain obligations will be upheld.
II. Application Form
A. General Information
1. Name of Corporation/Company:
|
Address:
|
Corporate Safety and Health Manager:
|
Phone Number: |
Email Address: |
VPP Contact Name/Title:
|
Phone Number: |
Email Address: |
2. Total Number of Corporate
Facilities In the United States:
|
Number of Facilities in Federal OSHA Jurisdiction:
|
Number of Facilities in State Plan
Jurisdiction: |
Number of Employees Employed by the
Corporation in the United States (include
regular and temporary employees):
|
Average Number of Temporary Employees: |
Average Number of Applicable Contractors: |
| 3. Type of Work Performed and Products Produced. Provide
a description of the work performed at this facility, the types of products produced, and the
major hazards typically associated with your industry. |
Standard Industrial Classification (SIC) Code: |
North American Industry
Classification System (NAICS) Code: |
| |
|
|
| |
|
|
| |
|
|
B. Corporate Eligibility
The eligibility for the VPP Corporate Pilot requires the Corporation to make a pledge to
strengthen corporate-wide involvement in VPP by bringing a significant number of facilities into
the program. Other eligibility requirements include commitment to mentoring and outreach
activities, a commitment to participate in the Special Government Employee (SGE) Program,
and the ability to effectively pre-screen potential candidate facilities. Each of these requirements
must be clearly described, as specified below:
- Commitment
- Describe your corporate commitment to VPP and plans to implement VPP corporate-wide.
Confirm that management commits to meeting and maintaining the requirements
of VPP.
- Provide a list of individual facilities and a schedule (if available) for obtaining VPP
approval for each facility. If unknown at the time of submitting the application, indicate
as such or provide any tentative plans.
- Pre-Screening
- Provide a description of the established internal process for pre-screening potential VPP
facilities, including
- Process description for conducting a pre-screening audit of the candidate facility.
(See Appendix C, for Sample Process)
- Process description for reviewing applications prior to submission to OSHA.
- Safety and Health Outreach/Mentoring and SGE Participation
Corporations that are new to VPP describe only planned activities for each of the areas
required to be addressed below.
- Describe current and planned outreach activities including providing assistance and
information to prospective VPP applicants or involvement in safety and health activities
in the community and involvement with organizations such as the National Safety
Council, Federal Safety and Health Councils, or Voluntary Protection Programs
Participants’ Association (VPPPA). (See Appendix A)
- Describe current and planned mentoring activities to assist other prospective VPP
participants, internally or to other companies, or a Federal agency such as assisting to
improve their safety and health management system. (See Appendix A)
- Describe current and planned participation in the VPP Special Government Employees
(SGE) Program and the Corporation commitment to support employee requests for
certification as Special Government Employees (SGE) and participation as members of a
VPP onsite evaluation team. (See Appendix A)
C. Corporate Commitment and Assurances
- Demonstration of Corporate Commitment
- Philosophy: Provide a written corporate philosophy and vision that integrates
requirements for the worker safety and health management systems.
- Communication: Provide policy statements, memorandums, and other forms of
communication recognizing the importance of safety and health and specify a corporate
commitment to occupational safety and health signed by corporate executives or senior
managers.
- Knowledge of Safety and Health Performance:
- Describe your system for tracking injury and illness performance at individual
facilities, and how this information is used for decision making.
- Describe how corporate executives and senior managers are informed of safety and
health performance (e.g., Annual Performance Report).
- Responsibility/Organization:
- Provide documents that describe (e.g., an organizational chart, a functional chart)
how safety and health fits into your organizations’ structure. Describe how safety
and health is integrated into your business.
- Describe how responsibility for safety and health is assigned at the corporate level,
including the highest safety and health officers, positions to whom they report, and
the corporate management position that is/will be responsible for implementing
VPP across corporate facilities.
- Describe how the person(s) responsible for implementing VPP across corporate
facilities has knowledge of VPP (for example, OSHA training courses, VPP
conferences, workshops).
- Describe any uniform, corporate-wide policies or guidance that applies across all
corporate facilities that prescribe how safety and health line and staff
responsibilities are assigned.
