This directive will be cancelled on October 1, 2005. Please refer to the following link for the new directive effective on that date: EAA 01-00-003

OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

Subject: Field Audit Program

A. PURPOSE. This instruction states agency policy concerning audits of field operations. It also prescribes actions required to attain the agency's audit objectives.

B. SCOPE. This instruction applies OSHA-wide.

C. REFERENCES.

1. The field audit program is one component of OSHA's internal control system as required by OMB Circular A-123, Subject: Internal Control Systems.

2. OSHA Instruction STP 2.22A, January 29, 1990, State Plan Policies and Procedures Manual.

3. OSHA Instruction FIN 3.2, August 27, 1984, Financial and Administrative Monitoring of the 23 (g) Grants, 7(c)(1) Cooperative Agreements and 24(b)(2) Grants and Contracts.

4. OSHA Instruction TED 3.5, April 27, 1987, Consultation Policies and procedures Manual.

5. On-Site Consultation Agreements, 29 CFR 1908.8 -- Consultant Specifications.

6. OSHA Instruction DIS .4B, May 21, 1990, Revised Section 11(c)/405 Investigator Manual.

7. OSHA Instruction DIS .7, February 27, 1986, Referral of Section 11(c) Discrimination Complaints to "State Plan" States.

8. OSHA Instruction TED 8.1, November 10, 1986, Revised Voluntary Protection Program (VPP) Policy and Procedures Manual.

9. OSHA Instruction CPL 2.45B, March 1, 1991, Revised Field Operations Manual (FOM).

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OSHA Instruction PAE 2.1C November 18, 1991 Office Field Programs

10. Federal Register, Vol. 53, No. 133, July 12, 1988, pages 26339-26348, Voluntary Protection Program.

D. CANCELLATION. OSHA Instruction PAE 2.1B, Field Audit Program, September 14, 1988, PAE 2.1B CH-1, January 29, 1990, and the following memoranda from Leo Carey: August 29, 1989, Subject: Audit Focus - FY90 and December 10, 1990, Subject: Management Reports are canceled.

E. ACTION. Regional Administrators (RAs) and the Director of the Office of Field Programs (DOFP) shall implement the audit policy described in F. Further, they shall fulfill their respective responsibilities as specified in G. of this instruction.

F. POLICY. OSHA shall operate an audit program which shall identify 1.) potential policy and procedural weaknesses, 2.) areas for improvement, 3.) the unsatisfactory execution of the agency's programs, and 4.) those activities which constitute either a failure to correct or a repeat finding from an earlier audit. In the event of limited resources to conduct audits as required by this instruction, the RAs shall advise the DOFP in writing of such resource problems. The RA should request permission to conduct limited audits of agency programs and operations which create the greatest vulnerability in achieving OSHA's objectives. DOFP will evaluate the request and respond in writing. If approved, an allowance letter will constitute a waiver from a full audit for that fiscal year.

1. VULNERABILITY. These are defined as programs, policies, and practices which relate directly to OSHA's mission and which, if improperly executed, can seriously impact agency performance. These vulnerabilities include programs, policies, and practices which directly affect employers and employees and/or substantially influence the perceptions of both the public and Government concerning OSHA's effectiveness. Vulnerabilities are described in the Appendixes and are subjects for audit. Although Appendix B addresses those programs that are either operated and/or monitored from the Regional Offices, there may

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

be some program responsibilities that have been delegated to an Area Office because of the Area Office's proximity to the program or because of the RA's decision to do so. Where the monitoring is done at an Area Office, Appendix B should be used by the Regional Office to review the Area Office's performance.

2. OTHER AUDIT SUBJECTS. Programs, policies, and practices other than the designated vulnerabilities may also be audited. These other subjects, if any, shall be designated by the RAs. All operations conducted by either the Regional or Area Office will be considered when determining other subjects for audit.

