State Plan Policies and Procedures Manual | Occupational Safety and Health Administration

Record Type:

OSHA Instruction
Current Directive Number:

CSP 01-00-002
Old Directive Number:

STP 2-0.22B
Title:

State Plan Policies and Procedures Manual
Information Date:

03/21/2001
Standard Number:

1902

1908

1953

1954

1956

NOTICE: This is an OSHA Archive Document, and may no longer represent OSHA Policy. It is presented here as historical content, for research and review purposes only.

INSTRUCTION

DIRECTIVE NUMBER: STP 2-0.22B	EFFECTIVE DATE: March 21, 2001
SUBJECT: State Plan Policies and Procedures Manual

ABSTRACT

Purpose:	This instruction cancels and replaces OSHA Instruction STP 2.22A Part II with chapters five through eleven of the OSHA State Plan Policies and Procedures Manual, sets out instructions for States in developing strategic and annual performance plans, and implements revisions to the State plan monitoring system.

Scope:	This instruction applies OSHA-wide.

References:	PL 91-596, The Occupational Safety and Health Act of 1970; OSHA Instruction TED 3.5B, Consultation Policy and Procedures Manual, December 9, 1996; 29 CFR Parts 1902, 1956, and 1954.

Cancellations:	OSHA Instruction STP 2.22A, dated May 14, 1986 and subsequent changes (except Change 3 of February 27, 1990) is cancelled by this Instruction.

State Plan Impact:	States with OSHA-approved plans must adhere to the requirements applicable to them as set out in this manual. No response to this instruction is necessary.

Action Offices:	National, Regional, and Area Offices involved in State plan monitoring and liaison, and States with State plans.

Originating Office:	Directorate of Federal-State Operations

Contact:	Directorate of Federal-State Operations Office of State Programs 200 Constitution Avenue, NW, Room N-3700 Washington, DC 20210 (202) 693-2244

Approval:	By and Under the Authority of R. Davis Layne Acting Assistant Secretary

Major Changes

This manual cancels OSHA Instruction STP 2.22A, dated May 14, 1986 and subsequent changes (except Change 3 of February 27, 1990). It lays out the overall policy framework for monitoring State programs in Chapters 1 and 5 through 11 of the new State Plan Policies and Procedures Manual. Chapters 2 through 4 of the Manual are reserved at this time, but will be incorporated in the near future to cover State plan approval and other policy issues and procedures that currently are contained in separate OSHA regulations, directives and documents. At that time, we will officially replace Change 3 of STP 2.22A through the formal issuance of OSHA's draft, revised procedures for notification, submission, and approval of State plan changes. We will reissue the entire Manual through the OSHA directives system. The major changes in the current document are:

States are required to develop five-year strategic plans and annual performance plans that contain results-oriented program goals.
States must include in their strategic plans a goal that addresses the core purpose of the national OSHA program: "Improve workplace safety and health for all workers, as evidenced by fewer hazards, reduced exposures, and fewer injuries, illnesses and fatalities."
Clearer guidance is established for determining what constitutes State program performance that is at least as effective as Federal program performance. Acceptable State performance is now defined as making reasonable progress toward annual performance goals and carrying out mandated activities.
Regular communication (quarterly discussions) about progress toward strategic and annual performance goals has replaced comparison of State activity levels to Federal levels. C-SPAMs, further review levels, and outliers have been eliminated and replaced with twenty State Activity Mandated Measures.
23(g) grant instructions have been incorporated in this manual and the grant narrative has been replaced by the annual performance plan.
Assurances have been added to the grant application to cover some mandated activities not covered by the State Activity Mandated Measures.
Policy and procedures for monitoring private sector 23(g) consultation have been conformed to the requirements of 29 CFR Part 1908.

Executive Summary

This manual cancels and replaces OSHA Instruction STP 2.22A Part II. It lays out the overall policy framework for monitoring State programs and revises and clarifies processes and procedures for administering and monitoring Consultation Projects operated by State programs.

This manual operationalizes the policy of partnership between OSHA and the States. The new procedures place primary emphasis on achieving significant program results through a common approach of strategic planning and making progress toward strategic and annual goals. This approach allows States to customize their programs to State-specific priorities and conditions. It also refocuses OSHA's monitoring in a way that supports State efforts toward positive program impact and performance improvement.

Table of Contents

Chapter 1
Introduction

Purpose
Scope
Action Information
1. Responsible Office
2. Action Offices
Actions Required
Cancellation
References
Federal Program Change

Chapter 2
Reserved

Chapter 3
Reserved

Chapter 4
Reserved

Chapter 5
Guidelines for Preparing Strategic and Annual Performance Plans

Introduction
Basic Principles
Strategic Plan Requirements
1. Defining Strategic Goals
  
  (a) Mandatory Goal
  (b) Optional Goals
  (c) Possible Approaches
2. Development Procedures
3. Core Elements of a Strategic Plan
Grant Application and Annual Performance Plan Requirements
1. Basic Requirements
2. Grant Application Instructions
  
  (a) Financial Documents
  (b) Annual Performance Plan
Review and Approval of Strategic Plans and the Annual State Plan Grant
1. Strategic Plans
2. Grant Document, including the Annual Performance Plan.
Changes to Strategic and Annual Performance Plans
1. Changes to Strategic Plans
  
  (a) Annual Review of Strategic Plans
  (b) Third-Year Review of Strategic Plans
2. Changes to Annual Performance Plans

Chapter 6
State Plan Monitoring and Evaluation Process

Introduction
Goal of the Monitoring and Evaluation System
Scope of the Monitoring System
Framework of the Evaluation Process
1. Performance Evaluation
2. Performance Tracking and Reports
3. Monitoring Process and Evaluation Tools
4. Dispute Resolution Process
5. Role of the Assistant Secretary
Monitoring Developmental State Plans

Chapter 7
Components of the Monitoring System

Introduction
Monitoring Against Annual Performance Plans
Quarterly Monitoring Discussions
1. Purpose
2. Scheduling
3. Focus of the Quarterly Monitoring Discussions
  
  (a) Discussion Topics
Criteria for Acceptable State Performance
The Annual Monitoring Plan
1. Introduction
2. Timing
3. Content of the Annual Monitoring Plan
The State Internal Evaluation Program

Chapter 8
Mandated Activities

Introduction
Mandated Activities
1. Program Assurances
2. State Activity Mandated Measures (SAMMs)
3. Mandated Activity Report for Consultation (MARC)
State Activity Mandated Measures (SAMM) Report
1. Frequency
2. Data Source
3. Measurement Standard or Guide
4. Guidelines for Use
  
  (a) Initial Review
  (b) Discussion of Findings
  (c) Further Review
Management Information Reports
1. The State Information Report (SIR)
  
  (a) Frequency
  (b) Guidelines for Use
2. Consultation Management Report (CMR)
  
  (a) Frequency
  (b) Guidelines for Use
Other Sources of Data

Chapter 9
Evaluation of State Performance and Annual Reports

Evaluation Reports
State OSHA Annual Report (SOAR)
1. Due Date
2. Development and Review Process
3. Contents of the SOAR
Federal Annual Monitoring and Evaluation (FAME) Report
1. Due Date
2. Development and Review Process
3. Contents of the FAME Report

Chapter 10
Analysis of State Performance

Introduction
1. Analytical Tools
2. Impact Assessment
Automated Performance Data Reports
Documents and Logs
1. Section 23 (g) Grants
2. State Operational Procedures and Policies
3. Tracking Database
4. State Internal Evaluations
5. Other Documents
Case File Review
1. Scope of Review
2. Selection of Case Files
3. Documentation of Findings
Field Monitoring
1. Accompanied Visits
Documentation of Findings

Chapter 11
Complaints About State Program Administration (CASPAs)

Introduction
Determining If a CASPA Warrants Investigation
CASPA Log
Confidentiality
Notification of Concerned Parties and Opportunity for a State Response
1. If an Investigation is Not Warranted
2. If an Investigation is Warranted
Review of Completed CASPA Investigations
1. Communication Between Region and State
2. Response to Complainant
3. Letter to the State
4. State Response
5. Forwarding the Response to Complainant to the Office of State Programs
6. Corrective Action
7. Resolution
Documentation of CASPA Investigations

Appendix A
Definitions of Strategic Planning Terms

Appendix B
Strategic Plan Summary Chart

Appendix C
Sample Chart of Break-out of Personnel

Appendix D
Performance Plan Summary Chart

Appendix E
State Activity Mandated Measures (SAMMs)

Appendix F
Interim State Information Report (SIR)

Appendix G
State OSHA Annual Report: State Results Summary Chart

Appendix H
Sample Acknowledgment Letter to CASPA Complainant

Index

Chapter 1
Introduction

Purpose. This instruction cancels and replaces OSHA Instruction STP 2.22A Part II with chapters five through eleven of the OSHA State Plan Policies and Procedures Manual, sets out instructions for States in developing strategic and annual performance plans, and implements revisions to the State plan monitoring system.
Scope. This instruction applies OSHA-wide.
Action Information.
1. Responsible Office. Directorate of Federal-State Operations, OSHA.
2. Action Offices. National, Regional, and Area Offices involved in State plan monitoring and liaison, and States with State plans.
Actions Required. All offices must implement the policy and procedures contained in this instruction.
Cancellation. OSHA Instruction STP 2.22A, dated May 14, 1986 and subsequent changes (except Change 3 of February 27, 1990) is cancelled by this Instruction.
References.
1. PL 91-596, The Occupational Safety and Health Act of 1970
2. OSHA Instruction TED 3.5B, Consultation Policy and Procedures Manual, December 9, 1996
3. 29 CFR Parts 1902, 1908, 1953, 1954 and 1956
4. OSHA Instruction CPL 2.103, Field Inspection Reference Manual, September 26, 1994
Federal Program Change. States are responsible for following the procedures assigned to them in the manual. No response to this Instruction is necessary.

Chapter 2
Reserved

Chapter 3
Reserved

Chapter 4
Reserved

Chapter 5
Guidelines for Preparing Strategic and Annual Performance Plans

Introduction. This manual specifies the requirements and procedures by which State plan States, in partnership with their Regional Administrators and the National Office, will develop 5-year strategic and annual performance plans comparable to those developed by OSHA in its approach to meeting the Government Performance and Results Act of 1993 (GPRA) requirements. Instructions for completing required financial documents and developing annual performance plans, which are part of the Application for Federal Assistance (Section 23[g] grant application), are included in this chapter. Definitions of strategic planning terms used in this instruction can be found in Appendix A.
Basic Principles. The following basic principles govern States' development of strategic and annual performance plans:
1. Each State must develop a five-year strategic plan made up of outcome-oriented strategic and performance goals.
2. All States must, at a minimum, adopt Federal OSHA's Strategic Goal 1 ("Improve workplace safety and health for all workers, as evidenced by fewer hazards, reduced exposures, and fewer injuries, illnesses and fatalities") as part of their strategic plans, either using identical performance goals and indicators or ones tailored to State-specific needs or issues.
3. States may choose to adopt Federal OSHA's other strategic goals or develop their own. However, each State's occupational safety and health program must continue to satisfy the mandated activities of the OSH Act and 29 CFR Parts 1902 and 1956 (e.g., standards, enforcement program, prohibition against advance notice).
4. States must develop performance goals that are broad enough to encompass all major components of the State program, including private and public sector enforcement, consultation, and compliance assistance, even if they choose to adopt only one strategic goal. Support activities, such as laboratories, need not be addressed specifically in strategic goals.
  