- Accountability:
- Describe your performance management system that holds senior leadership and
management staff and employees accountable for achieving corporate safety and
health goals (e.g., performance plans for executives and senior managers that include
safety and health elements). If applicable, describe any uniform, corporate-wide
policies for the managing the performance appraisal system.
- Resource Management:
- If applicable, describe your process for planning and budget allocation for safety and
health management systems Corporation-wide. For example, describe how resources
are assigned for programs, equipment, dedicated safety and health staff, certified
safety professionals, certified industrial hygienists, other licensed health care
professionals, or other experts needed based on the hazards of the facility.
- If applicable, describe corporate office resources, consultants, or other resources used
to help with your safety and health management system, and how they are used by the
corporate facilities.
- Corporate Goals and Performance Report
- Describe your system for establishing annual performance goals, tracking system to
evaluate the status of these goals, and any type(s) of corporate report(s) (e.g., annual)
issued that describes accomplishments.
- Describe any uniform, corporate-wide policies that are implemented across all
corporate facilities that prescribe how safety and health planning or goal setting is
performed at facility-level.
- Describe any uniform, corporate-wide policies that are implemented across all
corporate facilities that prescribe how VPP self-evaluations are conducted and how
the results are evaluated and implemented.
- Corporate Environmental, Safety and Health Certifications
- Describe, if applicable, any other types of certifications the Corporation maintains
that demonstrate excellence in environmental, safety and health such as accreditation
with the International Organization for Standardization (ISO).
- 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, 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 B. The assurances must be signed by a Senior Corporate Official. Signature
by the Senior Corporate Safety and Health Officer is acceptable.
D. Employee Involvement and Contractors
- Employee Involvement
- Involvement: Describe any uniform, corporate-wide policies
that apply across all facilities that prescribe how employees should be meaningfully involved
in safety and health management systems at those locations.
- Notification: Describe any uniform, corporate-wide policies that apply across all
facilities that prescribe how employee notification takes place at those locations or for
Corporation new to VPP describe how notification will be conducted.
- Orientation: Describe how employees at participating facilities, including newly
hired employees and contract employees, receive or will receive orientation on the
VPP, including employee rights under VPP and under the Occupational Safety and
Health (OSH) Act or 29 CFR 1960.
- Non-Discrimination: Describe how employees are notified or will be notified of their
rights and the protections afforded to employees given safety and health duties as part
of your safety and health management systems 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).
- Records Access: Describe how employees are notified or will be notified of their
right to access the results of self-inspections, accident investigations, and other safety
and health data, upon request. At unionized construction sites, this requirement may
be met through employee representative access to these results.
- Contractors
- Describe the corporate process for selecting contractors to perform jobs throughout the
Corporation (all facilities.)
- Describe any uniform, corporate-level policies for contractor management and oversight
at all corporate facilities.
E. Corporate Safety and Health Management System
Describe safety and health policy, procedures and systems that are consistently and uniformly
implemented throughout the Corporation (all facilities.) Program descriptions must contain
pertinent information that clearly explains the management and administration of the program
such as responsibilities and types of documentation maintained. In some cases, a table of
contents that lists program components may be suitable supporting documentation to attach with
the written description of the program.
- Worksite Analysis
For each element listed in this section, describe any corporate policies or procedures which
pertain to or prescribe the way each element should be conducted across your Corporation’s
facilities. If you do not have a corporate-level policy regarding an element, indicate that
there is no corporate-wide policy for the element.
- Hazard Analysis of Routine Jobs, Tasks, and Processes
- Hazard Analysis of Significant Changes
- Self-Inspection
- Employee Reports of Hazards
- Accident and Incident Investigations
- Trend/Pattern Analysis
- Hazard Prevention and Control
For each element listed in this section, describe any corporate policies or procedures which
pertain to or prescribe the way each element listed below should be conducted across your
Corporation (all facilities). If you do not have a corporate-level policy regarding an element,
indicate that there is no corporate-wide policy for the element.