3. CONDUCT OF AUDITS. Audits shall be conducted in accordance with the following:

a. RAs shall have responsibility for the audit of all operations within their Regions including both Area and Regional Offices' operations. Further, RAs shall be responsible for ensuring that all weaknesses in their operations noted through the audit are corrected.

b. Audits may take several forms. They may be accomplished by on-site visits, IMIS data reviews, questionnaire completion or other documentation reviews.

c. Each Area Office shall be audited annually and on- site at least once every 2 years. The subjects audited shall include those designated as Area Office Vulnerabilities found in Appendix A. If on-site audits are conducted bi-annually the intervening year's audits can be accomplished by alternative means mentioned above in F.3.b.

d. Subjects identified as vulnerabilities within Regional Office operations shall be audited at least once every 2 years. Personnel from another Region may be used to audit these vulnerabilities.

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e. RAs are encouraged to use the self-audit approach to increase the scope of their audit programs and to provide indications of possible vulnerabilities. Self-audits shall not be used as the sole means to audit subjects designated as vulnerabilities.

4. AUDIT REPORTS. It is recommended that all audit reports initially be submitted in draft form. This permits the office being audited to comment upon the accuracy of the findings before the report is finalized.

5. FOLLOWUP. Followup actions to ensure that all problems identified by the audits have been corrected in a timely manner shall be taken by the RAs.

6. OVERSIGHT OF THE AUDIT PROGRAM. The DOFP shall have the responsibility for overseeing the field audit program. This oversight shall include tracking the RA's compliance with this instruction and their audit plans. Methods of oversight shall include review and analysis of IMIS data and the Regions' audit reports. The DOFP shall audit Area and Regional Offices' operations as deemed necessary. These audits will not be limited solely to subjects designated as vulnerabilities. Further, the DOFP shall be responsible for revising the vulnerabilities as necessary to ensure that they are current and complete. The RAs and National Office Directors shall be consulted concerning the designation of subjects as vulnerabilities. The risk assessment derived from OSHA's activities under the Federal Managers' Financial Integrity Act and OMB Circular A-123 also shall be considered.

7. COLLECTION AND DISSEMINATION OF INFORMATION. The DOFP shall serve as the focal point for the collection and dissemination of information concerning audits. Such information will include innovative ideas and approaches to solving problems, audit findings of general interest, and special audit techniques which have proven to be effective. When, through the audit process, weaknesses in agency

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

policies or procedures come to the attention of the DOFP, this information will be made known to the RAs, Assistant Secretary, and/or the responsible Directorate so that corrections can be made.

G. RESPONSIBILITIES. Responsibilities of the RA and the DOFP are detailed as follows:

1. REGIONAL ADMINISTRATOR.

a. Designates an Audit Program Coordinator.

b. Conducts audits of all Area Offices in accordance with F.3., using at least the subjects designated as Area Office Vulnerabilities, found in Appendix A.

c. At least once every two years, conducts an audit of the Regional Office functions using at least the subjects designated as Regional Office Vulnerabilities, found in Appendix B. Also, audit the Region's oversight program of the Area Offices for compliance with vulnerabilities identified in Appendix A.

d. Submits an audit plan to the DOFP at the beginning of each fiscal year. This plan will cover audit activity scheduled for the fiscal year and will include descriptions of the types of audits scheduled and the time frames for the conduct of the audits. The DOFP shall be advised in writing of any changes in these plans during the course of the year.

e. Reports, stating the scope and purpose of the audit reports, will be prepared for each Area Office's audit, whether on- site or not, and Regional Office audit. The reports will specifically address the findings for each element of the vulnerabilities identified in Appendix A or Appendix B, as applicable. It should specify if any findings are repeat items since the last on-site audit. Where corrective actions are not completed by the response due date, specific time frames shall be given for the corrective actions.

f. When on-site audits have been conducted, no more than 45 days should elapse between on-site closing conferences and submission of the audit reports to the

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

Area Directors. Response to the audit reports should be no later than 30 days after the receipt of the reports. Altogether, no more than 90 days should elapse between the on-site opening conference, or the initiation of an alternative audit, and the response to the audit report, except in extraordinary circumstances. These circumstances will be addressed in the transmittal letter. Copies of all audit reports and responses will be forwarded to the DOFP as soon as responses to the reports are received.

g. Ensures response to a National Office audit within the time frames referenced in the transmittal memorandum. Response includes any applicable time frames for completion of any recommendations referenced in the audit.

h. Ensures that corrective actions have been taken to remedy any deficiencies noted during Regional and National Office's audits.

i. Notifies the DOFP of any policy and procedural issues having potential national implications. This action will be taken immediately upon discovery of the issues whether identified by audits or by other means.