  Note: As required by § 1908.1(a), State Plans operating private sector consultation programs under the authority of Section 18 of the Act and funded under Section 23(g) of the Act must be at least as effective as consultation programs operated under the authority of Section 21(d) of the Act. Significant changes in the revised 1908 regulations and this Instruction include: employer posting of the list of serious hazards and their abatement dates (1908.6(e)(8) and Chapter 6); requirements for employee participation (1908.6(c) and (d) and Chapter 2); and disclosure of certain confidential information to OSHA (1908.6(g) and Chapter 2). All States operating 23(g) consultation programs must amend their programs to reflect the revised Federal consultation program.
  
  Although public sector consultation programs are not funded under section 21(d) or directly subject to the requirements of 29 CFR 1908, States are encouraged to apply -- to the greatest extent feasible -- the principles established in the revised Federal private sector consultation program. States may, but are not required, to establish a recognition and exemption program for the public sector.
5. As part of the 23(g) grant application, each State must develop an annual performance plan describing the specific actions to be undertaken by the State to accomplish its strategic and performance goals during that fiscal year. This annual performance plan will serve as the required grant narrative.
6. OSHA will evaluate each State's performance on whether it makes reasonable progress towards accomplishing the strategic and performance goals contained in its strategic plan and the significance of the actual results achieved. OSHA will review State performance using the methods agreed upon by OSHA and the State in its annual monitoring plan.
7. States developing strategic plans with strategic and performance goals that differ from Federal OSHA's (e.g., targeting reductions based on data from State-based systems, such as workers' compensation) are responsible for identifying the data necessary to establish an appropriate measurement and reporting system. These data are to be agreed upon by the States and Regions. In addition, States with goals similar to OSHA's, such as reductions in injuries and illnesses in specific industries, can be accommodated using OSHA's Performance Tracking and Measurement System (OPTMS).
  
  Guidelines for State reporting and inclusion of State results in Federal OSHA's Annual Report to Congress are presented in Chapter IX of this manual.
8. The focus of a State's occupational safety and health program, as identified by the State's strategic and performance goals, establishes the parameters within which the State's program operations will be evaluated to determine whether they are at least as effective as Federal OSHA's. The State will still be expected to meet its mandated responsibilities under the OSH Act.
9. The Assistant Secretary will continue to address any significant issues or problems that impact a State's ability to carry out its mandated activities or substantially comply with its State plan commitments.
Strategic Plan Requirements. Each State must develop a five-year strategic plan containing outcome-oriented strategic and performance goals. Strategic and performance goals and baselines for comparison may be tailored to the State's own circumstances, subject to negotiation and OSHA approval. The strategic plan must cover a period of five years forward from the Federal fiscal year in which it is submitted and must contain a narrative describing strategies the State will apply to accomplish its strategic goals.
1. Defining Strategic Goals
  
  (a) Mandatory Goal. All State strategic plans must include Federal OSHA's Strategic Goal 1, using either identical performance goals or ones tailored to State-specific needs or issues.
  
  (b) Optional Goals. States may choose to adopt Federal OSHA's other strategic goals or develop their own. These options result in five possible approaches to developing the balance of the State strategic plan.
  
  (c) Possible Approaches Adopt Federal OSHA's strategic and performance goals (Under this option, States will be evaluated using the same measurement systems and procedures used for evaluating Federal OSHA).
  
  • Adopt Federal OSHA's broad strategic goals and their performance goals, but tailor the performance goals to reflect State-specific issues (e.g., target the State's most prevalent hazards, injuries, illnesses, or industries).
  
  • Adopt Federal OSHA's broad strategic goals, but develop unique performance goals for their achievement.
  
  • Adopt State-specific strategic and performance goals.
  
  • Adopt only the mandatory strategic goal, making it comprehensive of all of the major components of the State program (e.g., enforcement, consultation, training, and education).
2. Development Procedures
  
  (a) States should develop their Strategic plans in cooperation with their Regional Offices, communicating early in the process to agree upon strategic goals, performance goals, and baselines.
  
  (b) States may consider the views of their key stakeholders and partners in the development of their strategic plans.
3. Core Elements of a Strategic Plan. Each State Strategic plan must address, in narrative format, each of the following elements, unless it is identified as optional:
  
  (a) Mission. Clearly and concisely specify the State occupational safety and health program's mission, which should support both Federal OSHA's mission (as defined in its enabling legislation, P.L. 91-596, the Occupational Safety and Health Act of 1970), and State-specific requirements defined by State legislation or regulations.
  
  (b) Vision. (Optional) Present the State program's vision for the future, including:
  
  • Anticipated impacts on worker safety and health.
  • The activities or steps necessary to achieve the vision.
  
  (c) Stakeholders. If the State consulted with its stakeholders in the development of its Strategic plan, it must describe the nature and type of input received.
  
  (d) Strategic Goal(s). Identify broad, 5-year strategic goals for the State's occupational safety and health program.
  
  (e) Performance Goals. Identify performance goals that set specific target levels of performance for each of the broad, 5-year strategic goals. For example, performance goals should be stated as: "Reduce injuries and illnesses by x% (an agreed-upon percentage)," rather than, "Reduce injuries and illnesses."
  
  (f) Performance Indicators. Identify the performance indicators that will be used to evaluate progress toward achievement of the State's performance goals (including activity, intermediate outcome, and primary outcome measures). Include information on:
  
  • The source of data for the indicators.
  • The means for verifying indicators.
  
  (g) Baselines. Each State must establish baselines for each performance goal in its strategic plan. Baselines should be set in the year for which the most recent data is available. (Also see Chapter VII, Section D. 4.)
  
  (h) Strategies. Describe the specific activities, approaches, and programs that will be used by the State to accomplish its strategic goals (including, as appropriate, standards development, enforcement, compliance assistance, human resources, training, and outreach).
  
  (i) Impact Factors. Identify those factors (internal and external) which might impact on the State's ability to accomplish its strategic and performance goals.
  
  (j) Summary Chart. If the plan is largely in narrative format, summarize the State's strategic and performance goals in the chart format provided in Appendix B. The following elements should be included in the summary chart.
  
  • Strategic goal
  • Performance goal
  • Indicator
  • Data source
  • Comment
  
  If a State chooses to present the entire plan in a tabular format, only parts (a)-(c) (mission, vision, and stakeholders) need be in a narrative format. If a State uses terminology different from OSHA's, it must clearly define and cross-reference its terminology with Federal OSHA's.
Grant Application and Annual Performance Plan Requirements
1. Basic Requirements
  
  (a) All required financial documents and instructions for completing the grant application are available on the State Programs Limited Access Page. Each year, funding levels and requirements will be communicated in a memorandum to Regional Administrators and State Designees.
  
  (b) The 23(g) grant application includes an annual performance plan which replaces the previously-required grant narrative and any existing performance agreements between Federal OSHA and the State. The State's annual performance plan must be aligned with the State's strategic plan and describe the specific activities the State will perform to accomplish its annual performance goals.
  
  (c) States and Regions should agree upon a schedule which will allow submission of the 23(g) grant application to the National Office by August 15th each year. In the event of a delay in the issuance of the grant funding memo, a reasonable amount of time for completion of the grant will be allowed. However, Regions and states need not wait until receipt of the grant application to begin the annual performance planning process.
2. Grant Application Instructions. The contents of the grant application are outlined below.
  
  (a) Financial Documents. Each State is required to complete and submit the following financial documents with its grant application:
  
  • Form OSHA 110 - Grant Agreement. Funding will be at the prior year final base award level, unless otherwise noted in the funding memorandum.
  
  • SF 424 - Application for Federal Assistance
  
  • SF 424a - Budget Information (Non-Construction Programs). OSHA no longer requires that this information be presented according to the nine previously prescribed program activities, although States may choose to continue using them. Instead, funding under Section A (Budget Summary) should reflect the totals from Section B (Budget Categories). Funding under Section B should reflect these two new budget activities and identify those which are 100% State-funded:
  
  Administration. This activity includes the cost of salaries and expenses that are related to the management and support of grant operations. Costs may include, but are not limited to, policy development, budget, payroll, human resources, audit, and accounting. Positions above the first line supervisor would usually be included as administration. Under this activity, the 25% limit on administrative costs remains in effect. All indirect costs must be included under this activity.
  
  Program. This activity includes the cost of salaries and expenses that are directly related to carrying out grant operations. Group all funding for program-related activities under this activity.
  
  • Combined Assurances and Certifications. Cover all OMB assurances and certifications here, including:
  
  Lobbying Certification (requires the signature of designee) OSHA Restrictions and Conditions
  
  • Supportive Cost Break-out. Prepare a detailed break-out of costs by organizational unit and staffing level, tied to the State's own organizational structure. Each organizational unit should be broken out by object class category. Also include a break-out of any 100% State funds.
  
  (b) Annual Performance Plan. Each State must describe how it will align its 23(g) activities (including private and public sector consultation) with its annual performance goals. States providing consultation services under 21(d) agreements should identify how those activities relate to the accomplishment of their overall strategic and performance goals. Each annual performance plan must include the following elements:
  
  • Overview of the State's Occupational Safety and Health Program. Provide a comprehensive overview of the State's current occupational safety and health program, including the following information:
  
  Profile of the State Agency. Total number of allocated staff and break-out of compliance and consultation staff, expressed in full-time equivalents (FTEs). A sample format is provided in Appendix C. Also include an organizational chart.
  
  State Demographic Profile. Number of employers, by major Standard Industrial Classification (SIC) Division and number of covered employees, by major SIC Division.
  
  Identification of covered issues. List those issues that the State's OSH program covers and those that it does not.
  
  Statement of compliance or non-compliance with appropriations riders
  
  • Mandated Activities. Because activities mandated under the OSH Act (e.g., inspections, citations, employee rights) are considered core elements of an effective occupational safety and health program, they should be tied to achievement of the State's strategic goals. The annual performance plan should discuss the performance of mandated activities as strategic tools wherever appropriate to achieve the goals. For example, standards, inspections, and citations are among the tools which could be used to achieve the strategic goal of reducing injuries and illnesses.
  
  Where the mandated activities are neither tied to specific strategic goals nor addressed through the State Activity Mandated Measures report (See Chapter VIII) or the Mandated Activity Report for Consultation, the annual performance plan should contain assurances that these activities will be accomplished. These assurances should address:
  
  Prohibition against advance notice
  Employee access to hazard and exposure information
  Safeguards to protect an employer's trade secrets
  Employer recordkeeping
  Legal procedures for compulsory process and right of entry
  Posting of employee protections and rights
  Right of an employee representative to participate in walk-around
  Right of an employee to review a decision not to inspect (following a complaint)
  Voluntary compliance programs (See Appendix F in the TED 3.5C for fundamental program requirements relevant to 23(g) private sector consultation activities)
  
  • Annual Performance Goals. For each performance goal in the State's strategic plan that is to be addressed during that program year, the State must:
  
  Establish objective and measurable annual performance goals to be achieved by the State during the program year.
  
