Challenge Administrator

CHALLENGE ADMINISTRATOR APPLICATION AND INSTRUCTIONS

1. Complete the Challenge Administrator Application. If you intend to use a Challenge Coordinator to assist you as you work with Challenge participants, please complete a Challenge Coordinator Application for each proposed Coordinator.

2. Write and sign a Challenge Administrator letter of commitment. A sample letter of commitment is at the end of this application.

3. To submit electronically, attach the completed Challenge Administrator Application (and, if applicable, any completed Challenge Coordinator Applications) and a scanned copy of the signed Challenge Administrator letter of commitment to an email and send it to Annis.Jackie@dol.gov.

To submit via hard copy, send the completed Challenge Administrator Application (and, if applicable, any completed Challenge Coordinator Applications) and the signed Challenge Administrator letter of commitment to:

Jackie Annis

Industrial Hygienist

Directorate of Cooperative and State Programs

Occupational Safety and Health Administration

200 Constitution Avenue, NW, Room N3700

Washington, DC 20210

If you have questions about OSHA Challenge or the Challenge Administrator application Process, please contact Office of Partnerships and Recognition at 202-693-2213.

OMB Control No.1218 – 0239 Expires xx-xx-xxxx

Public reporting burden for this collection of information is voluntary and is estimated to average 5 hours per response, including time for reviewing instructions, 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 Office of Partnerships and Recognition, Department of Labor, Room N-3700, 200 Constitution Avenue, N.W., Washington, DC 20210

Challenge Administrator Application
Contact Information
Organization Name:
Organization Type (e.g., private company, federal agency, association, etc.):
Administrator Name within Organization:
Administrator Title within Organization:
Administrator Work Address:
Administrator Phone Number:
Administrator Fax Number:
Administrator Email Address:
Knowledge and Experience
In 400 words or less, please describe your organization’s knowledge and experience with developing, implementing, and evaluating safety and health management programs. Experience may include involvement in other OSHA cooperative programs such as the Voluntary Protection Programs, the OSHA Strategic Partnership Program, and/or experience in administering and evaluating corporate-wide safety and health programs.
Resources
In 100 words or less, please confirm the availability of resources (e.g., time and personnel) to administer OSHA Challenge and guide the Challenge participants through the Challenge stages.
Data Collection
In 250 words or less, please provide a description of what your process will be for collecting progress reports and baseline and quarterly/annual data from each of your Challenge participants and ensuring that the data obtained is accurate.

Note: Although it is not required, Challenge Administrators may select Challenge Coordinators to assist them in managing their Challenge participants. If the Challenge Administrator chooses to have a Challenge Coordinator, please complete this form. If the Challenge Administrator chooses to have more than one Challenge Coordinator, please complete a separate application for each prospective Challenge Coordinator.

Challenge Coordinator Application
Contact Information
Organization Name:
Organization Type (e.g., private company, federal agency, association, etc.):
Coordinator Name within Organization:
Coordinator Title within Organization:
Coordinator Work Address:
Coordinator Phone Number:
Coordinator Fax Number:
Coordinator E-mail Address:
Name of Challenge Administrator:
Knowledge and Experience
In 200 words or less, please describe the prospective Challenge Coordinator’s knowledge and experience in safety and health management programs.
Training and Certifications
In 150 words or less, please describe any relevant safety and health training completed (e.g., OSHA Special Government Employee training) and certifications that the prospective Challenge Coordinator has completed.
Evaluation Experience
In 200 words or less, please describe any relevant experience the prospective Challenge Coordinator has with evaluating safety and health management programs.

Challenge Administrator Application

Sample Letter of Commitment

Ms. Elizabeth Way

Director, Office of Partnerships and Recognition

Directorate of Cooperative and State Programs

Occupational Safety and Health Administration

200 Constitution Avenue, NW, Room N3700

Washington, DC 20210

Dear Ms. Way:

I am writing to inform you of the intent of <organization name> to participate in OSHA Challenge and serve as a Challenge Administrator. We have reviewed the OSHA Challenge requirements and believe <organization name> meets the necessary criteria. We assure you that <organization name> is committed to assisting Challenge participants progress through the Challenge stages and achieve an effective safety and health management program and to fulfilling the responsibilities inherent in being a Challenge Administrator.

Attached please find our Challenge Administrator Application which includes the Challenge Coordinator Information form (if applicable). Should you have any questions or need additional information, please contact me at <organization representative telephone number> or <organization representative email address>.

Sincerely,

<Organization representative name>

<Organization representative title>

<Organization name>

OSHA Challenge Administrator Application – revised 051012