2. DIRECTOR OF THE OFFICE OF FIELD PROGRAMS.

a. Oversee the total field audit program through review of IMIS data, the Regions' audit reports, audits of selected Regional and Area Offices' operations, and followups.

b. Ensure that designated vulnerabilities are current and are appropriate subjects for audit.

c. Inform the RA of indications of potential problems identified from the review of the IMIS data and audit reports and, where appropriate, request explanations from the RAs.

d. When audits are conducted, report findings and recommendations to the RAs. Timeliness requirements for the submission of the audit reports

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

shall be 45 days, except in extraordinary circumstances.

e. When policy and procedure issues are identified through the audit process, inform the RAs and the Assistant Secretary, and/or the responsible Directorate. Where applicable, suggested corrective actions shall be provided.

f. Serve as the focal point for the collection and dissemination of information concerning audits.

Gerard F. Scannell Assistant Secretary

DISTRIBUTION: National, Regional and Area Office

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

Appendix A

Area Office Vulnerabilities

A. INTERGRATED MANAGEMENT INFORMATION SYSTEMS. (IMIS)

1. Area Office IMIS will be in place for at least the following reports:

Violation Abatement.

Candidates for Followup Inspections.

Unsatisfied Activity.

OSHA-7 for Signature.

Employer Response Due.

Referral Tracking.

Citations Pending/Supervisor/Area Director.

Fatality/Catastrophe Tracking.

Debt Collection.

Case File Lapse Time.

Open Inspection (Tracker).

2. The audit of IMIS will ensure the Area Offices have performed the following actions:

a. Developed a written plan which delineates and assigns the duties of maintaining the IMIS including the flow of IMIS forms and related documents.

b. Trained appropriate personnel and are holding them accountable for their assigned duties with the IMIS.

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c. Assigned personnel to reconcile differences and/or errors identified by the Host in normal Start-of-Day, End-of-Day Transmissions and OMDS productivity reports.

d. Resolved regularly occurring problems under the control of the Area Office through training, job reassignments or other appropriate actions.

e. Developed and implemented a written plan for periodic verification that the data base accurately reflects the IMIS forms and related documents processed by the office, and that the forms accurately reflect the actual activities of the office.

f. Developed and implemented a written plan which describes how often each report will be generated and to whom it will be distributed.

B. ASSURANCE OF ABATEMENT.

1. Audit activity will include analysis of the IMIS and the information provided by the system. Case files also will be reviewed to the extent necessary to judge:

a. The timeliness with which the Area Office obtains information that the cited conditions have been abated;

b. That the employers' abatement actions indicate the cited conditions were corrected by the abatement date set in the citation; and

c. The sufficiency of case file documentation concerning the specific corrective actions for each violation.

2. Compliance with policy concerning situations where followup inspections are normally required.

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3. Propriety of PMA handling, that is:

a. Satisfaction of the five requirements.

b. Written justification from the employer for late PAMs is on file.

c. Compliance with prescribed time frames.

d. Performance of monitoring inspections where required.

e. Notifications to the RA for approval of PMAs of over one year duration.

f. Reasonableness of approvals and objections.

g. Potential PMAs are being tracked by the Area Office.

h. Written notification to the employee representative on PMA approval, rejection, or delayed decision.

C. TARGETING INSPECTIONS. Implementation of OSHA policy concerning programmed inspections will include reviews of:

1. Records of current and previous inspection cycles including carryover to ascertain if they were properly completed in accordance with OSHA policy.