  Identify the performance indicators (including activity, intermediate outcome, and primary outcome measures) that will be used to assess progress toward achievement of the State's performance goals during that program year.
  
  Describe the mix of program activities (strategies) that will be applied to accomplish the State's performance goals (e.g., enforcement, standards development, and compliance assistance). This section should consist of a complete, succinct, State-specific discussion of how the State will apply its resources and strategies to accomplish its goals.
  
  If the section above is in a narrative format, include, as an appendix, a summary chart outlining the annual performance goals and performance indicators that will be used to measure State performance. The summary chart should be prepared in the format presented in Appendix D.
  
  (c) Programming Changes. If goals or measures have been changed in a way that impacts the processing of IMIS data used for tracking a State's strategic and performance plan results, the State must submit the changes for review as directed.
Review and Approval of Strategic Plans and the Annual State Plan Grant
1. Strategic Plans. Each State negotiates its strategic plan with its Regional Administrator. Once reviewed and approved at the Regional level, the Regional Administrator forwards the strategic plan to the Directorate of Federal State Operations (DFSO) in Federal OSHA's National Office for review. The Assistant Secretary, OSHA formally approves the strategic plan and prepares an approval letter to the State Designee within 90 days of receipt of the plan from the Region.
2. Grant Document, including the Annual Performance Plan. Each State negotiates its annual performance plans with its Regional Administrator. Once reviewed and approved at the Regional level, the Regional Administrator forwards the completed grant document to the Directorate of Administrative Programs (DAP) and DFSO for review. Prior to October 1 each year, the Assistant Secretary, OSHA formally approves the entire grant document and prepares a grant approval letter to the State Designee within 30 days of receipt of the document from the Region, including any conditions for changes to the State's annual performance plan based on Regional and National Office review.

Changes to Strategic and Annual Performance Plans

Changes to Strategic Plans

(a) Annual Review of Strategic Plans

• States must review their strategic plans with their Regions each year as part of the performance planning process.

• Changes to strategic plans should be limited to major shifts in policies, programs, or implementation strategies. Formal, written changes to a State's strategic plan may be made no more than once a year. States may not change the end-dates of their strategic plans as a result of the annual review process.

• If a State elects to make a change to its strategic plan as a result of its annual review, it must submit a written rationale for the changes and a copy of the revised strategic plan to the Regional Administrator at the same time as the State's annual 23(g) grant is submitted. Changes are approved by the Regional Administrator as part of the sign-off process of the annual grant.

If, during the annual review of its strategic plan...	then the State must:	and may not...
a State elects to make formal, written changes to its strategic plan,	submit a rationale for the changes and a copy of the revised strategic plan to the Regional Administrator by August 15	change the end date of the strategic plan or make changes more than once a year.
a State elects to make no formal, written changes to its strategic plan,	continue managing its program according to its original plan	N/A

(b) Third-Year Review of Strategic Plans

• Following GPRA requirements, each State is required to conduct a comprehensive review of its strategic plan at least once every three years. States may either make changes to its plan at the three-year point or continue managing its program according to its original plan until the end date of that plan.

• If a State elects to make significant changes (e.g., selects new performance goals or targets) to its strategic plan as a result of its third-year review, the revision will effectively mark the beginning of a new strategic plan covering the performance period of five years from the start of the new fiscal year.

Note: Over time, strategic plans may contain goals with staggered end-dates, as some strategic goals may have been added in interim years. As a result, tracking of progress by goal may be more practical than tracking an entire strategic plan.

• If a State elects not to make significant changes to its strategic plan as a result of the third-year review, it must submit a new five-year strategic plan on or before August 15^th of the final year of its current strategic plan.

If, during the third-year review of its strategic plan...	then the State must:
a State elects to make significant changes to its strategic plan...	submit a revised strategic plan on August 15^th of that year and change the end date of the strategic plan to five years from the start of the new fiscal year
a State elects not to make significant changes to its strategic plan...	continue managing its program according to its original plan and submit a new five-year strategic plan on August 15^th of the final year of its current strategic plan

(c) Changes to a State's strategic plan resulting from either the annual or third-year review process must be negotiated and approved by the OSHA Regional Administrator, subject to further review by the Assistant Secretary. Any changes made must be consistent with the requirements detailed in Section F. of this chapter.

Changes to Annual Performance Plans

(a) A State may make adjustments or changes in strategy during the year, subject to discussion and negotiation with Federal OSHA Regional staff. Such changes do not require a formal, written revision of the State's annual performance plan.

(b) A State must describe and explain any major deviations from its current year's annual performance plan in the following year's annual performance plan. The State may also include this discussion in its State OSHA Annual Report (SOAR).

(c) Regions must document any major strategy changes in the Federal Annual Monitoring and Evaluation report (See Chapter IX.).

Chapter 6
State Plan Monitoring and Evaluation Process

Introduction. This chapter provides an overview of the State plan monitoring and evaluation process, including the goals, scope, and framework of the monitoring and evaluation system. This system is based on the following core principles:
1. Flexibility. The monitoring and evaluation process takes into account differences among State programs, in terms of both the program goals established and the methods for accomplishing them. A State's performance will be monitored against its own established performance goals and not against the performance of other States or Federal OSHA.
2. Partnership. The monitoring and evaluation process will be performed jointly by the States and Federal OSHA. The process described in this chapter identifies those activities to be performed by the States and those to be performed by Federal OSHA.
3. On-Going Communication. A key component of the monitoring and evaluation process is on-going communication between the States and Federal OSHA. In addition to regular, informal communication between States and Federal OSHA, formal communication processes are established through the procedures defined in this chapter, such as quarterly monitoring discussions.
4. Outcome Orientation. The focus of monitoring and evaluation is on evaluating a State's results against the goals contained in its strategic and annual performance plans.
5. Regulatory Consistency. OSHA will continue to monitor mandated activities to ensure that States meet the regulatory requirements.
6. Fairness. Evaluation of a State's performance will be based on a range of acceptable performance. Progress towards accomplishing its goals is evaluated, rather than whether a State did or did not meet an agreed-upon target percentage.
7. Consistent Application of Monitoring Methodology. The monitoring methodology is intended to provide a common standard and set of criteria for how monitoring is to be performed and the degree of importance assigned to issues.
Goal of the Monitoring and Evaluation System. While evaluation findings, conclusions, and recommendations remain OSHA's responsibility under the OSH Act, the evaluation process itself is a joint endeavor requiring collaboration and mutual agreement. The States are encouraged to participate in every phase.
1. The purpose of the monitoring and evaluation process is twofold: the objective and consistent analysis of data from all relevant sources to determine whether a State program is operating at least as effectively as the Federal program and the flexibility to address unique State situations.
Scope of the Monitoring System. The scope of OSHA's evaluation includes any State activity that:
1. Receives Federal funding under Section 23(g) of the Act; or
2. Would be covered by OSHA absent an approved State plan; or
3. Would be preempted by Section 18 of the Act, absent an approved State Plan.
4. If the State uses 100% State funding for activities that do not meet any of the foregoing tests, such activities will not generally be assessed by Federal OSHA, but their impact on a State's responsibilities under its plan will be subject to monitoring.
Framework of the Evaluation Process. Evaluating State programs is an on-going process. It entails the regular review of data from a variety of sources throughout the evaluation period to track a State's progress in achieving its strategic and annual performance goals and to ensure that the State is meeting its mandated responsibilities under the Act and 29 CFR Parts 1902, 1953, and for public-employee-only plans, Part 1956.

Throughout the evaluation period, Regional and State staff will review quarterly State Activity Mandated Measures (SAMM) reports, monthly State Information Reports (SIR), Mandated Activity Reports for Consultation (MARC), and Consultation Management Reports (CMRs).
1. Performance Evaluation
  
  (a) The principal parameters within which the State's program operations will be evaluated are established by the State's approved strategic and performance goals.
  
  (b) A State's overall performance will be evaluated in terms of progress toward accomplishing its strategic and performance goals, rather than in absolute terms. If a State is making reasonable progress toward meeting its goals and is fulfilling its mandated responsibilities, its program will be judged to be at least as effective as the Federal OSHA program.
  
  (c) States must continue to meet all mandated requirements of 29 CFR Parts 1902, 1953 and 1956 (for public-employee-only plans).
2. Performance Tracking and Reports
  
  (a) Federal OSHA and State staff will track State public- and private- sector activities through review of the SAMM to ensure that a State is meeting its mandated responsibilities. The SAMM will specify standards, baselines, or guidance for each measure that establish a point of reference for determining acceptable activity levels. For public-employee-only programs, only relevant SAMMs need be reviewed.
  
  (b) OSHA provides each State its SIR on a monthly basis as a "management information tool" for program management and review, and as a source of information for measuring progress toward annual and strategic goals. The SIR is also available as a micro-to-host report. (See Chapter VIII.)
  
  (c) On an exceptional basis, Federal OSHA may use the SIR to supplement the SAMM as a source of information to evaluate issues related to carrying out a mandated activity or accomplishing an annual or strategic goal.
  
  (d) Federal OSHA provides regular reports on State performance to those States with strategic and performance goals and measures that parallel Federal OSHA's. States developing their own strategic goals, performance goals, and indicators are responsible for establishing and documenting an agreed-upon measurement system, including measures of activity (in addition to those in the SAMM and SIR), intermediate outcomes, and primary outcomes. Any performance measurement system used by the State must include appropriate quality control components to ensure the accuracy of data and be available to Federal staff for review.
  
  (e) Those States operating private-sector 23(g) Consultation programs will be monitored using the Mandated Activity Report for Consultation (MARC), as used for 21(d) private-sector programs. Their performance will be evaluated in the Federal Annual Monitoring and Evaluation (FAME) report.
  
  (f) Those States operating public-sector 23(g) Consultation programs should review the Mandated Activity Reports for Consultation (MARC), and Consultation Management Reports (CMRs) as appropriate.
3. Monitoring Process and Evaluation Tools
  
  (a) At least once every quarter, Federal and State representatives must review and discuss State performance in terms of progress toward State strategic and annual performance goals and meeting mandated requirements. Records of the meetings must be retained to document the issues discussed and commitments made during the meetings, and to provide the basic information for the annual evaluation report.
  