- Engineering Controls
- Administrative Controls
- Work Practice Controls
- Personal Protective Equipment
- Safety and Health Rules
- Preventive/Predictive Maintenance
- Occupational Health and Care Program
- Emergency Preparedness
- Written Safety and Health Programs (e.g. Hazard Communication, Lockout/Tag out.
See Appendix D, Corporate VPP Application Checklist)
- Safety and Health Training
- Describe any safety and health training programs administered from the corporate-level,
and any conferences, seminars, workshops implement regarding safety and health.
Describe which courses, if any, are mandatory for managers, supervisors, or employees.
- Describe any uniform, corporate-wide policies that apply across all corporate facilities
pertaining to the formal and informal safety and health training provided for managers,
supervisors, and employees.
F. Renewal
- OSHA will develop a process for renewal of VPP Corporate recognition and will renew
the Corporation’s participation in VPP Corporate Pilot every 3 -5 years. This renewal is
required for remaining active in for VPP Corporate Pilot.
- Annually submit, by February 15, a copy of the most recent Annual Corporate Safety and
Health Report. This report should include a description of any success stories, such as
reductions in workers’ compensation rates, increases in employee involvement, and
improvements in employee morale.
Appendix A
Definitions
- Outreach:
- VPP-Related Outreach – Assistance and information provided to prospective VPP
applicants, including, but not limited to: conducting VPP workshops at conferences,
providing training in support of the VPP, holding community safety days, and serving
as an advocate in the business community for the VPP.
- Outreach (Other) – Assistance and information provided to either other internal
corporate entities or external corporations to promote general safety and health
principles and practices, including, but not limited to: participation in OSHA Strategic
Partnerships and Alliances, making presentations on safety and health issues at
conferences, or conducting training workshops.
- Mentoring:
- Informal Mentoring – One-on-one assistance from a VPP participant to a prospective
VPP participant (from their own company or someone from another company) to help
them improve their safety and health management system and/or prepare an application
for VPP.
- VPPPA Formal Mentoring – One-on-one assistance from a VPP participant to a
prospective participant from another company to help them improve their safety and
health management system and/or prepare an application for VPP. This program is
administered by the VPPPA. (Adapted from VPP Technical and Educational Directive,
page 1-4)
- Special Government Employee (SGE) Program:
- An applicant to the VPP Corporate Pilot must demonstrate a commitment to supporting
employees from their organization to receive training and being certified to become
Special Government Employees (SGE) and to provide these individuals' services as
members of a VPP onsite evaluation team.
- Pre-Screening Processes:
- Applicants to the VPP Corporate Pilot must have a system to evaluate potential
candidate facilities against the VPP requirements. The pre-screening evaluation must
include a worksite auditing system to identify program deficiencies that do not to
satisfy VPP criteria for the Merit or Star Level. A pre-screening process must also be
established to review and determine the completeness of the candidate facilities’ VPP
application prior to submission to OSHA.
- Temporary Employees. Employees hired on a non-permanent basis
by the applicant/participant site.
- Applicable Contractors: Those employers hired to provide services and whose employees
worked a total of 1,000 or more hours in at least 1 calendar quarter at your worksite.
- Contract Employees. Workers who are employed by a company that provides services
under contract to the VPP applicant or participant, usually at the VPP applicant's or
participant's worksite.
Appendix B
Written Statement of Assurances
In signing this document, the management of [insert company name], hereby assures that:
- We will comply with the Occupational Safety and Health Act (OSH Act) and correct at all
our facilities, 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).
- We are committed to doing our best to provide outstanding safety and health protection to
our employees through effective safety and health management systems and employee
involvement.
- Any employee with safety or health related duties will be protected from discriminatory
actions resulting from these duties, just as Section 11(c) of the Act and 29 CFR 1960.46(a)
protect employees who exercise their rights.
- We agree to provide the necessary safety and health and VPP information to the OSHA
Onsite Evaluation Team. We agree to retain these records until OSHA communicates its
decision regarding initial VPP participation. (OSHA Federal Register Notice 65:45649-
45663)
- We understand that any materials we feel are confidential or revealing of trade secrets,
OSHA will view in accordance with trade secret laws and ensure information does not
become subject to Freedom of Information Act requests.