2. Changes to the establishment or worksite lists shall be documented to show the rationale for any changes.

D. COMPLAINT AND REFERRAL PROCESSING. Audit activity will include analyses of the IMIS Reports and the information provided by the systems. Case files also will be reviewed to the extent necessary to determine:

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

1. Response times for formal complaints and referrals.

2. Non-formal letters sent to employers in a timely manner

3. OSHA-7 for signature sent to complainant in a timely manner.

4. Compliance with tenth letter complaint inspection policy.

5. Tracking non-formal responses from employers.

E. PENALTY CALCULATIONS, REDUCTIONS AND COLLECTION.

1. The IMIS Reports used to track the collection of penalties will be reviewed. Its effectiveness in identifying the following will be determined:

a. Penalty amounts and the due dates.

b. Demand letter actions.

c. Additional assessments.

d. Approved installment plans.

e. Referrals to National Office for collections.

f. Referrals to the Regional Solicitor.

g. Payments.

h. Contested penalties.

2. IMIS reports and case files will be reviewed to the extent necessary to determine:

a. Accuracy of penalty calculations for willful, failure to abate (FTA), and repeat violations.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

b. Reasonableness of penalty reductions, particularly as they apply to cases with willful, FTA or repeat violations, following informal conferences and settlement agreements.

F. HAZARD COMMUNICATION STANDARD. Audit activity will include analysis of IMIS data, as well as case file reviews, to the extent necessary, to determine:

1. OSHA instructions are used to ensure uniform enforcement.

2. Compliance staff's citation frequency, classification, and penalty are consistent with Regional percentages.

3. Area Office's citation frequency, classification, and penalty are consistent with Regional and National percentages.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

Appendix B

Regional Office Vulnerabilities

STATE PROGRAMS

A. PROGRAMS: SYSTEMS REVIEW. A systematic review process exists that ensures the following:

1. STATE PLAN ACTIVITY MEASURES (SPAM) REPORT OUTLIERS.

a. All outliers in the 6-month column are adequately reviewed, analyzed, and coordinated with the States.

b. The States are allowed an opportunity to participate in the outlier analysis.

c. Analytical plans are developed, used, and documented for each outlier.

d. Quarterly discussions with the States are held within 20 days of receipt of the SPAM report and documented.

e. Other IMIS reports are used for analysis of outliers and for tracking of State activities.

f. Special investigations are conducted to review those program aspects or outliers which cannot be adequately addressed through data analysis.

g. Followups are conducted to ensure implementation of any recommendations for previously addressed outliers.

2. COMPLAINT AGAINST STATE PROGRAM ADMINISTRATION (CASPA).

a. CASPA's are reviewed and analyzed in accordance with OSHA Instruction STP 2.22A.

b. The State is given an initial opportunity to respond

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

to the CASPA allegations except where determined inappropriate in accordance with CASPA procedures.

c. Complainants' names are kept confidential.

d. Resolutions are supported by factual documentation.

e. CASPA responses are coordinated with the State.

f. Followups are conducted to ensure that any necessary corrective action was accomplished.

g. CASPA resolutions and responses to complainants are timely.

3. ANNUAL REPORTS.

a. Annual reports are submitted within the sixty (60) days of receipt of the SPAM report for the period.

b. All 11 major categories are addressed.

c. All outliers are analyzed.

d. Other State-specific activities are addressed.

e. Efforts are made to obtain data not readily available.

f. The review is coordinated with other offices and agencies (e.g., Bureau of Labor Statistics (BLS), Office of the Solicitor(SOL)) when appropriate.

g. Appropriate recommendations are made where program deficiencies are noted.

h. The report addresses the status of recommendations made in previous reports.

i. Appropriate followup is made to ensure action on the issues addressed in the report.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

4. STATE PLAN CHANGES (INCLUDING STANDARDS).

a. Federal program changes are transmitted to the State in a timely manner.

b. A followup should be conducted for Federal program changes for which acknowledgments are not submitted within seventy (70) days (15 days for emergency temporary standards) and for State plan changes and standards which are not submitted within 6-months (30 days for emergency temporary standards), when required.

c. A followup should be conducted for State-initiated changes which the Region is aware of and which are not submitted within thirty (30) days for changes involving legislation or funding and within 6 months of other changes.

d. Submitted plan changes are reviewed and transmitted to the National Office in a timely manner.

e. States are promptly informed of any deficiencies in their change submissions and they are required to correct them.

f. FEDERAL REGISTER notices are prepared for standard submissions.

g. The logs of State responses to Federal program changes, State-initiated changes, and standard changes are maintained and submitted to the National Office within thirty (30) days of the end of each quarter.