  (b) Additional evaluation tools, including Federal OSHA interviews with State staff, may also be used. Case file reviews, accompanied inspections, or spot-check monitoring visits may be used on an exceptional basis to address questions regarding State performance in relation to its approved goals or its mandated responsibilities (See Chapter X, Section A). Federal OSHA also may use any of these evaluation tools in the investigation of a Complaint About State Plan Administration (CASPA), detailed in Chapter XI.
4. Dispute Resolution Process. Regions and States are expected to make every reasonable effort to resolve differences at the lowest organizational level possible. In the event that a State and Region cannot agree on the resolution of any issue relating to the administration of the State program or the monitoring and evaluation system, the State may seek resolution by the Assistant Secretary. The Assistant Secretary may consult with other States or their representatives concerning issues that could have a broad programmatic impact.
5. Role of the Assistant Secretary. The Assistant Secretary will continue to address any other significant issues or problems that impact a State's ability to carry out its mandated activities or substantially comply with its State plan commitments.
Monitoring Developmental State Plans
1. New State plans must develop strategic and annual performance plans in accordance with Chapter V of this manual. Initial goals will, of necessity, focus on completion of the developmental steps in accordance with the schedule in the State's approved plan.
2. Initial monitoring should focus on the State's progress toward meeting these developmental goals. Moreover, the Region should take into account the developmental nature of the program when reviewing data from the SAMM and SIR reports and other performance information.
3. As the State progresses toward operational status, monitoring should shift from an emphasis on meeting developmental goals to the routine procedures described in this manual.

Chapter 7
Components of the Monitoring System

Introduction. This chapter describes the methods that will be used to monitor State occupational safety and health programs, including:
1. Monitoring against annual performance plans
2. Conducting quarterly discussions
3. Criteria for acceptable State performance
4. Developing an annual monitoring plan
5. Operating a State internal evaluation program
Monitoring Against Annual Performance Plans. As described in Chapter V, Guidelines for Preparing Strategic and Annual Performance Plans, each State must prepare a strategic plan covering the State's performance for a five year period. The State must also prepare an annual performance plan that identifies the activities and strategies to be undertaken by the State during that fiscal year. The following general principles govern the development, review, and monitoring of annual performance plans:
1. Annual performance plans are the focus of monitoring and evaluation and must be negotiated between a State and its Regional Administrator. Regional and Federal OSHA approval of a State's annual grant document, of which the performance plan is a part, indicates agreement on the terms of the plan.
2. Annual performance plans must include the performance indicators that will be used to evaluate a State's performance against its performance goals. Sufficient documentation of the performance indicators to be used must be provided by the State to enable OSHA to judge whether the State's performance measurement system is sufficient for evaluating State performance. Responsibility for collecting and transmitting performance data is as follows:
  
  (a) The State collects, analyzes, and provides data on performance results to Federal OSHA for those performance goals which are unique to the State's measurement system.
  
  (b) Federal OSHA provides data on performance results to States on those performance goals which are the same as Federal OSHA's goals, even if the States have different injury, illness, or industry targets.
3. Performance data should be jointly reviewed by the State and Federal OSHA on at least a quarterly basis. Any problems or deficiencies in either the collection of data or in achieving performance results must be discussed during the quarterly discussions.
4. End-of-year evaluations of State performance will focus on the results achieved by the State compared to the goals identified in the State's annual performance plan.
Quarterly Monitoring Discussions. Quarterly monitoring discussions are at the core of the State plan and Consultation program monitoring and evaluation processes. Regions are encouraged to hold joint quarterly discussions with enforcement and consultation. Any issue of concern to either party may be discussed at these meetings. Quarterly discussions can take place in-person or via telephone.
1. Purpose. Quarterly monitoring discussions should cover on-going State performance in all program areas. Quarterly discussions ensure that monitoring activities do not occur exclusively at the end of the year. They also provide a forum for integrated discussion of all program areas. To this end, all appropriate staff-program administration, enforcement, and compliance assistance-should be involved in the quarterly discussion process. Communication is not limited to the quarterly monitoring discussions. Informal discussions, working sessions, and other meetings, for a variety of purposes including development of strategic and annual performance plans, should be held as needed.
2. Scheduling. The Region's representatives must discuss progress with representatives of the State on at least a quarterly basis. To the greatest extent possible, discussions should be scheduled so that appropriate enforcement and compliance assistance staff are able to participate. Sharing of information and conducting joint reviews of State performance goals on a quarterly basis will permit early identification of potential performance problems or issues and also facilitate the annual evaluation process. The availability of quarterly data, the extent of any preliminary review needed, and submission deadlines for annual performance plans and evaluation reports should be taken into consideration when scheduling quarterly discussions.
3. Focus of the Quarterly Monitoring Discussions:

Quarterly Discussion	Timing of the Meeting	Focus of the Meeting
First	October-November	Discuss end-of-year data for the previous fiscal year Develop the Annual Monitoring Plan, if necessary Review the details of and make any necessary minor adjustments to the State's annual performance plan Agree upon the annual monitoring plan and the role of the State Internal Evaluation Plan and make arrangements made for their completion Coordinate the annual evaluation process and begin discussing evaluation reports for the previous fiscal year
Second	January-February	Review first quarter performance and mandated activities data to assess the State's year-to-date progress toward its annual performance goals Discuss any additional issues that have arisen or were identified in the annual monitoring plan Prepare and complete evaluation reports for the previous fiscal year Discuss any other additional issues
Third	April-May	Discuss second quarter data, assessing the State's year-to-date progress toward its annual performance goals Discuss any additional issues that have arisen or were identified in the annual monitoring plan Begin discussing the goals and strategies to be included in the following year's annual performance plan Discuss any other additional issues
Fourth	July-August	Discuss third quarter data, assessing the State's year-to-date progress toward its annual performance goals Finalize the next fiscal year's annual performance plan Discuss any additional issues that have arisen or were identified in the annual monitoring plan

(a) Discussion Topics. Examples of relevant discussion topics include:

• Progress in meeting annual performance goals
• Review of mandated activity reports
• Status of Federal and State strategic or annual performance plans
• Agreement on the issues to be covered by State internal evaluations
• State internal evaluation findings
• Effect of State policies and procedures on State program administration
• Status of State responses to prior evaluation reports
• Progress on monitoring activities set out in the annual monitoring plan
• Ongoing grant monitoring
• State consultation activities and measures
• State responses to Federal Program Changes
• Standards developments, both State and Federal
• Legislative initiatives, both State and Federal
• Jurisdictional issues
• Upcoming State and Federal training courses
• Follow-up on general commitments made during previous conference
• Any other issues of concern to either party
• On-going Complaints About State Plan Administration (CASPA) investigations

(b) Documentation. The Federal OSHA Regional representative will maintain a written record of each quarterly monitoring discussion indicating the date, location, persons in attendance, a summary of the significant issues discussed, and the conclusions reached. Commitments made by either party, such as to supply information or assistance, should be documented and followed up by the appropriate parties. The Federal OSHA representative must provide a draft copy of quarterly monitoring discussion reports to the State for review.

Criteria for Acceptable State Performance. The following criteria are used by Federal OSHA Regional monitoring staff in determining whether a State's performance falls within the range of acceptability:
1. Monitoring of a State's program should focus on determining the extent to which a State has achieved what it set out to achieve in its annual performance plan. Mandated activities outside the scope of the annual performance plan must also be monitored (See Chapter VIII), but an individual State's performance should not be compared to the performance of other States or Federal OSHA, except where indicated in the State Activity Mandated Measures (SAMM) report.
2. There may be significant time lags in the reporting of primary outcome level data due to data collection constraints (e.g., the time lag for receipt of Bureau of Labor Statistics data is often up to 18 months). In the absence of outcome-level data, OSHA should review activity level data to evaluate whether a State has applied sufficient resources and intermediate outcome level data to evaluate whether the State directed those resources to areas where an impact is likely to be made.
3. Not all State annual performance goals can or should be judged against quantitative criteria. If a State demonstrates it has made sufficient progress in accomplishing the work plan milestones or objectives outlined in its annual performance plan, then the State's performance would likely be considered acceptable.
4. Reasonable baselines should be set for performance goals. For example, if a State sets a performance goal relating to its complaint response time, its baseline should be established using the data from the first year of the plan (or as soon as that data is available), since responding to complaints is an on-going work activity. If a State set a performance goal relating to continuing a special emphasis program that was begun a year or two before the first year of the strategic plan performance period, it is acceptable to set the baseline in the year that program was initiated.
  
  A State may not set baselines that pre-date the State's strategic plan by a significant number of years, i.e. three or more years prior to the beginning of the strategic plan performance period. In addition, a State may not set its baselines so that it its performance goals have already been accomplished before the performance period covered by the strategic plan has already begun, except in the case of "maintenance goals" to continue with a high level of performance such as maintaining a 95% customer satisfaction rating.
5. Progress in a positive direction should be considered when determining the acceptability of a State's performance. That is, State performance should not be evaluated against an absolute standard. For example, if a performance goal is to reduce injuries and illnesses in a targeted industry by 15% and the results indicate a reduction of 13%, this would likely be considered acceptable performance.
  
  However, substantial deviations from a targeted performance goal will require a discussion between the State and the Region to agree upon corrective actions to be taken by the State to address the performance deficiencies. For example, if a performance goal was a 15% reduction in injuries and illnesses in a targeted industry and the results indicated only a 2% reduction or an increase in injury and illness rates, then immediate action should be taken.
  
  Moderate deviations from a performance goal, such as a 5 - 10% reduction, rather than 15% reduction, will be evaluated using the professional judgment of both OSHA and State staff. Such deviations should be discussed by OSHA and the State to determine whether or not they represent a performance deficiency.
6. Procedures for the review of mandated activities data are described in Chapter 8. These procedures identify acceptable performance levels and the steps that should be taken to further review potential performance problems.
7. When State performance problems have been identified, Federal OSHA and the State will use the analysis and evaluation procedures outlined in Chapter 10 to determine the causes of performance deficiencies and to develop appropriate corrective action plans.
The Annual Monitoring Plan
1. Introduction. At a minimum, an Annual Monitoring Plan identifies the issues to be evaluated, establishes the schedule for the evaluation, and assigns responsibility for the evaluation. The level of detail in the annual monitoring plan is a matter to be decided by the Region and the State, and need not be extensive. It may also contain detailed procedures and a framework for ongoing assessment of the State's progress toward meeting the goals agreed to in the annual performance plan and the Grant Agreement and for ensuring the continuing effectiveness of the State program as it relates to mandated activities.
  
  The annual monitoring plan may be adjusted at any time during the evaluation period, with the agreement of both the State and the Region, to reflect newly identified issues for evaluation or the results of analyses already underway.
2. Timing. The annual monitoring plan should be developed prior to or at the first quarterly discussion of each evaluation year. The annual monitoring plan should be closely aligned with the State's annual performance plan. The State Internal Evaluation Plan may be developed in conjunction with the annual monitoring plan.
3. Content of the Annual Monitoring Plan. The annual monitoring plan may include the following:
  
  (a) Schedule for Monitoring Activities
  
  • The evaluation period
  • Schedule for quarterly discussions
  • Schedule for the start and completion of analysis
  • Schedule for preparation and submission of evaluation reports
  
  (b) Assignment of Monitoring Responsibilities
  
  (c) State Internal Evaluation Program (SIEP). Because the State's Internal Evaluation Plan (Section VI., below) is an integral part of the monitoring process, it should be incorporated or referenced in the annual monitoring plan.
  
