Apx E Interim-Year SHARP Self-Eval (CPPM doc)

Approved Form

OMB Number: 1218-XXXX

Expiration Date: XX-XX-2026

Paperwork Reduction Act Notice

Persons are not required to respond to this collection of information unless it displays a valid OMB control number. The Occupational Safety and Health Administration (OSHA) requires State On-Site Consultation program Consultants to review the Interim Year Safety and Health Achievement Recognition Program (SHARP) Site Self-Evaluation Template completed and submitted by employers participating in SHARP and provide any necessary technical assistance.

Employers participating in SHARP must conduct continuous assessment of the effectiveness of the safety and health program implemented in their workplace; complete the Interim Year SHARP Site Self-Evaluation Template in the year following the last on-site evaluation by the Consultant to assess criteria for SHARP participation; and submit the template to the Consultation program.

In accordance with 29 CFR 1908.6(h)(1) and (2), Consultants must preserve the confidentiality of information obtained as a result of a consultative visit, including information that contains or might reveal a trade of secret of the employer.

OSHA estimates that it will take an employer an average of 3 hours to complete the self-evaluation and a Consultant an average of 2 hours to review and provide any necessary technical assistance to facilitate effective safety and health program implementation by small business employers participating in SHARP.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Office of Small Business Assistance, Occupational Safety and Health Administration, Room N-3660, 200 Constitution Avenue, NW, Washington, DC 20210.

Appendix E

Interim-Year Safety and Health Achievement Recognition Program (SHARP) Site Self-Evaluation Template

Establishment Name: Address:

Employer/Representative’s Name: Title/Position:

Date:

1. Safety and Health Program Recommendations and Status: SHARP participants are committed to continue maintaining and improving their Safety and Health Programs. Please explain the systems you are working on to maintain or improve or any recommendations you are acting on, and any actions you have taken to improve your safety and health program in the past year.

1. Program/Recommendations:

Status:

2. Program/Recommendations:

Status:

3. Program/Recommendations:

Status:

4. Program/Recommendations:

Status:

2. Significant Events: Please discuss below any significant events that have occurred over the past year and the steps that you have taken to ensure that your safety and health program is operating effectively. (Include any fatalities, catastrophes, imminent danger incidents, recordable serious injuries and illnesses, complaints, OSHA enforcement inspections, and the results of all investigations and program changes made.)

1. Event:

Correction:

2. Event:

Correction:

3. Days Away, Restricted, or Transferred (DART) Rate and Total Recordable Case Rate (TRC) Requirements:

DART Rate Calculation
Year	Hours Worked	Sum of Columns H + I*	Rate
Employer's Two-Year or Three-Year Rate: ___________ Bureau of Labor Statistics (BLS) Average for NAICS: ______________ Percent Below the BLS Rate: ______________

________________________________
*OSHA Form 300

TRC Rate Calculation
Year	Hours Worked	Sum of Columns H + I + J*	Rate
Employer's Two-Year or Three-Year Rate: ___________ BLS Average for NAICS: ______________ Percent Below the BLS Rate: ______________

*OSHA Form 300

4. Other Safety and Health Program Improvements: Please outline improvements that you have made or activities you have engaged in to improve your safety and health program.

Please provide accurate information. Submit a copy of your establishment’s most recent OSHA Forms 300 and 300A as well as injury and illness incident reports with the self-evaluation. You must promptly correct any deficiencies noted by the Consultation program upon review.