B. FINANCIAL: SYSTEMS REVIEW. A systematic review process exists that ensures the following:

1. ON-SITE MONITORING.

a. Annual visits, pursuant to OSHA Instruction FIN 3.2,

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

are made and the States' financial and administrative systems are reviewed for compliance with the appropriate grant regulations.

b. The findings and proposed recommendations from the annual visit are discussed with the grantee. The annual report sent to the grantee shall contain all findings and recommendations discussed with the grantee.

c. A copy of the latest annual visit report is on file for each grantee.

d. A followup should be conducted on each grantee to ensure compliance with the report's recommendations.

e. Federal and State Operations is provided a copy for possible inclusion in the annual report for the States.

2. ON-GOING REVIEW.

a. Grant applications are:

(1) Coordinated with the appropriate regional staff.

(2) Evaluated for compliance with annual grant instructions from the National Office, Department of Labor (DOL) regulations and Office of Management and Budget (OMB) Circulars.

(3) Reviewed and submitted to the National Office in a timely manner.

b. Communications with the States on request for revisions, deletions, etc., are documented.

c. Grant files are up-to-date with copies of the grant, drawdowns, expenditure reports, a summary sheet showing the current financial status, and any other

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

pertinent communications with the State relating to the grant.

d. Periodic analyses of budget vs. actual are done to ascertain grant financial status, spending patterns, and possible unexpended balances.

e. Cash management regulations (Cash Management Act of 1990, P.L. 101-453) are being adhered to by the States.

3. CLOSE-OUT: (ANNUAL RECONCILIATION).

a. Final reports are complete, accurate, and timely.

b. Close-out documents are forwarded to the National Office.

c. A copy of the written request for an extension from the State and the Region's response to the request are on file. Any extension request for more than 60 days requires National Office approval. Copies are sent to the National Office for the official file.

CONSULTATION

A. PROGRAMS: SYSTEMS REVIEW. A systematic review process exists that ensures the following:

1. PROJECT OPERATIONS REVIEW (POR):(ON-SITE MONITORING).

a. POR's are conducted in accordance with guidelines established in OSHA Instruction TED 3.5.

b. Case file sampling protocol is followed.

c. As a result of the review of the case files, conclusions are reached on the following issues and, where appropriate, recommendations are made:

(1) Hazard Identification and Classification (measure 9).

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

(2) Appropriateness of hazard correction recommendations (measure 11).

(3) Adherence to safety and health program assistance criteria (measure 14).

(4) Adherence to training and education criteria (measure 16).

(5) Adherence to inspection exemption program criteria (measure 18).

(6) Accuracy of Data entry (measure 22).

(7) Quality of written reports (measure 24).

(8) Where appropriate, monitors address the issue of whether or not case files contain verification that serious hazards are corrected.

(9) Monitors carefully review the issue of granting extensions to correction due dates for serious hazards.

d. Activity measures (reported on the Consultation Activity Measures [CAM] Report) are discussed with the Project Manager. "Outliers" covered by the visit are discussed and, as necessary, strategies for addressing outliers are discussed.

e. Any recent developments in the Consultation Project which could impact the effectiveness of the project's performance are discussed.

f. The monitor reviews the Cooperative Agreement with the Project Manager to ensure that the basic provisions (Appendix F) of the agreement are administered and implemented. As appropriate, plans are developed to assist a project in meeting specific requirements.

