Site-Based Participation

Evaluation Report

Company Name
City, State

Onsite Evaluation Date

Month – Start/End Date, 20XX

VPP Evaluation Team

Name, Title
Name, Title
Name, Title
Name, Title
Name, Title
0
 EXECUTIVE SUMMARY

I. Purpose and Scope of Review

An onsite review was conducted from <Date>, at the <Organization> in <City, State>. The
purpose of the evaluation was to determine the site’s <eligibility or continued eligibility> for
site-based participation in the Occupational Safety and Health Administration’s (OSHA)
Voluntary Protection Programs (VPP). The VPP Evaluation Team consisted of:

Name, Title/Special Government Employee (SGE), Office, City, State

Name, Title/Special Government Employee (SGE), Office, City, State
Name, Title/Special Government Employee (SGE), Office, City, State
Name, Title/Special Government Employee (SGE), Office, City, State
Name, Title/Special Government Employee (SGE), Office, City, State

II. Methods of Data Collection

The information for this report was obtained from the site’s VPP application, documentation
reviewed onsite, interviews with employees and management personnel, annual evaluation
reports, and physical observations of the facility(ies).

III. Employees at the Worksite

There are <XXX> employees working on site. In addition, there are <XXX> contractor
employees onsite performing maintenance, capital projects, guard services, janitorial services,
etc. Employees at the site are represented by the <insert union name(s) and local(s)>.
(Employees at the site are not represented by a collective bargaining agent.) Formal interviews
were conducted with <XX >site employees and <XX> contract employees. Informal interviews
were conducted with <XXX> site employees and <XXX> contract employees.

IV. The Worksite

The site is properly classified under North American Industrial Classification System (NAICS)
code <XXXXXX>. Provide a description of the site, e.g., size, location, operation, buildings,
etc. Describe the site’s processes, productions, and applications. Housekeeping at the
facility was considered by the VPP Evaluation Team to be <please select one: poor, fair, good
or excellent>.

V. Worksite Hazards

The hazards at the site include, but are not limited to <state hazards>. The site <does or does
not> use chemicals considered to be highly hazardous and in sufficient quantity to place the site
under the Process Safety Management (PSM) Standard.

1
VI. Injury and Illness Rates

The three-year Total Case Incidence Rate (TCIR) and Days Away/Restricted/Transferred Case
Incidence (DART) rate for the period <20XX-20XX> are <XX> and <XX>, respectively. The
site TCIR is <XX%> <above/below>, and the DART rate is <XX%> <above/below> the 20XX
Bureau of Labor Statistics (BLS) industry average for NAICS code <XXXXXX> for 20XX.

Team leader must verify that a comparison has been conducted against the site’s injury and
illness rates reviewed during the evaluation and the site’s injury and illness rates reported in its
annual self- evaluation.

Number of
Cases
Involving Days
Year Hours Total # of TCIR Away from DART
Cases Rate Work, Rate
Restricted
Activity or Job
Transfer
20XX
20XX
20XX
Total
Three-Year Rate (20XX-20XX)
BLS National Average for 20XX
(NAICS XXXXXX)
20XX YTD

VII. OSHA Activity

There has been no OSHA inspection activity or fatalities at this site within the past <XX> years.
The site maintains an excellent relationship with its local OSHA Area and Regional offices.

VIII. Elements of the VPP Review/Program Changes

The VPP Evaluation Team has examined each of the required elements of the site’s safety and
health management programs. All VPP requirements have been met and all OSHA standards are
appropriately covered.

Bullet summary information of VPP Elements.

 Management Leadership and Employee Involvement
 Worksite Analysis
 Hazard Prevention and Control
 Safety and Health Training

2
<For Reapproval evaluations>, discuss significant program or site changes since the last visit.
A bulleted list is acceptable. [For Star reapproval evaluations recommending One-Year
Conditional, add the following sentence: Refer to Section XI for discussion of safety and health
management program corrections.]