- We will follow renewal process required by OSHA to remain in the VPP Corporate Program.
- We will annually submit by February 15th a copy of the most recent Annual Corporate
Safety and Health Report that includes new information and any major achievements and
successes in our safety and health management systems.
- Withdrawal – 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: ____________________________________
Signature: ________________________________
Title: ____________________________________
Date: ____________________________________
Signature: ________________________________
Title: ____________________________________
Date: ____________________________________
Appendix C
Sample VPP Pre-Screening Process
The next section provides the process used by Georgia Pacific (GP) Corporation to prepare GP
facilities for application for VPP membership. Also, comprehensive checklists are used by GP to
evaluate the implementation of the safety and health management system. Several of these
checklists are provided as examples.
1.0 PURPOSE
To provide a step-by-step procedure for Georgia-Pacific Corporation locations to certify
and maintain their VPP certifications.
2.0 PROCESS
2.1 INITIAL DECISION
2.1.1 The VPP process begins with the decision by the facility management and
employees/union to pursue VPP certification. This pursuit includes a
thorough review of the programs, physical facility, and management
systems, and may entail substantial upgrading of any one or all of these. It
will ultimately result in the preparation and submission of a VPP Application. The Corporate VPP
Managers in the Corporate Safety Office
or the nearest OSHA Regional (or State) Office can assist the GP facility
with questions about the application guidelines.
The facility should contact the appropriate VPP manager and their
divisional HR Director/VP to obtain the proper authorization to pursue
VPP and ensure the proper resources are allocated.
2.1.2 The VPP coordinator for the facility will help coordinate a structured plan
of action. A review of the facility’s safety performance will include a
comparison of the facility total case (TCIIR) and days away and restricted
(DART) incidence rates for the most recent 3 years against the most
recently published BLS rates for the facility SIC.
2.2 PREPARATIONS AND APPLICATION SUBMITTAL
2.2.1 An initial on-site comprehensive review will be conducted by a VPP
Manager or Corporate Safety representative to assess and establish a
baseline for the facility. The review will include a detailed examination of
the written safety programs to ensure they are site-specific and reflect the
current processes of the facility. The VPP manager and/or Corporate
Safety representative will advise the facility on the proper presentation of
the written programs and documentation. This is most commonly referred
to as the Binder System (see appendix A). Interviews will be conducted of
facility management and employees to assess the level of knowledge and
interest in safety and VPP. In addition, a detailed inspection will be
conducted of the physical facility. Areas of concern will be identified and
the VPP manager and/or Corporate Safety representative will assist the
facility in determining the best course of action to address any issues.
2.2.2 The Binder System is a foundation to the VPP application and certification
maintenance process. Simply put, this system is a well-organized, systematic method of presenting
and maintaining all documentation of necessary written programs, inspections and corrective actions, and
training. It is composed of a set of 3-ring binders, each devoted to a
safety-related subject area. A detailed guideline has been included at the
end of this APM to assist the facility in this process. (It should be noted
that this is a guideline. If a binder is listed and does not apply to your
facility then it is not required that it be included. The facility may also
choose to expand and include a binder not listed in the guideline.) The
main purpose of the Binder system is to provide the facility with a method
to quickly and efficiently access documentation needed to create the VPP
application. It will also serve the facility during the OSHA on-site review
as well as during future Corporate Safety evaluations.
2.2.3 The VPP Application is constructed by the facility with guidance from the
VPP manager. It is vital that the facility follows the appropriate
application format for their OSHA Region or State Plan. While similar,
each State Plan or Region follows its own format. The VPP manager or
OSHA contact can advise the facility as to the proper format.
Once the VPP Application is completed, and prior to submission to the
nearest OSHA Region (or State Plan) Office, it must be reviewed by the
appropriate Corporate VPP Manager to ensure that it is ready for OSHA’s
review. This is to ensure, as well, that all appropriate documents, exhibits,
and/or attachments are properly included.
Upon final review by the appropriate VPP Manager, two (2) copies of the
VPP Application should be prepared and submitted to the nearest OSHA
Region (or State Plan) Office. This review process could take up to forty-five
(45) days.