  (d) Areas for Review and Analysis
  
  • Progress on Strategic and Annual Performance Goals. The annual monitoring plan may describe how State performance data will be collected and analyzed, if that is not specified in the annual performance plan.
  
  For any annual performance goals that reflect developmental activities (with no quantitative data available), such as the implementation of emphasis programs or the creation of survey instruments, the annual monitoring plan should state what information will be required to assess progress and the anticipated schedule for submission and review. Except where not feasible, progress on goals should be reviewed and documented quarterly.
  
  • Effectiveness Related to Mandated Activities. Any Federally-mandated activities that are not covered by annual performance goals, together with other issues that Federal OSHA and the State agree to evaluate during the year, should be included in the annual monitoring plan. The annual monitoring plan should also specify how those issues are to be addressed. For example, they may be addressed by:
  
  Assurances from the State of the continuation of effective procedures
  
  State Internal Evaluation
  
  Review of SAMM, MARC, SIR, CMR, and any other relevant automated reports
  
  Analysis by Federal monitors by means of the evaluation tools described in Chapter X
  
  • Work Plans. In some cases, a work plan describing the evaluation protocol may be developed for issues to be analyzed by Federal OSHA. Work plans should contain, at a minimum, the following:
  
  Issue to be analyzed
  
  Evaluation methodology, including the method of data selection and data criteria
  
  Assignment of responsibility for analysis
  
  Time frames for analysis
The State Internal Evaluation Program

A State's program for comprehensive evaluation of its internal operations is a critical component of the monitoring system. Providing that mandates are met, States have the flexibility to design and implement programs that will fit each individual State's needs and personnel resources.
1. Each State must periodically conduct reviews of its activities under the plan, focusing on key issues and areas of concern to the State.
2. The program must provide for integrity and independence in conducting evaluations.
3. States must maintain documentation of their internal evaluations and make it available for review by Federal monitors. Requests for materials that are not in Federal OSHA files will be referred to the individual State for a decision on releasability based on the State's own laws.

Chapter 8
Mandated Activities

Introduction. Under the OSH Act, Federal OSHA and the State programs are responsible for carrying out mandated activities. States' further responsibilities are described in 29 CFR Parts 1902, 1953, 1954, and 1956. The Assistant Secretary for Occupational Safety and Health is responsible for monitoring and reporting on the States' performance. The framework for evaluation established by OSHA and the States is one in which both parties jointly establish the measures of performance, where possible, and both participate in the review, assessment, and discussion of performance data.
Mandated Activities. Review of the mandated activity measures is designed to ensure that the mandated activities are being implemented at a level consistent with and as effective as the Federal program. State performance of mandated activities is addressed by one of two means:
1. Program Assurances. Maintenance of the following fundamental program requirements must be assured through an annual commitment (assurance) from the State, to be included as part of the 23(g) grant application:
  
  (a) Prohibition against advanced notice
  
  (b) Employee access to hazard and exposure information
  
  (c) Safeguards to protect employer trade secrets
  
  (d) Employer recordkeeping
  
  (e) Legal procedures for compulsory process and right of entry
  
  (f) Posting of employee protections and rights
  
  (g) Right of employee representative to participate in walk-around
  
  (h) Right of an employee to review decision not to inspect (following a complaint)
  
  (i) Voluntary compliance programs (See Appendix F in the Consultation Policies and Procedures Manual, TED 3.5C, for fundamental program requirements relevant to 23(g) private sector consultation activities.)
2. State Activity Mandated Measures (SAMMs). Other mandated activities will be tracked on a quarterly basis by comparing State activity data to an established reference point. These measures are not necessarily the only data source for evidence of mandated activities, as performance measurement data relating to the strategic and annual performance goals will also, in many cases, reflect on mandated activities. Relevant SAMMs should be used to evaluate public-employee-only programs. (See Appendix E for a complete listing of the SAMMs.)
3. Mandated Activity Report for Consultation (MARC). For States operating Consultation programs under 23(g), mandated consultation activities will be tracked on a quarterly basis using the MARC. Significant issues identified through the use of MARCs should be discussed in quarterly discussions and reflected in the annual evaluation report. (See the Consultation Policy and Procedures Manual for a detailed description of the MARC.)
State Activity Mandated Measures (SAMM) Report. The State Activity Mandated Measures report provides a set of universal indicators for the mandated responsibilities of State programs; a standard, baseline, or performance guide for each; and State performance data.
1. Frequency. The report is run quarterly, for each State, providing quarterly and past-12-month data. The report is also available as a micro-to-host report to be run independently by a State.
2. Data Source. The source of most performance data is the IMIS, but in some instances, such as staffing levels and data on denials of entry, it will be provided by the State to the Regions.
3. Measurement Standard or Guide. The State's performance is compared to a national or State standard or guide that is set by regulation, negotiation, or trend, as described below. Except in the case of performance standards set by regulation, these are not intended to serve as mandated performance goals, but as a point of reference to facilitate tracking and to aid in determining whether further analysis is needed. See Appendix E for the SAMMs.

If:	then:
A national standard has been established	The national standard applies to all States (e.g., SAMM 3, SAMM 4)
A State has a related strategic or annual performance goal	The State's performance goal is the performance guide (e.g., SAMM 1, SAMM 2)
There is neither a national standard nor a related State performance goal	The State may negotiate an appropriate activity level with the Regional Office (e.g., SAMM 1, SAMM 2)
It is difficult or impractical to establish a national standard or State performance goal	Performance would be compared with an established and accepted norm or trend for the individual State (e.g., SAMM 9, SAMM 10)

Guidelines for Use. Regional and State staff should jointly review the State Activity Mandated Measures (SAMM) reports quarterly and discuss performance that falls outside the guide or standard. Initial review by designated Federal and State officials and sharing of findings should take place before the quarterly discussion.

(a) Initial Review. Any potential problem found during initial review should be assessed to determine its significance and the amount and type of attention it should receive. Both Federal and State reviewers must explore the cause and extent of data that fall outside the performance guides.

• During the initial review, designated Federal and State managers should discuss their findings and ideas about the significance of any performance variances and discuss what action should be taken. Depending on the size of the variance and its potential impact on the program, single-instance variances may be monitored for another quarter to see if they indicate an emerging trend. Some performance variations may represent performance problems, others may represent data anomalies, and still others may signal the eventual need to reset a measurement standard or guide.

• If the review indicates a first-time, 3-month performance variance from the guide or standard or a statistically insignificant performance variance, additional review need not be automatic. On the other hand, the fact that a performance variance occurs for the first time does not necessarily rule out further analysis. These circumstances call for the application of professional judgement.

• The initial review should fully address the question of data accuracy to be entirely certain the issue is not one of erroneous performance data or erroneous historic data.

• The initial review should also determine the extent to which the issue has already been assessed through the State's internal audit program.

(b) Discussion of Findings. OSHA and the State should present their findings and preliminary conclusions regarding any performance variances at the quarterly discussion, where possible corrective courses of action should be discussed, if appropriate.

(c) Further Review. If additional analysis is appropriate, OSHA will take the lead in analyzing cases concerning a mandated activity. Data collection and review of data should be joint, where practical. The data sources to be used and the method of evaluation should be discussed at the quarterly discussion, as should issues of potential data accuracy, where appropriate. (See Chapter X for available evaluation tools.). The Assistant Secretary may, at any time, request further review of findings.

Management Information Reports
1. The State Information Report (SIR). The SIR is intended to be a comprehensive internal management report that reflects most of a State program's activities in enforcement and consultation; private and public sector; safety and health; and training and technical assistance. (The SIR in current use is referred to as the "Interim SIR," because it consists of a subset of the old C-SPAMs that will be carried over to the final SIR. See Appendix F for a complete listing of the Interim SIRs.)
  
  (a) Frequency. The report is run monthly and contains monthly and year-to-date totals. The report is also available as a micro-to-host report.
  
  (b) Guidelines for Use. The SIR is primarily a report of activity data for State OSH managers' use in the internal management of their program. For measures that fall outside the performance guides and are thus not measured by SAMMs, OSHA and State staff should use the State Information Report to supplement the SAMM as a source of information for evaluating a potential problem related to carrying out a mandated activity.
2. Consultation Management Report (CMR). This report contains management information on the operations of a Consultation Project, including efficiency measures and intermediate outcome measures (See Appendix E in the Consultation Policies and Procedures Manual for a list of proposed CMRs).
  
  (a) Frequency. The CMR is run monthly and contains monthly and year-to-date totals. The report is also available as a micro-to-host report.
  
  (b) Guidelines for Use. The CMR is primarily a report of activity data for a Consultation Project Manager's use in internal management. OSHA representatives and Project staff may also use the CMR to supplement the MARC as a source of information for evaluating potential problems related to carrying out mandated activities.
Other Sources of Data. Some information regarding program resources is documented in States' strategic and annual performance plans and is thus not tracked through a mandated activity measure. This information includes the percent of compliance staffing benchmarks met through authorized staffing levels and the percentage of allocated compliance positions filled.

Chapter 9
Evaluation of State Performance and Annual Reports

Evaluation Reports. This chapter describes the methods to be used by States and OSHA monitoring staff to analyze State performance data, evaluate States' effectiveness in carrying out their occupational safety and health programs, determine whether States are continuing to maintain their at least as effective status and prepare annual reports documenting evaluation results and findings. Two annual evaluation reports are prepared to document the results of a State program's activities
State OSHA Annual Report (SOAR). At the conclusion of each Federal fiscal year, each State must prepare a progress report outlining its accomplishments with respect to the annual performance plan submitted with its grant application at the beginning of the fiscal year. The SOAR must include a description of the progress the State has made toward achievement of its strategic and annual performance plan performance goals, any special accomplishments, and a discussion of areas where annual goals were not met. The report is presented in a concise summary format to facilitate the inclusion of State results in Federal OSHA's Government Performance and Results Act (GPRA) annual report to Congress.
1. Due Date. The SOAR must be prepared by the State and submitted to the OSHA Regional Administrator by December 1 each year to accommodate the March 31^st submission of OSHA's annual GPRA report.
2. Development and Review Process. Each State will submit a draft copy of the SOAR to its Region two weeks prior to the December 1 due date for review. The Region will provide feedback to the State on any areas of deficiency with sufficient time for the state to make any necessary changes and still meet the deadline. The Region will submit a final version of the SOAR, in electronic format, to the Directorate of Federal-State Operations (DFSO) in the OSHA National Office by December 1^st each year.
3. Contents of the SOAR. The SOAR must include the following elements:
  
  (a) Summary of Annual Performance Plan Results. The State must summarize its results compared to the annual performance goals established in its annual performance plan. This summary should include results in terms of the activity, intermediate outcome, and primary outcome performance measures, where available, that are part of the State's performance measurement system. As lagging data becomes available, the State may update information about the results it achieves. Appendix G presents a recommended template for summarizing the results.
  