<Incentive Programs>The site utilizes an incentive program which meets the requirements of
revised Memorandum #5: Further Improvements to the Voluntary Protection Programs (VPP)
dated 8/14/14. OR The site does not utilize an incentive program.

<Whistleblower Activity(ies)> Briefly document the site’s policy on anti-retaliation/

discrimination. Indicate whether the site has had or not had any whistleblower activity(ies)
within the past <XX> years. If so, include brief description and findings/outcome.

IX. Areas of Excellence

All elements of the site's safety and health management programs met the high quality expected
of VPP participants (or describe the program requirements that you considered an area of
excellence). NOTE: Do not characterize the safety and health management programs as
meeting the high quality expected of VPP participants if the team is recommending One-Year
Conditional reapproval.

X. Recommendation for Participation

The VPP Evaluation Team recommends <Site name, City, State> be approved for participation
in the OSHA VPP <Star or Merit> Program (add if relevant but placed on One-Year
Conditional status or but required to develop an agreed upon Two-Year Rate Reduction Plan).

XI. Goals (if applicable)

 Merit Goal(s) (if relevant)

 One-Year Conditional Goal(s) (if relevant)
 Two-Year Rate-Reduction Plan (if relevant)

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0
Site-Based Participation
Site Worksheet

Company Name
City, State

Onsite Evaluation Date

Month – Start/End Date, 20XX

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 How
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Yes
or
No
Section I: Management Leadership & Employee Involvement

A. Written Safety & Health Management System

A1. Are all the elements (such as Management Leadership and Employee Involvement, Worksite
Analysis, Hazard Prevention and Control, and Safety and Health Training) and sub-elements of a basic
safety and health management system part of a signed, written document? (For Federal Agencies,
include 29 CFR 1960.) If not, please explain.


A2. Have all VPP elements and sub-elements been in place at least 1 year? If not, please identify
those elements that have not been in place for at least 1 year.


A3. Is the written safety and health management system at least minimally effective to address the
scope and complexity of worksite hazards? If not, please explain. MRX


A4. Have any VPP documentation requirements been waived (as per FRN, VOL. 74, NO. 6, 01/09/09
page 936, IV, A.4.)? If so, please explain.

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Section I: Management Leadership & Employee Involvement

B. Management Commitment & Leadership

B1. Does management overall demonstrate at least minimally effective, visible leadership with respect
to the safety and health management system (as per FRN, VOL. 74, NO. 6, 01/09/09 page 936, IV. A.5.
a-h)? Provide examples. MRX

B2. How has the site communicated established policies and results-oriented goals and objectives for
employee safety to employees?


B3. Do employees understand the goals and objectives for the safety and health management system?


B4. Are the safety and health management system goals and objectives meaningful and attainable?
Provide examples supporting the meaningfulness and attainability (or lack there of if answer is no) of
the goal(s). (Attainability can either be unrealistic/realistic goals or poor/good implementation to
achieve them.)


B5. How does the site measure its progress towards the safety and health management system goals
and objectives? Provide examples.

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Section I: Management Leadership & Employee Involvement
C. Planning
C1. How does the site integrate planning for safety and health with its overall management planning
process (for example, budget development, resource allocation, or training)?


C2. Is safety and health effectively integrated into the site’s overall management planning process? If
not, please explain.


C3. For site-based construction sites, is safety included in the planning phase of each project? MRX

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Section I: Management Leadership & Employee Involvement

D. Authority and Line Accountability

D1. Does top management accept ultimate responsibility for safety and health? (Top management
acknowledges ultimate responsibility even if some safety and health functions are delegated to others.)
If not, please explain. MRX


D2. How is the assignment of authority and responsibility documented and communicated (for
example, organization charts, job descriptions, etc.)?


D3. Do the individuals assigned responsibility for safety and health have the authority to ensure that
hazards are corrected or necessary changes to the safety and health management system are made? If
not, please explain. MRX


D4. How are managers, supervisors, and employees held accountable for meeting their responsibilities
for workplace safety and health? (Are annual performance evaluations for managers and supervisors
require?)