2.3 ONSITE REVIEW
2.3.1 Upon final review and acceptance by OSHA, an OSHA VPP
representative will contact the facility to set up a mutually agreeable onsite
evaluation date. OSHA must visit the facility to verify that the safety
and health programs described in the VPP Application are fully
operational and address all potential hazards at the facility. This
evaluation will include a thorough review of the OSHA Logs and back-up
medical documentation; an appraisal of written site-specific programs, an
assessment of the facility’s physical conditions, interviews of management
and employees, both formally and informally, and the preparation of a
draft report.
2.3.2 The on-site portion of the review typically takes about four (4) days. The
OSHA on-site Team consists, at a minimum, of a Team Leader, Safety
Specialist, and an Industrial Hygienist, and if a PSM-covered process, a
PSM Specialist. The Team will hold a brief introductory meeting with the
facility’s key management and employee representatives. Employees who
are accountable for meeting or maintaining VPP requirements should also
attend. During the opening conference, the facility should give a brief
overview of the site layout and processes, the safety system, and highlight
any particular achievements.
2.3.3 Normally one to two days of the on-site week will consist of program
reviews, while one to two days are devoted to the physical inspection.
Employee interviews are conducted off and on all week. The onsite team
normally has lunch with representatives of the facility, featuring a “best
practice” safety presentation conducted by non-management personnel.
2.3.4 Before leaving, the Team will have a closing meeting to discuss its
findings and recommendations. If Team members think that additional
work needs to be done before approval into VPP, they may make 90-day
recommendations for the work to be completed.
If Team members determine that a major component of one or more of the
required elements is missing, the Team will recommend Merit rather than
Star level certification, and recommend Merit Goals that the site must
complete.
General recommendations may be made regarding
enhancements/improvements in the safety and health programs.
2.4 CONDUCT
2.4.1 Conduct during the VPP on-site should be maintained at a professional
level at all times. It is important to remember that the OSHA team is at the
facility because they were invited to be there. OSHA is not there on a
compliance or complaint review. As part of the VPP commitment, we
agree to work with OSHA to resolve any issues or concerns that may arise
during the on-site review. If a disagreement occurs, instead of engaging
the OSHA team, refer to the VPP manager or Corporate Safety
representative assisting with your on-site for guidance in resolving the
issue.
2.4.2 OSHA uses the employee roster to select employees for the formal
interviews. The facility needs to provide OSHA with an accurate list of
employees including identifying specific employees such as committee
members, union officials, etc. This will help the on-site team ensure they
have a chance to interview the VPP leadership of the facility. If a selected
employee has concerns about talking with OSHA let the team leader know
and he or she may choose to make another selection.
2.5 FOLLOW-UP
2.5.1 The facility must follow up to ensure that all 90-Day items are completed
on time and OSHA is notified of the completed items. This will ensure
the final report is not delayed. If a facility is recommended for Merit then
the OSHA on-site team will establish specific Merits Goals that must be
completed within an 18-24 month period. Completion and status of these
goals must be communicated to the appropriate VPP Manager and OSHA.
Once the Merit Goals are completed OSHA will then coordinate an on-site
visit to verify completion of the Merit Goals and to ensure all other VPP
criteria has been maintained before upgrading the facility to VPP Star
level.
2.6 CERTIFICATION
2.6.1 The OSHA VPP team’s on-site report is reviewed at Region and National
level before the facility is notified of its official certification at Star or
Merit level in a letter from the Assistant Secretary of Labor, USDOL.
State Plans have a similar state-level review and notification process.
2.6.2 When notified of the official certification, the facility should contact its
VPP Manager and Corporate Communicator to arrange for a celebration
event during which OSHA will present the Star or Merit certificate and
flag to the facility.
2.7 RECERTIFICATION
2.7.1 Recertification of a VPP Merit site is normally conducted on an 18-24
month schedule.
2.7.2 Recertification of a VPP Star site is normally conducted on a 3 to 5 year
schedule, depending on the strength of the Star program at the facility and
the policy of the Region or State Plan. First time certifications can expect
a third year review.