NOTE: The discussions mentioned in 1.d, 1.e, and 1.f above should be reduced to writing and made a part of the work files.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

g. The monitor reviews the project's accompanied visits plan and determines the effectiveness of the plan; i.e., was it implemented. Actual performance evaluations effectively assess individual consultant performance and, where necessary, the monitor works with the project manager to develop a more credible consultant evaluation plan.

h. Monitors are ensuring that consultants' employee training goals (IDP's) are being met.

2. ANNUAL REPORTS.

a. Annual evaluation reports are developed in accordance with guidelines established in OSHA Instruction TED 3.5 and July 18, 1990 memo to RA's and sent to the projects for review.

b. The report addresses the project's performance in relation to each of the eight consultation program objectives discussing both areas of positive accomplishment and areas in need of improvement.

c. The report reaches conclusions on the project's effectiveness in meeting each of the eight objectives. The conclusions are based on sound analysis of all available information such as CAM reports, case file sampling, etc.

d. Where deficiencies are noted, there is sufficient data and/or supporting information referenced in the report to substantiate the findings. For each identified deficiency, a feasible corrective recommendation is made.

e. The report addresses "repeat" deficiencies; i.e., those identified in previous reports.

f. A statement of the overall effectiveness of the program is provided. It is consistent with the information provided in the report.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

g. The report provides, as appropriate, feasible and attainable recommendations on how the project might improve its performance with regard to specific program objectives.

          h.   There is appropriate Regional followup to ensure
                that "action items" are adequately responded to by
               the project.

i. The report is submitted to the National Office within the prescribed time frame established in OSHA Instruction TED 3.5. and July 18, 1990 memo.

3. CONSULTATION ACTIVITY MEASURES (CAM) REPORT OUTLIERS.

a. All outliers in the 6-month column are adequately reviewed, analyzed, and coordinated with the States.

b. The States are allowed an opportunity to participate in the outlier analysis.

c. Analytical plans are developed, used, and documented for each outlier.

d. Quarterly discussions with the States are held within 20 days of receipt of the CAM report and documented.

e. Other IMIS reports are used for analysis of outliers and for tracking of State activities.

f. Special investigations are conducted to review those program aspects or outliers which cannot be adequately addressed through data analysis.

g. Followup communications are conducted to ensure implementation of any recommendations for previously addressed outliers.

4. EXEMPTION PROGRAM. The State exemption activity is monitored via analysis of State-provided data and on site visits per OSHA Instruction TED 3.5.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

5. REGIONAL ADMINISTRATOR'S REVIEW OF PROJECT PERSONNEL. As specified in 29 CFR 1908.8(b)(1), all consultant personnel are approved by the RA prior to their assignment to work.

6. APPLICATION REVIEW.

a. Annual agreement proposals are reviewed and analyzed in accordance with National Office instructions contained in either the application package and/or the transmittal letter with the signed agreement.

b. The proposals are concurrently reviewed by the Management Office and the Offices of Training and Education, Consultation Programs, and Federal Agency Programs (TEC/FAP).

c. The Regional Office negotiates necessary changes to specific proposals prior to forwarding them to the National Office of Consultation Programs. The Regional Office provides a summary recommendation on the acceptability of each proposal to the National Office. The recommendations are endorsable.

B. FINANCIAL: SYSTEMS REVIEW.

1. ANNUAL MONITORING VISITS.

a. The monitoring visits are made in accordance with OSHA Instruction FIN 3.2.

b. Findings and recommendations are discussed with the designee or other appropriate State Official, and should be made a part of the work file.

c. Followups are conducted on the findings and recommendations.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

2. APPLICATIONS REVIEW.

a. The application is reviewed for compliance with appropriate OMB and DOL guidelines, and is coordinated with TEC/FAP

b. Program projections are commensurate with the funding request; i.e., personnel, travel, equipment, supplies, etc., are sufficient to support the program goals.

3. ON-GOING REVIEW.

a. There is a consistent review of the financial file during the fiscal year to ensure that the State operates within its program and funds are expended for their prescribed purposes.

b. Appropriate drawdown and expenditure figures are available to reflect the current status of the agreement. Supporting documentation is in each file that supports each expenditure.

c. There is coordination with TEC/FAP on financial and administrative issues.

d. Cash management regulations (Cash Management Act of 1990, P.L. 101-453) are adhered to by the designee or other appropriate State Official.