D5. Are adequate resources (equipment, budget, or experts) dedicated to ensuring workplace safety
and health? Provide examples. MRX


D6. Is access to experts (for example, Certified Industrial Hygienists, Certified Safety Professionals,
Occupational Nurses, or Engineers), reasonably available, based upon the nature, conditions,
complexity, and hazards of the site? If so, under what arrangements and how often are they used?

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Section I: Management Leadership & Employee Involvement

E. Contract Employees
E1. Does the site utilize contractors? Please explain.


E2. Were there contractors/sub-contractors onsite at the time of the evaluation?


E3. When selecting onsite contractors/sub-contractors, how does the site evaluate the contractor’s
safety and health management system and performance (including rates)?


E4. Are contractors and subcontractors required to maintain an effective safety and health
management system and to comply with all applicable OSHA and company safety and health rules and
regulations? If not, please explain.


E5. Does the site’s contractor program cover the prompt correction and control of hazards in the event
that the contractor/sub-contractor fails to correct or control such hazards? Provide examples. MRX


E6. How does the site document and communicate oversight, coordination, and enforcement of safety
and health expectations to contractors?


E7. Have the contract provisions specifying penalties for safety and health issues been enforced, when
appropriate? If not, please explain.


E8. How does the site monitor the quality of the safety and health protection of its contract employees?

E9. Do contract provisions for contractors require the periodic review and analysis of injury and
illness data? Provide examples

E10. If the contractors’ injury and illness rates are above the average for their industries, describe the
site’s procedures that ensure that all employees are provided effective protection on the worksite? If
yes, please explain.


E11. Based on your answers to the above items, is the contract oversight minimally effective for the
nature of the site? (Inadequate oversight is indicated by significant hazards created by the contractor,
employees exposed to hazards, or a lack of host audits.) If not, please explain. MRX

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Section I: Management Leadership & Employee Involvement
F. Employee Involvement
F1. How were employees selected to be interviewed by the VPP team?


F2. How many employees were interviewed formally? How many were interviewed informally?


F3. Do employees support the site’s participation in the VPP? MRX


F4. Do employees feel free to participate in the safety and health management system without fear of
discrimination or reprisal? If so, please explain. MRX


F5. Are employees meaningfully involved in the problem identification and resolution, or evaluation
of the safety and health management system (beyond hazard reporting). (As per FRN page 936 IV,
A.6.) For site-based construction sites, does the company encourage strong labor-management
communication in the form of supervisor and employee participation in toolbox safety meetings and
training, safety audits, incident investigations, etc.?


F6. Are employees knowledgeable about the site’s safety and health management system? If not,
please explain.


F7. Are employees knowledgeable about the VPP? If not, please explain.


F8. Are the employees knowledgeable about OSHA rights and responsibilities? If not, please explain.


F9. How were employees informed of the safety and health management system, VPP and OSHA
rights and responsibilities? Please explain.

F10. Did management verify employee’s comprehension of the site’s safety and health management
system, VPP and OSHA rights and responsibilities?


F11. Do employees have access to results of self-inspection, accident investigation, appropriate
medical records, and personal sampling data upon request? If not, please explain.

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Section I: Management Leadership & Employee Involvement

G. Safety and Health Management System Evaluation

G1. Briefly describe the system in place for conducting an annual evaluation.


G2. Does the annual evaluation cover the aspects of the safety and health management system,
including the elements described in the Federal Register? If not, please explain. MRX


G3. Does the annual evaluation include written recommendations in a narrative format? If not,
please explain.


G4. Is the annual evaluation an effective tool for assessing the success of the site’s safety and health
management system? Please explain.


G5. What evidence demonstrates that the site responded adequately to the recommendations made
in the annual evaluation?


G6. Is the annual evaluation conducted by competent site, corporate or other trained
personnel experienced in performing evaluations?

