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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.

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.

Year	Hours	Total # of Cases	TCIR Rate	Number of Cases Involving Days Away from Work, Restricted Activity or Job Transfer	DART Rate
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

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

<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.]

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)

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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. MRØ
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.

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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. MRØ
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.

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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? MRØ

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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. MRØ
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. MRØ
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. MRØ
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?

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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. MRØ
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. MRØ

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
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? MRØ
F4. Do employees feel free to participate in the safety and health management system without fear of discrimination or reprisal? If so, please explain. MRØ
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.

			How Assessed
Section I: Management Leadership & Employee Involvement	Yes or No		Interview	Observation	Doc Review
G. Safety and Health Management System Evaluation
G1. Is there a minimally effective system for conducting accident/incident investigations, including near-misses? If not, please explain.
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. MRØ
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?

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.

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
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. MRØ
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. MRØ
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?

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
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?

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
C. Hazard Analysis of Routine Activities
C1. Is there at least a minimally effective hazard analysis system in place for routine operations and activities? MRØ
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?

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
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. MRØ
D2. Are routine safety and health inspections conducted monthly, with the entire site covered at least quarterly (construction sites: entire site weekly)? MRØ
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? MRØ
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.

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
E. Hazard Reporting
E1. Is there a minimally effective means for employees to report hazards and have them addressed? If not, please explain. MRØ
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.

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
F. Hazard Tracking
F1. Does a minimally effective hazard tracking system exist that result in hazards being controlled? If not, please explain. MRØ
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.

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
G. Accident/Incident Investigations
G1. Is there a minimally effective system for conducting accident/incident investigations, including near-misses? If not, please explain. MRØ
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.

			How Assessed
Section II: Worksite Analysis	Yes or No		Interview	Observation	Doc Review
H. Trend Analysis
H1. Does the site have a minimally effective means for identifying and assessing trends? MRØ
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.

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.

			How Assessed
Section III: Hazard Prevention and Control	Yes or No		Interview	Observation	Doc Review
A. Hazard Prevention and Control
A1. Does the site select at least minimally effective controls to prevent exposing employees to hazards? MRØ
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.
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? MRØ
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?
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. MRØ
A22. Which chemicals that trigger the Process Safety Management (PSM) standard are present? MRØ
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? MRØ
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. MRØ
A25. Is the PSM program adequate in that it addresses the elements of the PSM standard and the PSM directive? Please explain. MRØ

			How Assessed
Section III: Hazard Prevention and Control	Yes or No		Interview	Observation	Doc Review
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. MRØ
C2. Is the recordkeeper knowledgeable of 29 CFR 1904, OSHA’s recordkeeping standard? MRØ
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. MRØ
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.

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.

			How Assessed
Section IV: Safety and Health Training	Yes or No		Interview	Observation	Doc Review
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? MRØ
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. MRØ
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.

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.

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:
Type of Visit: Initial Approval: ____________ Reevaluation: ___________		Participation: Site-based: __________________ Mobile Workforce: ___________ Corporate: __________________
MAO Requested: Yes_____ No_______ If Yes, Date:	MAO Rec’d Before Onsite: Yes_____ No_______		Date MAO Rec’d:
90/30 Day Items: Yes_____ No_______		Date 90/30 Day Items Completed:
Team Members Team Leader (TL): Back-Up Team Leader: Team Member 2: Team Member 3: Team Member 4: Team Member 5:		Discipline of Members Team Leader: Back-Up Team Leader: Team Member 2/or indicate if SGE: Team Member 3/or indicate if SGE: Team Member 4/or indicate if SGE: Team Member 5/or indicate if SGE:

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

	Application Review	Onsite Prep	Onsite	Report Writing	Total
Team Hours Spent (Est)