2.7.3 Recertifications normally follow the same process as the original on-site.
This includes a complete review of the written, site-specific safety
programs, tracking systems, management systems, physical inspection of
the facility, and employee interviews. The recertification on-site is 3-4
days with a team of at least 3 members.
At the time of this revision, Region IV OSHA has a pilot program for
recertifications for sites that meet specific requirements. The program is
referred to as the “OSHA Day.” Facilities that have maintained excellent
safety programs, have experienced a low number of injuries, and have not
experienced any major changes or events may qualify for this program.
Those facilities meeting the requirements will undergo recertification
during a one-day visit. OSHA will focus on a small number of safety
programs, conduct interviews with a limited number of employees, and
will conduct a streamlined physical inspection. The facility will not know
which programs are to be reviewed until the actual on-site.
2.8 ANNUAL REPORT
2.8.1 Each Merit and Star site must file an annual VPP Report to OSHA by
February 15th of each year. Each Region or State Plan has a format
specific to their program. The VPP Manager, Corporate Safety Team
member, or OSHA representative will advise you as to which format to
utilize. A copy of the Annual Report should be forwarded to the
appropriate VPP Manager for review. The Annual Report informs OSHA
of the facility’s updated TCIIR and DART rates, changes in key personnel
or processes, safety activities, accomplishments, and goals. It also
demonstrates the facility’s continued commitment to VPP and safety.
1. REVIEW OF MANAGEMENT SYSTEMS
1.1. OSHA RECORDKEEPING (APM-131)
___
___
___
___
___ |
Location is following current federal guidelines
for OSHA Recordkeeping.
OSHA 300 is posted from February 1 – April 30.
OSHA 300/200 entries are consistent with medical, first aid, accident investigations, & medical
reports.
OSHA Form 301/101 or equivalent form is on file for each entry on the log.
OSHA poster is displayed in a readily accessible area of the facility. |
1.2. ACCIDENT INVESTIGATIONS (APM-121)
___
___
___
___
___
___
___
___ |
Location has written Accident Investigation
Procedure with assigned responsibilities.
Recordable, first aid, property damage and near miss injuries/events are all investigated.
Root causes are identified in each accident investigation report.
Corrective actions to eliminate root causes are identified in each accident investigation
report.
Accountability is assigned for implementing each corrective action, with timetables.
Tracking system exists to ensure that corrective actions are made in timely manner.
Individuals involved in accident investigation are trained.
Investigation report indicates when corrective measures were taken and by whom. |
1.3. SAFETY & HEALTH PROGRAM PLANNING (APM 341)
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___ |
Location has a current Safety Action Plan (SAP).
Management has set goals and activities to improve safety & health performance.
Above goals and activities are reviewed quarterly and updated annually.
Trends of injuries & illnesses by dept., job title, nature of injury, etc., have been analyzed.
A site-specific action plan is being followed to reduce injuries & illnesses where trends are
high.
Facility has written procedures for doing JHAs and SOPs with assigned responsibilities.
Job hazard analyses (JHAs) have been conducted for the most hazardous jobs.
Written safe operating procedures (SOPs) based on JHAs are in place.
JHAs and SOPs are reviewed when accidents occur and revisions made if determined to be
necessary.
Individuals involved in writing/reviewing JHAs/SOPs have been trained.
Facility has written procedures for inspections with assigned responsibilities.
Individuals involved in inspections have been trained in inspection techniques.
Supervisors are personally involved in periodic self-inspections.
Routine self-inspections with written reports are conducted at least monthly.
Tracking system exists to ensure findings from JHAs and inspections are adequately addressed to
conclusion.
Facility has written procedures for pre-use analysis of new equipment and chemicals.
Evaluation of equipment and processes (new) prior to use is documented. |
1.4. MANAGEMENT COMMITMENT (APM 341)
___
___
___
___
___
___
___
___ |
Top management periodically participates in safety
meetings and inspections.
Top management reviews accident reports and safety committee minutes.
Production meetings are opened with discussion of safety performance and activities.
Crew safety meetings are held regularly for all departments, with written minutes kept.
