Voluntary Protection Program, Special Government Employee

Attachment A

Format for Annual VPP Participant Submissions

Effective 12/1/12

This document replaces Appendix C of the April 18, 2008 VPP Policies and Procedures Manual. It will be made available on OSHA’s VPP webpage.

OSHA requires each VPP participant to perform annually a self-evaluation of its safety and health management system. This self-evaluation, reflecting the previous calendar year’s experience, must be submitted to the participant’s OSHA Regional VPP Manager by February 15 of each year. Participants will find it useful to review the VPP Federal Register Notice, 74 FR 927, January 9, 2009, which includes annual submission requirements, safety and health management system requirements applicable to all participants, plus additional requirements unique to the participant’s chosen way to participate.

OMB Control Number: 1218-0239 Expires 01-31-2018

Public reporting burden for this collection of information is estimated to average 20 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Cooperative and State Program U.S. Department of Labor, 200 Constitution Ave., Suite N3700 NW, Washington, DC 20210-4537 and reference the OMB Control Number 1218-0239

The annual self-evaluation is not a compliance audit. It is a critical review to assess the effectiveness of all four VPP elements and their sub-elements, and to analyze participant and contractor injury and illness data and trends. It should include a review of written programs, a walk-through of the workplace, and interviews with employees. During this process, participants should answer the following questions relating to each element and sub-element of their safety and health management system:

1. Is it comprehensive?

2. Is it operating effectively and meeting established goals and objectives?

3. Are there problems that require the development and implementation of solutions in order to maintain excellent worker protection and continued VPP eligibility?

4. What improvements can be made to make it even more effective?

5. What goal modifications should be made for the upcoming year?

OSHA expects the evaluation to include participant and applicable contractor injury and illness data, progress toward Merit or 1-Year Conditional Star goals (if applicable), and success stories, including best practices. OSHA uses the submitted information to update records and statistics, showcase successes related to implementation of the VPP requirements, and demonstrate that participants are committed to continuous improvement of worker safety and health at their facilities.

Additionally, participants that fall under OSHA’s Process Safety Management (PSM) standard must provide responses to all applicable questions found in the PSM Supplement B questionnaire. The responses must cover all PSM operations within the site/DGA.

OSHA encourages participants to use the following suggested format in preparing their annual self-evaluation submission:

Revised Suggested Format for Participant’s Annual Submission

Section A: Summary Information

Table A-1 Participant Summary Sheet
To be completed by all VPP Participants
VPP Participant Name Address Phone							Calendar Year					Date Submitted
Corporate Information (if different from above)			Name Address Phone
Site/DGA Manager Name Phone E-Mail Fax			Site/DGA VPP Contact Name Phone E-Mail Fax				NAICS Code
							VPP Status
Does the site have Pressure Vessels?					Does the site fall under the OSHA PSM Standard? (If yes, you must complete PSM Supplement B.)
To be completed by Site-Based Non-Construction Participant (1)
Number of Employees			Hours Worked					TCIR			DART Rate
Summary – All Applicable Contractors of a Site-Based Non-Construction Participant (2)
Total Number of Applicable Contractor Employees	Hours Worked Onsite of All Applicable Contractor Employees					Combined Applicable Contractor TCIR				Combined Applicable Contractor DART Rate
To be completed by Site-Based Construction or Mobile Workforce Participant (3)
Total Number of All Site/DGA Employees Including All Contractor Employees		Hours Worked of All Site/DGA Employees Including All Contractor Employees		Combined TCIR					Combined DART Rate

(1) Site-based Non-Construction Participants: Enter the average number of employees employed at the site and the total hours worked by the participant’s own employees (including temporary and contractor employees regularly intermingled with and directly supervised by participant employees) at the approved site. Injury and illness data should correspond with information normally found in the appropriate column of the participant’s OSHA 300 (A) Summary of Work-Related Injuries and Illnesses and optional worksheets.