  (b) Progress Toward Strategic Plan Accomplishment. The State must provide a narrative summary describing its progress toward accomplishment of its five-year strategic goals. This section should highlight key areas where positive outcomes have been observed, and present an analysis of the data used in measuring outcomes. It should also describe all strategies used to support goal accomplishment, such as enforcement, compliance assistance, and standards.
  
  (c) Special Accomplishments (Optional). This section provides a summary of additional State accomplishments that may directly or indirectly affect a State's strategic goals or operations. Relevant data should be included, where available.
  
  (d) Adjustments or Other Issues (Optional). This section should identify those areas where a State's annual performance goals have not been met and describe how the State has adjusted or plans to adjust its strategies to accomplish its goals in the future. These issues should also be addressed in the comment column of the summary chart (See Appendix D). However, this section provides States an opportunity to expand on the discussion and describe proposed adjustments in more detail.
  
  (e) Mandated Activities (Optional). States may include a summary of the State's performance of its mandated activities in this section.
Federal Annual Monitoring and Evaluation (FAME) Report. The FAME report, to be prepared by OSHA, evaluates whether the State is maintaining its "at least as effective as" status by making progress towards its strategic and annual performance goals and continuing to perform its mandated activities. This report should not duplicate the information contained in the State's annual report, which is included as an attachment to the FAME report, but should provide an evaluation of the State performance results described in the State report. The evaluation must also include an assessment of the end-of-year results from the State Activity Mandated Measures (SAMM) report. For States with private sector 23(g) consultation programs, it must also include an assessment of results from the Mandated Activity Report for Consultation (MARC).
1. Due Date. The Federal Annual Monitoring and Evaluation (FAME) report is issued by the Regional Office to the State and submitted to the Directorate of Federal-State Operations in the OSHA National Office no later than March 31 each year. Prior to issuance of the report, the Region submits a draft to both the State and Directorate of Federal-State Operations with sufficient time for their review and comment.
2. Development and Review Process. The Regional Office must submit a draft copy of the FAME report to the State Designee for review at least two weeks prior to the March 31 due date. The State Designee and the Regional Office should discuss any areas of concern regarding the contents of the report before the Regional Office issues a final version of the FAME report. The Region issues the final version, in electronic format, simultaneously to the State and to the Directorate of Federal-State Operations in the OSHA National Office no later than March 31 of each year. The March 31^st deadline is intended to enable those Regions that must evaluate multiple States to produce drafts, receive comments, and finalize their reports in a timely manner.
3. Contents of the FAME Report. The FAME report must include the following elements:
  
  (a) Executive Summary. This section provides an overview of the State's progress towards achieving its performance goals, including results accomplished, and documents any significant issues (related to the annual performance plan, legislation, enforcement activities, or CASPAs) in the last year that have significantly impacted the State plan. The Executive Summary must also indicate whether the State continues to meet its State plan requirements. The Executive Summary should not include all of the details of the State program's performance, which are to be included in the body of the report. The purpose of this summary is to provide an overview of what is working well and to highlight areas where future attention is needed.
  
  (b) Introduction. This section will include a brief profile of the State plan, including the department or division within the organizational structure of the State government in which the program is operated and the identity of the State Plan Designee and manager of the State program. It must also include a brief description of the size of the program in terms of the number of full- and part-time staff and the State program budget. In addition, this section must include a brief description of the program and its major unique features or significant differences from the Federal program. Describe how onsite consultation is provided in the state. If private sector consultation is provided under 23(g), it must be assessed in the report.
  
  (c) Major New Issues. This section should discuss any new significant issues during the evaluation period that have had significant impact on the program and program performance.
  
  (d) Assessment of State Performance
  
  • Assessment of State Progress in Achieving Annual Performance Goals. This section provides an assessment of whether the State has made sufficient progress toward achieving its annual performance goals and is thus on track to accomplish its five-year strategic goals. The Region will review the State's performance results, including activity, intermediate outcome, and outcome measures. The Region should base its analysis on the data provided by the State in the SOAR.
  
  The Region's assessment must identify the State's annual performance goals that are not on target for successful completion and identify recommendations for improvement.
  
  The Region's assessment must also include a review of the actions the State took in response to previous OSHA recommendations on the implementation and achievement of the State's strategic and performance goals or measurement system.
  
  • Assessment of State Performance of Mandated Activities. This section will address State performance of the required (mandated) program items, including:
  
  Enforcement (including complaint investigations, right of entry, first instance sanctions, and abatement of violations)
  
  Standards adoption
  
  Variances
  
  Public employee program
  
  Review procedures
  
  Discrimination program
  
  Voluntary compliance program (See Appendix F in the TED 3.5C for fundamental program requirements relevant to 23(g) private sector consultation activities)
  
  Program administration
  
  The evaluation, with the exception of the review of State standards that are different from Federal standards, should be based to the greatest extent possible on the analysis of available data. The State's performance will be judged either against national or State standards or guides, as identified in the State Activity Mandated Measures (SAMM) report. The Region must provide a general conclusion regarding the acceptability of State performance of mandated activities and describe in detail only those elements in which further analysis beyond review of the SAMM was conducted.
  
  Any systemic problems within a State program, as identified through investigation of CASPAs, must be documented in this section. A description of the problem and recommended solutions should be included.
  
  Corrective actions taken by the State in response to a previous evaluation must also be discussed in this section.
  
  • Other Issues (Optional). The Region may wish to address or highlight additional State performance issues that were not included in either 4(a) or 4(b) above.
  
  • Appendices. The FAME report must include at least the following two appendices:
  
  State OSHA Annual Report (SOAR)
  
  Data printout of the end-of-year State Activity Mandated Measures (SAMM) report
  
  Data printout of the end-of-year Mandated Activity Report for Consultation (MARC) (for private sector 23(g) consultation programs

Chapter 10
Analysis of State Performance

Introduction. Given that a States' progress toward meeting its annual performance goals is the focus of monitoring, performance issues to be analyzed are most likely to be related to the performance goals. Nonetheless, issues or activities outside of the performance goals but within the scope of Federal monitoring responsibilities may arise and require evaluation or analysis. For example, additional monitoring may be initiated by Federal OSHA or the State in response to significant changes to a State plan or data from automated reports which show a deficiency in carrying out a mandated activity. Likewise, allegations made in a Complaint About State Plan Administration (CASPA) may require further analysis. Once identified, issues for analysis should be included in the annual monitoring plan or its amendments.
1. Analytical Tools. Issues identified for evaluation in the annual monitoring plan or in the course of routine monitoring must be analyzed in terms of their impact on the effectiveness of a State's program. Unless the State agrees to an alternative method in advance, further analysis should consist of one of the methodologies described below. Selection of an analytical tool should be based on cost, suitability, verifiability, and unintrusiveness of the method. Thus, data available in automated reports should always be the first choice over documents requiring special preparation or compilation for review. Likewise, document review is preferable to onsite activity.
2. Impact Assessment. It is the Region's responsibility to ensure that the program impact of each such issue is assessed. Whenever possible, analysis of issues should be conducted jointly, regardless of whether the decision to conduct the analysis originates with Federal OSHA or the State.
Automated Performance Data Reports. Quantitative data available from automated reports should be the first source of information for analysis. Should these data sources not allow for an adequate analysis, the monitor may utilize other methods, including customized IMIS host reports with limited selection criteria. These reports are listed by type below.
1. State Activity Mandated Measures Reports (SAMMs) and State Information Reports (SIR)
2. Standardized host reports
3. Standard micro reports
4. Other IMIS reports
5. State-generated data related to State-specific strategic goals
6. Mandated Activity Report for Consultation (MARC) or Consultation
7. Management Reports (CMRs)
Documents and Logs. Documents that are readily available for general use and logs that are routinely prepared and shared should be the next source of information concerning issues to be evaluated. Examples of such documents and activities are as follows:
1. Section 23 (g) Grants. Each State's grant application contains both the financial data and program narrative. The grant narrative delineates goals for each program activity funded under the grant.
2. State Operational Procedures and Policies. Any and all documents pertaining to the State's operational procedures and policies may contain relevant information.
3. Tracking Database. This database contains records of State actions, including response to Federal actions, such as new or revised standards or Federal program changes. It includes information on the following areas:
  
  (a) State standards development and promulgation
  (b) State response to Federal program changes
  (c) State-initiated program changes
  (d) CASPAs
  (e) Variances
4. State Internal Evaluations. Findings of a State's required internal evaluation program should be discussed at a quarterly discussion and must be made available to the Region upon request. If the State conducts a complete and appropriate analysis of an issue as part of its internal evaluation, its findings and conclusions regarding that issue may form the basis for the Region's findings in its own evaluation report.
5. Other Documents. These may be additional State Records, legislation or other documents.
Case File Review. Federal monitors may review State inspection or consultation case files. Such case file reviews may be used to the extent that the automated data and on-site monitoring techniques listed above do not provide an adequate basis for analysis of an issue. TYNA -- 23g private sector consultation programs are not subject to the requirement of biannual onsite review
1. Scope of Review. The scope of review depends upon the issue being analyzed and may encompass the entire case file or be limited to a specific subject.
2. Selection of Case Files. The selection of case files will also depend upon the issue being analyzed. If the monitor needs to draw statistically valid conclusions from case file reviews, he or she must review a statistically valid sample of randomly selected case files.
3. Documentation of Findings. The monitor must document findings regarding each case file reviewed. The monitor must also document the conclusions reached regarding program impact based on the analysis of all the cases reviewed.
Field Monitoring. Federal monitors may attend relevant meetings and hearings, such as training sessions, cases before the appeals board, discrimination hearings, and public advisory committee meetings. If the review of automated reports, documents, and the other monitoring techniques listed above is inadequate as a basis for analyzing an issue, Federal monitors may join State compliance personnel conducting on-site activities in an accompanied visit. The Region must notify the State and the Directorate of Federal-State Operations if it plans to enter a work site previously visited by the State.
1. Accompanied Visits. The scope of the review will determine the criteria used in selecting the visits on which the Federal monitor will accompany State personnel. During accompanied visits, Federal monitors should observe the following procedures:
  
  (a) Effects of Individual Performance. Accompanied visits are not intended to evaluate the performance of individual compliance officers, as this is the responsibility of State program management. If, however, an accompanied visit suggests that the practices of a particular compliance officer are not consistent with adopted policies and procedures, the Federal monitor must inform the appropriate State manager of these practices.
  
  (b) Observed Violations. If a monitor observes an apparent serious or willful violation that the State compliance officer has failed to note, the monitor must privately advise the compliance officer of the violation prior to the closing conference.
  
  • If the State compliance officer agrees to document the apparent violation and identifies it to the employer, no further action is required at the work site.
  
  • If the State compliance officer refuses to document and identify an alleged hazard to the employer, the monitor must document the alleged hazards.
  
  If time permits, before documenting the hazard, the monitor should contact his or her first level supervisor, initiating a chain of contact that may result in the Area Director and the State Designee deciding how to eliminate the hazard as quickly as possible.
  
  If the State does not have an operational status agreement and a determination pursuant to Section 18(e) has not been made, Federal OSHA may issue citations for any violation observed during the accompanied visit but not documented and identified by the State as an apparent violation.
  
