Instructions: The purpose of this template is to help
participants and OSHA staff share successes and best practices as a direct
result of participating in OSHA’s Voluntary Protection Programs (VPP). Once
completed, please submit this form to
Jaclyn Schede,
Office of State Programs, OSHA’s National Office.
*Note: Any information submitted may be posted to OSHA’s public web page or used in other outreach activities.
I. General Information: Please
complete the below table.
| Date Submitted: ____________________ |
| Submitted By |
Company/Agency Name |
Email |
Phone |
| |
|
|
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| Year/Date Entered VPP |
|
| NAICS |
|
#employees
covered: |
|
# of employers |
|
This submission is a (both can be checked if applicable):
|
|
Success Story – A story that highlights successes
resulting from participating in the OSHA cooperative program such as reduced
TCIR and DART rates, increased workers’ compensation savings, increased employee
involvement and morale, increased management commitment, increased productivity,
and the overall impact of participating in the OSHA cooperative program. |
| |
|
|
|
Best Practice – A story involving an innovative and
effective method or system for improving worker safety and health resulting in
superior outcomes. (Example: changing work processes to reduce ergonomic
injuries resulting in improved employee morale and reduced workers’ compensation
costs.) |
II. Success Story or Best Practice Narrative: Please check the appropriate box
or boxes below that your story includes, followed by your narrative. Each
narrative should include two or three paragraphs (at most).
It is possible that a story may include one category.
|
|
Quantitative (ex: reductions in illness and injury rates;
workers compensation savings) |
|
|
|
|
|
Anecdotal/Human Interest (ex: increased management
commitment; increased employee involvement, morale) |
|
|
|
|
|
Quote (quotes from employees, management, corporate
leadership, union officials) |
III. Quantitative Results Data: Please appropriately complete
the below table to provide data for the most recent three year period if
you are submitting a success story that includes rate and/or number reductions.
You do not need to complete every column – just what relates to your
story.
| |
*TCIR |
**DART |
Dollar Value of Workers Compensation Claims |
***Insurance EMR Rate |
| Year 1: |
|
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|
|
| Year 2: |
|
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|
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| Year 3: |
|
|
|
|
3-Year Rate
(Avg.) |
|
|
|
|
2007 Bureau of Labor Statistics’
National Average (by Industry) |
|
|
|
|
* TCIR: (Total Case Incident Rate) = (# of injuries x 200,000) / total hours
worked
** DART: (Days Away, Restricted, Time away) = (# of lost time injuries x
200,000) / total hours worked
***EMR: Experience Modifier Rate
Thank you for promoting
OSHA’s Cooperative Programs!
|
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