Safety and health rules specific to the location are written, posted and communicated to all
employees.
Specific safety & health responsibilities have been assigned for all levels of management.
Annual evaluations (all management levels) are based upon performance of these specific
responsibilities.
Disciplinary action is taken for safety and health infractions and this is documented. |
1.5. EMPLOYEE INVOLVEMENT (APM 341)
___
___
___
___
___
___ |
Location has joint management-employee safety
committee that meets regularly.
Written minutes of safety committee meetings are kept and action items tracked for follow-up
until completed.
Safety committee members are trained in all safety and health functions they are expected to
perform.
Safety committee members participate in walk-around inspections, JHA/SOP completion/review and
accident investigations.
Location has system for employees to notify management of hazards with adequate, timely and
documented response.
Tracking system exists to ensure adequate and timely responses to employee safety concerns. |
1.6. SAFETY & HEALTH TRAINING (APM-383)
___
___
___
___
___
___
___
___
___
___
___ |
Location has an annual schedule for training that
ensures all OSHA-required topics are covered.
Training pertinent to the location as identified in APM #383 is provided.
New employee orientation is conducted and documented.
Tracking system exists to ensure all supervisors and employees get pertinent training.
Documented training is provided on all specific topics, substances, etc. upon transfer to a new
position.
Make-up sessions are held for employees who miss scheduled OSHA-required training.
Documentation exists for class content (lesson plans or minutes) & understanding (tests,
observation).
Record of employee attendance at training is maintained with signatures (sign-off forms,
rosters). Tracking system exists to ensure all supervisors and employees get pertinent training.
Employee feedback about the training is obtained using evaluations or other methods.
The training program is evaluated and updated at least annually based on employee
Feedback, observation of training effectiveness and new or revised regulations. |
2. SAFETY PROGRAMS:
2.1. PERSONAL PROTECTIVE EQUIPMENT (APM-351)
___
___
___
___
___ |
Location has a written certified hazard assessment
that identifies the PPE required for each job, task, or area.
The hazard assessment identifies the location, date, and signature of the certifying person.
Each employee (new, transferred, when PPE requirements change, or at least annually) who is
required to wear PPE is trained in the limitations, use, care and disposal of the PPE.
Written certification is maintained that the employee understood the training, which identifies
the subject of the training, the date conducted, trainer’s signature, and the names of the
employees trained.
Location has an inspection system that ensures that all defective PPE is removed from service. |
Appendix D
Corporate VPP Application Checklist
The checklist below serves a dual purpose. It provides guidance for applicants on the type of
information to provide in the Corporate VPP Application for each VPP element and sub-element. The
checklist should also be used by the Corporate Office/Headquarters to inform candidate facilities
applying for VPP, the information provided in the Corporate VPP Application. This coordination will
eliminate duplication of effort and ensure only necessary information is provided at the
Corporate-level and at the facility-level.
For elements below, describe in detail specific information that clearly explains how the
requirement is being satisfied. Include information such as responsibilities, tracking, reporting,
and recordkeeping. Submit with the application sample documents such as memorandums, charts, brief
reports, or any other forms of written communication that demonstrate corporate fulfillment of
requirements for these elements. In most cases, listing of key elements and a brief description of
each or including a table of contents is adequate. Do not submit lengthy written programs or
procedures. The complete written policy/ plan/program/procedure may be reviewed during the OSHA
Corporate Program Evaluation.