(2) Summary of Applicable Contractors of Site-Based Non-Construction Participants: All data in these cells must reflect the combined employee numbers and hours worked of only applicable contractors’ employees at the approved site. Applicable contractor data must not be combined with participant employee numbers and site hours unless contractor employees are regularly intermingled with and directly supervised by participant employees.

(3) Site-Based Construction and Mobile Workforce Participants: All data must reflect the combined workforce of participant employees and all contractor/subcontractor employees.

Table A-2 Union Information
Union Name
Union Local Number
Union Representative for the Site/DGA
Address
Phone
E-Mail
Fax

Section B: Injury & Illness Rate Information

Injury and illness rate information for the previous calendar year must be received in the Regional Office or appropriate Field Office no later than February15th of each year, along with your annual self-evaluation.

(1) Site-based Non-Construction Participants: Use Table B-1 below to submit data for your own site employees including temporary employees and any contractor employees regularly intermingled with and directly supervised by your employees. On the Participant Summary Sheet (see Section A, Table A-1), you will record some of the data you record in Table B-1.

(2) Site-based Non-Construction Participants with Applicable Contractors: Use Table B-2. Provide a separate Table B-2 for each applicable contractor (an applicable contractor is a contractor whose employees worked 1,000 hours or more at your site in any calendar quarter). Report applicable contractor injury and illness experience only for work at your site. Do not combine this data with your own site employee data. The NAICS code should reflect the applicable contractor’s primary work activity at your site, and not necessarily the participant’s NAICS code. On the Participant Summary Sheet (see Section A, Table A-1) you will record combined data for all applicable contractors.

(3) Site-Based Construction and Mobile Workforce Participants: Use Table B-1. Submit combined work hours and combined injuries and illnesses of all employees. This must include your own employees including temporary employees plus all contractor/subcontractor employees. Use this combined data to calculate your site or DGA TCIR and DART rate. On the Participant Summary Sheet (see Section A, Table A-1) you also will record combined data.

Table B-1 VPP Participant’s Recordable Non-Fatal Injury and Illness Case Incidence Rates
1	2	3	4	5	6	7
Year	Total Number Employees	Total Work Hours	Total Number of Injuries & Illnesses	Total Case Incidence Rate for Injuries and Illnesses (TCIR)	Total Number of Injury & Illness Cases Involving Days Away from Work, Restricted Work Activity, and/or Job Transfer	Days Away from Work, Restricted Work Activity, and/or Job Transfer Rate (DART rate)
Most recent published BLS rate for NAICS code _________
Percent above or below National Average
Participant’s 3-Year TCIR and DART rate

Table B-2 Applicable Contractor Recordable Nonfatal Injury and Illness Case Incidence Rates (for use by site-based non-construction participants) (for the applicable contractor’s work at your site only)
Name of Applicable Contractor
NAICS Code for applicable contractor’s work at your site
1	2	3	4	5	6	7
Year	Total Number Employees*	Total Work Hours	Total Number of Injuries & Illnesses	Total Case Incidence Rate for Injuries and Illnesses (TCIR)	Total Number of Injury & Illness Cases Involving Days Away from Work, Restricted Work Activity, and/or Job Transfer	Days Away from Work, Restricted Work Activity, and/or Job Transfer Rate (DART Rate)
Most recent published BLS rate for NAICS code _________
Percent above or below National Average

* Estimated average number of applicable contractor employees.

Calculating Rates for Tables B-1 and B-2

Annual rates are calculated by the formula (N/EH) x 200,000 where:

N = Total number of recordable nonfatal injuries and illnesses during the calendar year. Site-based non-construction participants: This number will be the total injuries and illnesses of your site employees including temporary employees and any contractor employees regularly intermingled with and directly supervised by your employees. Site-based construction participants and mobile workforce participants: This number will be total injuries and illnesses of your own employees plus all contractor/subcontractor employees.

For the TCIR use the total number of injuries and illnesses.