8
Section I: Management Leadership & Employee Involvement
Merit Goals: (Include cross- reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations: (optional)

1.

2.

Documents Referenced, Programs Reviewed: (optional)

1.

2.

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Section II: Worksite Analysis

A. Baseline Hazard Analysis

A1. Has the site been at least minimally effective at identifying and documenting the common safety
and health hazards associated with the site (such as those found in OSHA regulations, building
standards, etc., and for which existing controls are well known)? If not, please explain. MRX


A2. What methods are used in the baseline hazard analysis to identify health hazards? (Please
include examples of instances when initial screening and full-shift sampling were used. See FRN
page 937, B.2.b)


A3. Does the company rely on historical data to evaluate health hazards on the worksite? If so, did
the company identify any operations that differed significantly from past experience and conduct
additional analysis such as sampling or monitoring to ensure employee protection? If so, please
describe.


A4. Does the site have a documented sampling strategy used to identify health hazards and assess
employees’ exposure (including duration, route, and frequency of exposure), and the number of
exposed employees? If not, please explain. MRX


A5. Do sampling, testing, and analysis follow nationally recognized procedures? If not, please
explain.


A6. Does the site compare sampling results to the minimum exposure limits or are more restrictive
exposure limits (PELs, TLVs, etc.) used? Please explain.


A7. Does the baseline hazard analysis adequately identify hazards (including health) that need
further analysis? If not, please explain. For site-based construction sites, does the hazard analysis
include studies to identify potential employee hazards, phase analyses, task analyses, etc.?


A8. Does industrial hygiene sampling data, such as initial screening or full shift sampling data,
indicate that records are being kept in logical order and include all sampling information (for
example, sampling time, date, employee, job title, concentrated measures, and calculations)? If not,
please explain the deficiencies and how they are being addressed.


A9. For site-based construction sites, are hazard analyses conducted to address safety and health
for each phase of work?


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Section II: Worksite Analysis

B. Hazard Analysis of Significant Changes

B1. When purchasing new materials or equipment, or implementing new processes, what types of
analyses are performed to determine impact on safety and health, and are these analyses adequate?


B2. When implementing/introducing non-routine tasks, materials or equipment, or modifying
processes, what types of analyses are performed to determine impact on safety and health, and are
these analyses adequate?

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Section II: Worksite Analysis

C. Hazard Analysis of Routine Activities

C1. Is there at least a minimally effective hazard analysis system in place for routine operations and
activities? MRX

C2. Does hazard identification and analysis address both safety and health hazards, if appropriate?
If not, please explain.


C3. What hazard analysis technique(s) are employed for routine operations and activities (e.g., job
hazard analysis, HAZ-OPS, fault trees)? Please explain.


C4. Are the results of the hazard analysis of routine activities adequately documented? If not,
please explain.

C5. For site-based construction sites, are hazard analyses conducted to address safety and health
hazards for specialty trade contractors during each phase of work?


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Section II: Worksite Analysis

D. Routine Inspections
D1. Does the site have a minimally effective system for performing safety and health inspections
(i.e., a minimally effective system identifies hazards associated with normal operations)? If not,
please explain. MRX


D2. Are routine safety and health inspections conducted monthly, with the entire site covered at
least quarterly (construction sites: entire site weekly)? MRX


D3. For site-based construction sites, are employees required to conduct inspections as often as
necessary, but not less than weekly, of their workplace/area and of equipment? MRX


D4. Does the site incorporate hazards identified through baseline hazard analysis, accident
investigations, annual evaluations, etc., into routine inspections to prevent reoccurrence?

D5. Are employees conducting inspections adequately trained in hazard identification? If not,
please explain.


D6. Is the routine inspection system written, including documentation of results indicating what
needs to be corrected, by whom, and by when? If not, please explain.


D7. Did the VPP team find hazards that were not found/noted on the site’s routine inspections? If
so, please explain.