| ELEMENT |
SUGGESTED FORMAT |
YES |
NO |
| Corporate Eligibility |
| Commitment to VPP |
Describe policy
Attach a list of facilities and a schedule
(time-table) for obtaining VPP approval |
|
|
| Prescreening Processes (Facility and Application) |
Attach process description and table of contents or
outline main sections |
|
|
| Outreach/Mentoring |
Attach a list of current and/or planned outreach and
mentoring activities. |
|
|
| Special Government Employee (SGE) Participation |
Attach a list of current and/or planned SGE
participation. |
|
|
| Corporate
Commitment |
| Philosophy |
Provide written philosophy |
|
|
| Communication |
Provide examples of written communication that
describes corporate commitment to worker safety and health. |
|
|
| Knowledge of Safety and Health Performance |
Summarize policy for reporting safety and health
performance to senior managers. Attach table of contents of reports and other types of information |
|
|
| Responsibility/Organization: |
Provide organization chart/list policy that
establishes responsibilities for safety and health |
|
|
| Accountability |
Define responsibilities of managers and employees and
provide examples of performance standards |
|
|
| Resource Management |
Describe policy and process for planning allocation
of budget |
|
|
| Corporate Goals and Performance Report |
Attach table of contents from report such as
strategic plan, annual report, etc. |
|
|
| Corporate Environmental, Safety and Health
Certifications and Awards |
List all applicable certifications and awards |
|
|
| Employee
Involvement and Contractors |
| Employee Involvement |
Summarize policy and provide examples |
|
|
Notification:
- Orientation
- Non-Discrimination
- Records Access |
Summarize policy
Attach any examples of notification documents |
|
|
| Contractors |
Summarize policy, responsibilities List of specific
rules/regulations |
|
|
| Worksite
Analysis |
| Hazard Analysis of Routine Jobs, Tasks, and Processes |
Describe responsibilities, frequency, documentation,
corrective actions, inspection forms, tracking |
|
|
| Hazard Analysis of Significant Changes |
Describe responsibilities, frequency, documentation,
corrective actions, inspection forms, tracking |
|
|
| Routine Self-Inspections |
Describe responsibilities, frequency, documentation,
corrective actions, inspection forms, tracking |
|
|
| Hazard Reporting System for Employees |
Summarize process, attach sample forms
(if applicable) |
|
|
Investigation of Accidents and
Near-Misses |
Describe responsibilities, procedure and
investigation guidelines, investigation forms, follow-up
Attach sample forms (if applicable) |
|
|
| Trend/ Pattern Analysis |
Summarize process
Attach sample analysis report or outline of key sections |
|
|
| Hazard
Prevention and Control |
| Engineering Controls |
Describe policy
List/describe key elements |
|
|
| Administrative Controls |
Describe policy
List/describe key elements |
|
|
Work Practice Controls and
Hazard Control Programs |
Describe program responsibilities
List/describe key elements |
|
|
| Personal Protective Equipment (PPE) |
Describe program - responsibilities
List/describe key elements |
|
|
| Safety and Health Rules |
Describe awareness, enforcement, disciplinary
procedures |
|
|
| Preventive/Predictive Maintenance |
Describe program - responsibilities
Attach table of contents
List/describe key elements |
|
|
| Occupational Health Care Program |
Describe program – responsibilities
Attach table of contents
List/describe key elements |
|
|
| Emergency Preparedness |
Describe program – responsibilities
List/describe elements of Emergency Action Plans
List/describe elements of Emergency Evacuation Procedures |
|
|
| Safety and
Health Written Programs |
| Recordkeeping and Posting |
Describe responsibilities
List records maintained and posting requirements |
|
|
| Hazard Communication |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Blood borne Pathogens |
Describe policy
Attach table of contents
List/describe key elements |
|
|
Employee Exposure
Assessment/Industrial Hygiene |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Confined Space Entry |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Trenching and Excavation |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Elevated Work and Fall Protection |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Mobile Equipment and Material Handling |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Respiratory Protection |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Hearing Conservation |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Personal Protective Equipment |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Asbestos and Lead Management |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Fire Prevention and Protection |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Hot Work Permitting |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Electrical Safe Work Practices |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Spill Release and Prevention |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Emergency Evacuation Plan |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Ergonomic Awareness Program |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Process Safety Management |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Lockout/Tagout |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| Fleet Safety |
Describe policy
Attach table of contents
List/describe key elements |
|
|
| List any others below: |
|
|
|
| |
|
|
|
| |
|
|
|
| Safety and
Health Training |
| Managers |
Describe policy
Attach list of all required training |
|
|
| Supervisors |
Describe policy
Attach list of all required training |
|
|
| Employees |
Describe policy
Attach list of all required training |
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
|
Printing Instructions
Back to Top
www.osha.gov