  If the State has an operational status agreement or if a determination pursuant to Section 18(e) has been made, the level of federal enforcement described in the State's subpart of 29 CFR Part 1952 determines whether or not Federal OSHA may issue citations for a particular violation observed during the accompanied visit.
  
  During the closing conference the monitor must inform the employer of the alleged violation and that the State will be (or has been) notified of it so that further action can be taken.
  
  Immediately after the accompanied visit, the monitor must report the alleged violations to his or her immediate supervisor, who must send a memorandum containing this information to the State. The State must then decide if a citation is appropriate.
  
  (c) Imminent Danger. If the monitor observes an apparent imminent danger but the compliance officer disagrees, the monitor should immediately attempt to have the employer remove employees from risk. The next step is to contact his or her supervisor, who in turn must contact the State to discuss whether or not to seek voluntary abatement or removal of employees from exposure and, if necessary, post a Notice of Alleged Imminent Danger (or the State's equivalent notice). The State then determines what further action is appropriate and notifies the Region of its decision.
Documentation of Findings
1. At the conclusion of each accompanied visit, the monitor must document all pertinent information regarding the inspection, such as date, place, establishment inspected, and inspection ID number. The documentation must describe the methods used, findings, and recommendations made. The monitor must also document any other issues that have an impact on the program. All documentation must be maintained for a period of three years, together with the documentation of the quarterly discussion at which the analyses were discussed.
2. Conclusions and Recommendations
  
  (a) If the monitor concludes that the issue could diminish the State program's effectiveness, a remedial strategy and timetable for its implementation must be worked out with the State. The monitor is responsible for documenting the analysis, which must include conclusions and recommendations.
  
  (b) If the monitor concludes that the issue results from deficiencies in the State's procedures, the monitor must document the reasons and discuss with the State any necessary changes to the State plan in accordance with the procedures in this manual.

Chapter 11
Complaints About State Program Administration (CASPAs)

Introduction. A Complaint About State Program Administration (CASPA) is an oral or written complaint about some aspect of the operation or administration of a State plan made to OSHA by any person or group. The CASPA process provides a mechanism for employers, employees, and the public to notify Federal OSHA of specific issues, systemic problems, or concerns about a State program. CASPAs do not, however, provide an appeal mechanism for individual complainants who seek to overturn administrative or judicial determinations made by the State.

The complaint may relate to a specific State action, such as an inspection, or it may reflect a more generic criticism of State program administration. If the Region determines that an investigation of the CASPA is warranted, the investigation is carried out according to the framework for further analysis presented in Chapter X, using the tools such as those described in Chapter VI, Section D.3.(b).

Because State plans operate pursuant to State law and are administered by State agencies, Federal OSHA has no authority to effect a change in the outcome of a particular State administrative or judicial action, but the results of the investigation may lead to recommendations for changes in the State's policies or operating procedures that were the cause of the complaint.
Determining If a CASPA Warrants Investigation. Within five calendar days of receiving a CASPA, the Region must determine whether the CASPA warrants investigation.
1. If a CASPA alleges that a situation of imminent danger exists, the Region must make a determination regarding imminent danger immediately and follow the procedure outlined below in Section E.2.(b), below.
2. All CASPAs must be investigated, unless:
  
  (a) A complainant has not exhausted the available administrative remedies provided for by State procedures and regulations. For example, if a CASPA involves a State case under contest and the contest could provide the complainant with an administrative remedy, the Region must notify the complainant that, once the contest is determined, if the result is unsatisfactory, the complainant may then file a CASPA.
  
  (b) A complaint pertains to an authorized action by the State.
  
  (c) The complaint pertains to a matter that is not within the jurisdiction of the State program.
  
  (d) The Region has already investigated a sufficient number of complaints of the same nature to make an additional investigation unnecessary.
  
  (e) The events pertaining to the complaint occurred so long ago that an investigation in the context of current conditions would be meaningless.
3. If the Region lacks sufficient information to determine whether it should investigate, it must solicit additional information from the complainant or from the State in a timely manner. If there is still insufficient information, the Region must notify the complainant that the case is being closed due to the lack of sufficient information.
4. Anonymous CASPAs will be investigated only if there is sufficient information to proceed with an investigation.
CASPA Log. All CASPAs must be entered into the CASPA Log (See Chapter X, Section C.3).
Confidentiality. Federal regulations (29 CFR 1954.21) require that the identity of any CASPA complainant be kept confidential.
1. The Region must withhold the name of the complainant in any contact with a State concerning a CASPA and in any record published, released, or made available.
2. The Region may attempt to obtain a written waiver of confidentiality from the complainant if, in the judgment of the Regional Administrator, the waiver would facilitate investigation of the CASPA.
Notification of Concerned Parties and Opportunity for a State Response
1. If an Investigation is Not Warranted. The Region must notify the complainant in writing of a determination that an investigation is not warranted. The Region must inform the complainant of the reasons for the determination and that the complainant may ask the Regional Administrator to reconsider the decision. The Region must forward a copy of the letter of preliminary determination to the State after deleting any information that would identify the complainant.
2. If an Investigation is Warranted
  
  (a) Routine CASPAs
  
  • Informing the State. As soon as the Region determines that a CASPA investigation is warranted, it must forward a letter describing the nature of the complaint to the State. The Region must provide the State an opportunity to respond to the CASPA within a reasonable time, and the State's timely response must be considered as part of the Region's investigation. The Region may, if appropriate, identify the issues on which a response from the State would be most useful.
  
  For CASPAs involving a specific incident or cases where State corrective action may be both possible and appropriate, the Region must normally allow the State a minimum of two weeks and no longer than a month to respond. The State may request an extension, in writing, explaining the circumstances necessitating the delay.
  
  For all other routine CASPAs, the Region must allow the State up to one month to respond.
  
  • Response to the Complainant. The Region must notify the complainant that the CASPA is being investigated, that the complainant may be contacted to obtain additional information, and that a written response detailing the results of the investigation will be sent to the complainant. (See Appendix H for an example of a letter to a CASPA complainant acknowledging receipt of a CASPA.)
  
  (b) Special Circumstances
  
  • CASPAs Alleging Situations of Imminent Danger
  
  Informing the State. If a CASPA alleges that an imminent danger exists, the Regional Administrator must immediately contact the State to ensure that appropriate State enforcement action is taken.
  
  Responding to the Complainant. The Region must notify the complainant of its action in a timely manner and keep the complainant informed of the CASPA investigation, as appropriate.
  
  • CASPAs where Notifying the State of the Nature of the Allegation Is Not Appropriate. The Region may determine that informing the State of the specific nature of a CASPA allegation and providing the State an opportunity to respond is not appropriate, for example, if the CASPA complainant is an employee of the State OSHA program. In such cases, the Region must notify the State that it is investigating a CASPA and provide whatever general information it can release.
  
  • Discrimination. If a complainant has filed a single timely discrimination complaint with both the State and Federal OSHA, the complaint should be handled in accordance with OSHA Instruction DIS.7, Referral of Section 11(c) Discrimination Complaints to State Plan States.
  
  (c) State's Response. If the State responds to the Region in a timely manner, the Region must verify the information provided by the State and treat it as an information source in its own investigation of the CASPA. However, the Region may begin its own investigation before receiving the State's response, if that response is delayed or if it is clear that supplemental Regional review will be needed.
  
  (d) Investigating a CASPA. The Region chooses the method or methods to be used to investigate a CASPA from those described in Chapter X. For routine CASPAs involving a specific incident or cases where State corrective action may be possible and appropriate, the investigation must not exceed 60 days. Any delays must be explained in a notation entered into the investigation file.
Review of Completed CASPA Investigations
1. Communication Between Region and State. Immediately after a CASPA investigation is completed, the Region and State must discuss the Region's findings, the recommendations made (if any), and any action the State is planning to make in response to the CASPA.
2. Response to Complainant. Within 30 days from the date the Region and the State have discussed the findings and recommendations resulting from the CASPA investigation, the Region must notify the complainant in writing, summarizing the investigative steps taken, the analysis conducted, the conclusions reached, and any corrective action taken or planned by the State. This letter must also advise the complainant of his or her right to request reconsideration by the Regional Administrator. In complex cases, the Region may forward a draft copy of this letter to the State for comment.
3. Letter to the State. The Region must send a letter to the State setting out the conclusions of its investigation, its recommendations for corrective action, if any, and a proposed timetable for any corrective action recommended. The Region must also send the State a copy of its final response to the complainant, maintaining the confidentiality of the complainant's identity.
4. State Response. If the State disagrees with any aspect of the investigation, it may file a written response. The Region must allow sufficient time for the State to prepare its written response and include a copy of it with the other materials (See 5, below) it sends to the Office of State Programs in OSHA's National Office.
5. Forwarding the Response to Complainant to the Office of State Programs. For CASPAs having national or significant program impact, upon completion of the investigation, the Region must forward to the Office of State Programs a copy of the response sent to the complainant and a copy of the letter sent to the State.
6. Corrective Action. In individual cases where allegations in a CASPA are determined to have merit, the State must take the corrective action specified by the Region or an agreed-upon alternative. The State must also put in place a procedure to avoid recurrence of the problem. The Region must monitor the State's corrective action.
7. Resolution. If the State fails or refuses to take corrective action, and the Region is unable to negotiate a solution, the issue must be handled in accordance with the resolution process outlined in Chapter VI, Section D.4..
Documentation of CASPA Investigations. The amount and kind of information that is collected and analyzed will vary for each CASPA. In many cases, the Regional Administrator's written response to the complainant may satisfy most of these documentation requirements. Each case file should contain written documentation of the following:
1. The allegations that were investigated
2. The information reviewed in the course of investigating the CASPA
3. An analysis of the allegations and conclusions regarding their validity
4. Recommended corrective actions and timetable for their implementation
5. The actions taken by the State
6. Any follow-up actions taken by the Region

Appendix A
Definitions of Strategic Planning Terms

Term	Definition
Activities	• The goods or services produced as a result of internal activity or effort on the part of an agency or program Example: Conducting inspections, delivering training programs, conducting consultation visits
Annual Performance Goals	• Target levels of performance relating to a performance goal for a specific fiscal year Example: Reduce fatalities in the construction industry by 3% in FY 2000
Baselines	• Statements of current performance levels used as a basis for comparison when assessing progress towards a strategic goal or objective
Indicators	• Means of evaluating progress towards achievement of performance goals Example: Percent reduction in fatalities in the construction industry
Mission	An agency's purpose. A mission statement succinctly identifies what the agency does, why, and for whom it does it and reminds everyone - the public, the Governor, Legislators, the Courts, and agency personnel - of the unique purposes promoted and served by the agency.
Outcomes	• The results of a program or activity as compared to its intended purpose. There are two types of outcome measures: Primary Outcomes - The ultimate results intended to be achieved by the program activities Example: Percent reduction in lost workday injury and illness rates, percent reduction in fatalities Intermediate Outcomes - Assessments of incremental progress towards primary outcomes; outcomes that lead to the ends desired, but are not ends themselves Example: Percentage of inspection visits which result in the identification of targeted hazards
Performance Goals	• Statements of specific long-range performance targets relative to the strategic goal Example: Reduce fatalities in the construction industry by 15% by focusing on the leading causes of fatalities (falls, struck-by, crushed-by, and electrocutions and electrical injuries)
Strategic Goals	• Broad statements of the strategic direction an agency wants to take over a five-year term Example: Change workplace culture to increase employer and worker awareness of, commitment to, and involvement in safety and health.
Strategic Planning	• The process of assessment, goal-setting, and decision-making that results in an agency envisioning what it hopes to accomplish in the future
Strategies	• The mix of programs and activities that will be used by the State occupational safety and health program to accomplish its mission Example: Standards development, inspections, compliance assistance, training and education, outreach
Vision	An inspiring picture of a preferred future. A vision is free of time constraints, represents global and continuing purposes, and serves as a foundation for a system of strategic planning.