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Section II: Worksite Analysis
E. Hazard Reporting
E1. Is there a minimally effective means for employees to report hazards and have them addressed? If
not, please explain. MRX


E2. Does the hazard reporting system have an anonymous component?


E3. Does the site have a reliable system for employees to notify appropriate management personnel in
writing about safety and health concerns? Please describe.


E4. Do the employees agree that they have an effective system for reporting safety and health
concerns? If not, please explain

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Section II: Worksite Analysis
F. Hazard Tracking
F1. Does a minimally effective hazard tracking system exist that result in hazards being controlled? If
not, please explain. MRX


F2. Does the hazard tracking system result in hazards being corrected and provide feedback to
employees for hazards they have reported? If not, please explain.


F3. Does the hazard tracking system result in timely correction of hazards with interim protection
established when needed? Please describe.


F4. Does the hazard tracking system address hazards found by employees, hazard analysis of routine
and non-routine activities, inspections, and accident or incident investigations? If not, please explain

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Section II: Worksite Analysis

G. Accident/Incident Investigations
G1. Is there a minimally effective system for conducting accident/incident investigations, including
near-misses? If not, please explain. MRX


G2. Is the accident/incident investigation policy and procedures documented and understood by
all? If not, please explain.

G3. Is there a reporting system for near-misses that include tracking, etc.? If not, please explain.


G4. Are those conducting the investigations trained in accident/incident investigation techniques?
Please explain what techniques are used, e.g., Fault-Tree, Root Cause, etc.


G5. Describe how investigators discover and document all the contributing factors that led to an
accident/incident or a near-miss.


G6. Were any uncontrolled hazards discovered during the investigation previously addressed in any
prior hazard analyses (e.g., baseline, self-inspection)? If yes, please explain.


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Section II: Worksite Analysis

H. Trend Analysis
H1. Does the site have a minimally effective means for identifying and assessing trends? MRX


H2. Have there been any injury and/or illness trends over the last three years? If so, please
explain.


H3. Did the team identify trends that should have been identified by the site? If so, please describe.


H4. If there have been injury and/or illness trends, what adequate courses of action have been
taken? Please explain.


H5. Does the site assess trends utilizing data from hazard reports and/or accident/incident
investigations to determine the potential for injuries and illnesses? If not, please explain.


H6. Are the results of trend analyses shared with employees and management and utilized to
direct resources, prioritize hazard controls and modify goals to address trends? If not, please
explain.

17
 Section II: Worksite Analysis
Merit Goals: (Include cross- reference to section, subsection, and question, e.g., II.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations: (optional)

1.

2.

Documents Referenced, Programs Reviewed: (optional)

1.

2.

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Section III: Hazard Prevention and Control

A. Hazard Prevention and Control

A1. Does the site select at least minimally effective controls to prevent exposing employees to hazards?
MRX

A2. When the site selects hazard controls, does it follow the preferred hierarchy (engineering controls,
administrative controls, work practice controls [e.g., lockout/tagout, bloodborne pathogens, and
confined space programs], and personal protective equipment) to eliminate or control hazards? Please
provide examples, such as how exposures to health hazards were controlled.


A3. Describe any administrative controls used at the site to limit employee exposure to hazards (for
example, job rotation).


A4. Do the work practice controls and administrative controls adequately address those hazards not
covered by engineering controls? If not, please explain.


A5. Are the work practice controls (e.g., lockout/tagout, bloodborne pathogens, and confined space
programs) recommended by hazard analyses implemented at the site? If not, please explain.


A6. Are follow-up studies (where appropriate) conducted to ensure that hazard controls were
adequate? If not, please explain.


A7. Are hazard controls documented and addressed in appropriate procedures, safety and health rules,
inspections, training, etc.? Provide examples.

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Section III: Hazard Prevention and Control

Disciplinary System
A8. Are there written employee safety procedures including a disciplinary system? Describe the
disciplinary system?