For the DART rate use injuries and illnesses resulting in days away from work, restricted work activity, and/or job transfer.

EH = Total number of hours worked by employees during the year. Site-based non-construction participants: This number will be hours worked by your site employees including temporary employees and any contractor employees regularly intermingled with and directly supervised by your employees. Site-based construction participants and mobile workforce participants: This number will be hours worked by your own employees including temporary employees and contractors directly supervised by applicant/participant plus all contractor/subcontractor employees.

200,000 = equivalent of 100 full‑time employees working 40 hours per week, 50 weeks per year.

BLS data: Insert the TCIR and DART rates for your industry from the Bureau of Labor Statistics (BLS) Table of Incidence Rates of Nonfatal Occupational Injuries and Illnesses by Industry. Find the table at www.BLS.gov or obtain from your Regional VPP Manager. Compare your rates to the most recently published BLS average rates for your industry: Calculate the percent above or below the BLS national average for your TCIR and DART rates using the formula: [(Site rate - BLS rate) ¸ BLS rate] x 100.

When Participant Rates Have Increased

If your 1-year site/DGA TCIR or DART rate has increased since last year, you must identify and describe the contributing factors and corrective actions you have taken. Include this information in the narrative evaluation of each related element and sub-element. See Section D below.

If your 3-year site/DGA TCIR or DART rate now exceeds the highest rate of the last 3 years published by the BLS statistics for your NAICS code, you must submit a rate reduction plan based on your findings. Contact your Regional VPP Manager to discuss the terms of your rate reduction plan.

Section C: Significant Events or Changes

Describe the impact of any significant event, the change that occurred, and the steps taken to ensure or restore employee safety and health e.g. change in management, corporate buy-out, complaint, accident, catastrophe, fatality, etc.

Section D: Narrative Evaluation of Safety and Health Management System

In narrative form, describe the effectiveness of each of the four elements (and their sub-elements) of your safety and health management system. They are:

1. Management Leadership and Employee Involvement

a. Management Commitment to Safety and Health Protection and to VPP Participation

b. Policy

c. Goals, Objectives, and Planning

d. Visible Top Management Leadership

e. Responsibility and Authority

f. Line Accountability

g. Resources

h. Employee Involvement

i. Contract Employee Coverage

j. Written Safety and Health Management System

2. Worksite Analysis

a. Hazard Analysis of Routine Jobs, Tasks, and Processes

b. Hazard Analysis of Significant Changes, New Processes, and Non-Routine Tasks

- Including pre-use analysis and new baselines

c. Routine Self-Inspections

d. Hazard Reporting System for Employees

e. Industrial Hygiene Program

f. Investigation of Accidents and Near-Misses

g. Trend/Pattern Analysis

3. Hazard Prevention and Control

a. Certified Professional Resources

b. Hazard Elimination and Control Methods

- Engineering Controls

- Administrative Controls

- Work Practice Controls and Hazard Control Programs

- Safety and Health Rules and Disciplinary System

- Personal Protective Equipment

c. Process Safety Management (if applicable)

d. Occupational Health Care Program

e. Preventive/Predictive Maintenance

f. Tracking of Hazard Correction

g. Emergency Preparedness

4. Safety and Health Training

a Managers

b. Supervisors

c. Employees

d. Emergencies

e. PPE

For each sub-element also include a description of:

• Improvements made since the previous year and completion of the previous year's recommendations.

• Any deficiencies identified, recommendations for improvement, the person(s) responsible for fulfilling each new recommendation, target dates for their completion, and the data/information reviewed to assess the effectiveness of the sub-element.

Section E: Summary Chart of Merit or 1-Year Conditional Goals

Please fill in the table below, using as many rows as necessary to summarize all of the goals currently awaiting completion of implementation, either from the previous year or the current year.

Goal	Status
Goal 1:
Goal 2:
Goal 3:

Section F: Best Practices and Success Stories

Please describe any best practices and/or 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.

Attachment A - 1