Appendix B
Strategic Plan Summary Chart

Strategic Goal 1 Improve workplace safety and health for all workers, as evidenced by fewer hazards, reduced exposures, and fewer injuries, illnesses, and fatalities
Performance Goal 1.1A	Reduce three of the most significant types of workplace injuries and causes of illnesses by 15% (Lead Exposure)
Indicator	Percent change in average lead exposure severity
Data Source	OSHA Integrated Management Information System (IMIS) Baseline(s): FY 1995: Industries
Comment	OSHA will measure average lead exposure in establishments where OSHA had lead-related interventions
Strategic Goal 2 Change workplace culture to increase employer and worker awareness of, commitment to, and involvement in safety and health
Performance Goal 2.1A	Fifty percent (50%) of employers who are targeted for or request an OSHA intervention will implement an effective safety and health program, including, where appropriate, an ergonomic program
Indicator	Percent of employers (in general industry) who are targeted for or request an OSHA intervention who have implemented an effective safety and health program, including, where appropriate, an ergonomic program
Data Source	OSHA Integrated Management Information System (IMIS) Baseline: The first year OSHA will collect data on this goal is FY 2001
Comment

Performance Goal 2.2A	Reduce injuries and illnesses by 15% at work sites engaged in voluntary, cooperative relationships with OSHA
Indicator	Percent change in injury and illness rates at work sites engaged in voluntary, cooperative relationships with OSHA
Data Source	Under Development
Comment

Performance Goal 2.3A	Ninety percent (90%) of employers and workers rate OSHA's compliance assistance (e.g., consultation, training, education, and outreach) as useful in improving safety and health in their workplaces
Indicator	Percent of employers and workers rating OSHA's compliance assistance as useful
Data Source	Survey of employers and workers receiving OSHA's compliance assistance Baseline: Survey to be administered in FY 2000

Appendix C
Sample Chart of Break-out of Personnel

Position	Type of Staff	Number of Grant-Funded Staff^**	Number of 100% State-Funded Staff^**	Total^**
Compliance Officers^*	• Safety
Compliance Officers^*	• Health

23(g) Consultants^*	• Safety
23(g) Consultants^*	• Health

21(d) Consultants^*	• Safety
21(d) Consultants^*	• Health

Total Number of Allocated State Plan Personnel^***

^* Include all allocated positions in which more than 50% of the time is spent conducting inspections (or consultation visits)

^** Expressed in allocated FTEs. Include only those positions for which no Federal funds are used.

^*** Include both allocated administrative and program positions

Appendix D
Performance Plan Summary Chart

Strategic Goal 1

Improve workplace safety and health for all workers, as evidenced by fewer hazards, reduced exposures, and fewer injuries, illnesses, and fatalities

Performance Goal 1.1A

Reduce three of the most significant types of workplace injuries and causes of illnesses by 15%

Annual Performance Goal 1.1A

FY 2001:	Reduce three of the most significant types of workplace injuries and causes of illnesses by 11% from baseline
FY 2000:	7%
FY 1999:	3%

Indicator

• Percent change in average silica exposure severity
• Percent change in average lead exposure severity
• Percent change in amputation rate

Data Source(s)

• OSHA Integrated Management Information System (Silica and Lead)
• NIOSH Study (Silica)
• BLS Annual Survey of Occupation Injury and Illness (Amputations)

Baseline

• Silica - Industries: FY 1996; establishments with interventions
• Lead - Industries: FY 1995; establishments with interventions
• Amputations - CY 1993-1995

Comment

• Silica - OSHA will measure average silica exposure in establishments where OSHA had silica-related interventions
• Lead - OSHA will measure average lead exposure in establishments where OSHA had lead-related interventions in each targeted industry
• Amputation - A three-year moving average is used to reduce fluctuations in order to highlight trends in performance measures.

Appendix E
State Activity Mandated Measures (SAMMs)

Issue	Indicator	Reference or Standard
Enforcement	1. Average number of days to initiate complaint inspections	Negotiated fixed number for each State
	2. Average number of days to initiate complaint investigations	Negotiated fixed number for each State
	3. Percent of complaints where complainants were notified in timely manner-within 20 working days of citation issue date or 30 working days of closing conference with citations	100%
	4. Percent of notices (complaints and referrals) of imminent danger responded to within 24 hrs (Combined public and private)	100%
	5. Number of denials where entry not obtained (Combined public and private)	0
	6. Percent of S/W/R violations verified abated within abatement date + 30 days (Separate public and private)	100%
	7. Average number of calendar days from opening conference to citation issuance (Separate safety and health)	Previous year national average^*
	8. Percent of programmed inspections with S/W/R violations (Separate safety and health)	3-year national average^*
Effective Sanctions	9. Average number of violations per inspection, broken out by S/W/R, and other-than-serious violations	3-year national average^*
Effective Sanctions	10. Average penalty per serious violation (Private sector only)	3-year national average^*
Public Employee Program	11. Percent of total inspections conducted in the public sector	State's individual 3-year average
Review Procedures	12. Average lapse time from receipt of contest to first level decision	3-year national average^*
Discrimination	13. Percent of discrimination investigations completed within 90 days	100%
	14. Percent of discrimination complaints that are found meritorious	3-year national average^*
	15. Percent of meritorious discrimination complaints that are settled	3-year national average ^*
Program Administration	16. Percent of required Federal program changes adopted within established time frame	100%
Program Administration	17. Percent of State-initiated changes submitted within established time frame	100%
Standards	18. Percent of permanent standards adopted within 6 months; emergency temporary standards adopted within 30 days	100%
Variances	19. Number of permanent variances granted	State's individual 3-year average
Variances	20. Number of temporary variances granted	State's individual 3-year average

* The national average includes both Federal OSHA and State data

Appendix F
Interim State Information Report (SIR)

Scope	Indicator
Private Sector	1. Percent programmed inspections - Safety - Health
	2. Percent programmed inspections with violations - Safety - Health
	3. Percent serious violations - Safety - Health
	4. Abatement period - Safety % - Health %
	5. Average penalty (other than serious) - Safety - Health
	6. Inspections per 100 hours - Safety - Health
	7. Percent violations vacated
	8. Percent violations reclassified
	9. Percent penalty retention
Public Sector	1. Percent programmed inspections - Safety - Health
Public Sector	2. Percent Serious Violations - Safety - Health
Review Procedures	1. Percent violations vacated
	2. Percent violations reclassified
	3. Percent Penalty retention

Note: Each measure is broken out into 3-month, 6-month, 12-month, and 24-month columns, each of which is broken out into Federal and State columns.

Appendix G
State OSHA Annual Report: State Results Summary Chart

For each performance goal in a State's annual performance plan, the State must provide its results using the following template. Note that not all of a State's Performance Goals will have multiple activity measures, intermediate outcome measures, or primary outcome measures. This chart should be adapted to meet the requirements of a State's own measurement system.

Strategic Goal:

Performance Goal:

Performance Indicator Type	Indicator	Results	Comments
Activity Measures	Indicator 1
	Indicator 2
	Indicator 3
	Indicator 4

Intermediate Outcome Measures	Indicator 1
	Indicator 2
	Indicator 3
	Indicator 4

Primary Outcome Measures	Indicator 1
Primary Outcome Measures	Indicator 2

Appendix H
Sample Acknowledgment Letter to CASPA Complainant

(ADDRESS)

Re: CASPA #

Dear :

This is in response to your Complaint About State Program Administration regarding

An investigation will be conducted to look into your allegations, and to determine if the State's actions in this case are in compliance with OSHA-approved procedures. Please be aware that Federal OSHA is not an office of appeal for an individual who is dissatisfied with a decision or finding resulting from a State investigation or hearing. Although the CASPA procedure may include an investigation of such decisions or findings, the focus of the investigation is the State's adherence to its own laws and policy. If you wish to contest a state decision or finding, an appeal should be made to the appropriate State agency or court.

Our first step in the investigation will be to contact the State to request its response to your issues of concern. Your name will be withheld and is considered confidential, unless you give specific authorization for its release. Based on the State's response, further action may be initiated, as appropriate. We may be contacting you to obtain additional information. Upon completion of the investigation, OSHA will inform you of the findings, conclusions, and any recommendations made to the State.

We appreciate your interest in the effective implementation of the (State) occupational safety and health program.

Sincerely,

(REGIONAL ADMINISTRATOR)

Index

Accompanied Visits

Documentation of Findings

Activities

Annual Performance Goals

Annual Monitoring Plan

Annual Performance Plan

Annual Performance Goals

Summary Chart

Assessment of State Performance

Automated Performance Data Reports

State Information Reports (SIR)

Baselines

Case File Reviews

Changes to Annual Performance Plans

Complaints About State Program Administration

CASPAs Alleging Situations of Imminent Danger

Corrective Action

Determining If a CASPA Warrants Investigation

Documentation of CASPA Investigations

Notification

Response to Complainant

Routine CASPAs

Consultation Management Report (CMR)

Frequency

Guidelines for Use

Definitions

Federal Annual Monitoring and Evaluation (FAME) Report

Field Monitoring

Accompanied Visits

Imminent Danger

Observed Violations

Grant Application

Financial Documents

Indicators

Mandated Activities

Program Assurances

State Activity Measures

Mission

Monitoring Against Annual Performance Plans

Monitoring and Evaluation Process

Dispute Resolution

Evaluation Tools

Framework

Goal

Monitoring Developmental State Plans

Monitoring Process

Performance Evaluation

Performance Tracking and Reports

Scope

Outcomes

Performance Goals

Quarterly Monitoring Meetings

Documentation

State Activity Measures (SAM) Report

State Information Reports (SIR)

State Internal Evaluation Program

State OSHA Annual Report

Strategic Goals

Strategic Plan

Annual Review of Strategic Plans

Changes to Strategic Plans

Core Elements of a Strategic Plan

Development Procedures

Mandatory Goal

Optional Goals

Possible Approaches

Review and Approval of Strategic Plans and the Annual State Plan

Summary Chart

Third-Year Review of Strategic Plans

Strategic Planning

Strategies

Tracking Database

Vision