A9. Has the disciplinary system been clearly communicated and enforced equally for both management
and employees, when appropriate? If not, please explain.


Emergency Procedures
A10. Does the site have minimally effective written procedures for emergencies? MRX


A11. Did the site explain the frequency and types of emergency drills held (including at least an
evacuation drill annually)?


A12. Is the emergency response plan updated as changes occur in the work areas e.g., evacuation routes
or auditory systems?


A13. Did the site describe the system used to verify all employees’ participation in at least one
evacuation drill each year?


Preventative/Predictive Maintenance
A14. Does the site have a written preventative/predictive maintenance system? If not, please explain.


A15. Did the hazard identification and analysis (including manufacturers’ recommendations) identify
hazards that could result if equipment is not maintained properly? If not, please explain.


A16. Does the preventive maintenance system detect hazardous failures before they occur? If not, please
explain. Is the preventive maintenance system adequate?


Personal Protective Equipment (PPE)
A17. How does the site select Personal Protective Equipment (PPE)?


A18. Did the site describe the PPE used at the site?

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Section III: Hazard Prevention and Control


A19. Where PPE is required, do employees understand that it is required, why it is required, its
limitations, how to use it, and how to maintain it? If not, please explain.


A20. Did the team observe employees using, storing, and maintaining PPE properly? If not, please
explain.


Process Safety Management (PSM)
A21. Is the site covered by the Process Safety Management standard (29 CFR 1910.119)? If yes, please
answer questions A22-A25 below. Additionally, please complete either the onsite evaluation supplement
A or B, and the onsite evaluation supplement C. If not, skip to section B. MRX


A22. Which chemicals that trigger the Process Safety Management (PSM) standard are present? MRX


A23. Which process(es) were followed from beginning to end and used to verify answers to the questions
asked in the PSM application supplement, the PSM Questionnaire, and/or the Dynamic Inspection
Priority Lists? MRX


A24. Verify that contractor employees who perform maintenance, repair, turnaround, major renovation
or specialty work on or adjacent to a covered process have received adequate training and demonstrate
appropriate knowledge of hazards associated with PSM, such as non-routine tasks, process hazards, hot
work, emergency evacuation procedures, etc.? Please explain. MRX


A25. Is the PSM program adequate in that it addresses the elements of the PSM standard and the PSM
directive? Please explain. MRX


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Section III: Hazard Prevention and Control

B. Occupational Health Care Program

B1. Describe the occupational health care program (including availability of physician services, first
aid, and CPR/AED) and special programs such as audiograms or other medical tests used.


B2. How are licensed occupational health professionals used in the site’s hazard identification and
analysis, early recognition and treatment of illness and injury, and the system for limiting the severity of
harm that might result from workplace illness or injury? Is this use appropriate?


B3. Is the occupational health program adequate for the size and location of the site, as well as the
nature of hazards found here? If not, please explain.


C. Recordkeeping
C1. Are OSHA required recordkeeping forms being maintained properly in terms of accuracy, form
completion, etc.? If not, please explain. MRX


C2. Is the recordkeeper knowledgeable of 29 CFR 1904, OSHA’s recordkeeping standard? MRX


C3. What records were reviewed to determine compliance with the recordkeeping standard?


C4. Do the injury and illness rates accurately reflect work performed by contractors/sub-contractors
at the site evaluated? Please explain. MRX


C5. Was there any evidence of recordable injuries/illnesses not being reported due to management
pressure, production concerns, incentive programs, etc.? If yes, please explain.

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 Section III: Hazard Prevention and Control
Merit Goals: (Include cross reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations: (optional)

1.

2.

Documents Referenced, Programs Reviewed: (optional)

1.

2.

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Yes

Section IV: Safety and Health Training

A. Safety and Health Training
A1. What are the safety and health training requirements for managers, supervisors, employees, and
contractors? Please explain.


A2. Is the training delivered by qualified instructors?

A3. Does the training provided to managers, supervisors, and non-supervisory employees (including
contract employees) adequately address safety and health hazards? MRX


A4. Does the company/site operate an effective safety and health orientation program for all employees
including new hires? Please explain.


A5. How are the safety and health training needs for employees determined? Please explain.


A6. Does the site provide minimally effective training to educate supervisors and employees (including
contract employees) regarding the known hazards of the site and their controls? If not, please explain.
MRX


A7. Are managers, supervisors, and non-supervisory employees (including contract employees) taught
the safe work procedures to follow in order to protect themselves from hazards during initial job
training and subsequent reinforcement training?


A8. Who is trained in hazard identification and analysis?


A9. Is training in hazard identification and analysis adequate for the conditions and hazards of the
site? If not, please explain.


A10. Does management have a thorough understanding of the hazards of the site? Provide examples
that demonstrate their understanding.


A11. Do managers, supervisors, and non-supervisory employees (including contract employees) and
visitors on the site understand what to do in emergency situations? Please explain.

24
 Section IV: Safety and Health Training
Merit Goals: (Include cross reference to section, subsection, and question, e.g., I.B2)

1.

2.

90-Day Items: (Delete this section for final transmittal to National Office)

1.

2.

Best Practices:

1.

2.

Comments including Recommendations: (optional)

1.

2.

Documents Referenced, Programs Reviewed: (optional)

1.

2.

25
 VPP Participant and Onsite Evaluation Team Data Sheet

VPP Participant Information:

Company Name:

Site Address:

Mailing Address:

Site Manager Name:

Site Manager Phone: Site Manager E-mail Address:

VPP Contact Name: if same as Site Manager, state “same as above”

VPP Contact Phone: VPP Contact E-mail Address:

Small Employer (<250 employees onsite AND <500 employees corporate-wide: Yes_____ No_______

NAICS Code: No. of site employees: No. of site contract employees:

Union Information

Union Name & Local No.:

Site Representative:

Mailing Address:

Telephone Number:

Union Information

Union Name & Local No.:

Site Representative:

Mailing Address:
 Telephone Number:

Onsite Evaluation Team Information:

Evaluation Start Date: Evaluation End Date:
Participation:
Site-based: __________________
Type of Visit:
Mobile Workforce: ___________
Initial Approval: ____________ Reevaluation: ___________
Corporate: __________________

MAO Rec’d Before Onsite:

MAO Requested: Yes_____ No_______
Yes_____ No_______ Date MAO Rec’d:
If Yes, Date:

90/30 Day Items: Yes_____ No_______ Date 90/30 Day Items Completed:
TCIR/DART 3-Year Rate Change: Yes_____ No______
If Yes, Explain:
(Onsite vs. Annual Submission)
Team Members Discipline of Members
Team Leader (TL): Team Leader:
Back-Up Team Leader: Back-Up Team Leader:
Team Member 2: Team Member 2/or indicate if SGE:
Team Member 3: Team Member 3/or indicate if SGE:
Team Member 4: Team Member 4/or indicate if SGE:
Team Member 5: Team Member 5/or indicate if SGE:

PARTICIPANT AREAS OF EXCELLENCE/BEST PRACTICES CHECKLIST

Ergo Program Confined Space Program LO/TO Program

PSM Hazard Analysis Contractor Program
Medical Program Self-Inspections Accountability
Industrial Hygiene Employee Involvement Tracking of Hazards
Pre-Job Analysis Other:      

STRATEGIC PLAN
High Hazard Industries
Landscaping – 078 Oil/Gas – 138 Fruits/Vegetables 203
Concrete/Gypsum/Plaster – 327 Blast Furnace/Steel Production – 331 Ship/Boat Building/Repair – 373
Wholesale Storage – 422

Hazards
Ergo Lead Silica
Amputations – Construction Amputations – General Industry

VPP CORPORATE TRACKING

Application Onsite Prep Onsite Report Total

Review Writing
Team Hours Spent (Est)