4. CLOSE-OUT: (ANNUAL RECONCILIATION).

a. Final reports are complete, accurate, and timely.

b. Close-out documents are forwarded to the National Office.

c. A copy of the written request for an extension from the State, and the Region's response to the request are on file. An extension request for more than 60 days must be approved by the National Office. Copies are sent to the National Office for the official file.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

11(c)/405 DISCRIMINATION PROGRAM

A. SCREENING PROCEDURES. A systematic review process exists that ensures the following:

1. The OSHA Form 82 was prepared in accordance with Appendix A, DIS .4B.

2. The complaint was screened upon receipt or within 3 work days. (See the FOM, Chapter IX, A.3.d.(1)(c).)

3. A screening report was prepared containing sufficient detail to determine appropriateness for opening or administrative closing. (See the FOM, Chapter X, C.2)

4. Cases involving protected activity were opened for investigation unless the complainant no longer wished to pursue the complaint. (See the FOM, Chapter X, C.2.b.(2).)

5. The supervisor documents the case file agreeing to the recommendation for administrative closing. (See the FOM, Chapter X, C.2.b.(4).)

6. The completed file was reviewed by the supervisor 5 days following the receipt of the case file.(See OSHA Instruction DIS.4B, Chapter VI, D.1)

7. The complainant was notified by letter that the case file was administratively closed. (See the FOM, Chapter X, C.2.b.(2).)

8. Complaints are evaluated for safety and health hazards. (See the FOM, Chapter X, C.1).

9. What percentage of screenings exceeded 3 workdays.

B. FULL FIELD INVESTIGATION PROCEDURES.

1. The telephone log is maintained as calls are made.

2. A signed statement is taken from the complainant.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

3. The essential elements of an investigation (protected activity, knowledge, animus and reprisal) are explored in the statement.

4. When a statement is not obtained from the complainant, a memorandum to the file is prepared documenting the substance of the interview. The memorandum should explain the reason why a written statement was not taken.

5. Statements are taken from the respondent or a memorandum to the file is prepared documenting the substance of the interview.

6. When a statement cannot be obtained from a witness, a memorandum to the file is prepared by the investigator setting forth the information obtained verbally.

7. The investigator adequately resolves any issues regarding desperate treatment.

8. When necessary to resolve discrepancies, the investigator corroborates complainant's information with witness interviews or other evidence, determines and records the respondent's defense, corroborates the respondent's defense, obtains the complainant's response to the defense, and corroborates answers to resolve discrepancies.

9. A closing is held with the complainant to explain findings.

10. The Final Investigative Report presents the findings in a clear and succinct manner that effectively communicates the results of the investigation to the reader of the report.

11. Disposition of cases is documented by letters to the complainant and,as appropriate, the respondent.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

12. A Case determined to be meritorious is submitted for litigation after an attempt at negotiated settlement.

13. A Case referred to the Solicitor is tracked to ensure timely response from the Solicitor.

14. Negotiated settlements are reflected by a settlement agreement and Notice to Employees whenever possible.

If the "Notice" is not used, the file should explain why.

15. The supervisor has a management control system to ensure that cases approaching the overage time frames are reviewed with the investigator and that the review is documented in the case file.

16. Completed investigation files submitted by the investigator for review are reviewed within 5 days of receipt. What percentage exceeded 5 days?

17. Complainants are notified of the determination of the cases within the 60/90 days as required by law. If not, what was the reason for each delay?

18. What percentage of cases exceeds the 60/90-daytime frame?

C. STATE PROGRAMS.

1. State defined 11(c) complaints are referred to the States per OSHA Instruction DIS .7.

2. Reviews of the States' 11(c) programs are conducted quarterly per OSHA Instruction STP 2.22A and DIS.4B.

3. Followups are conducted on the findings and recommendations of the reviews.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

VOLUNTARY PROTECTION PROGRAMS (VPP)

A. PROGRAM APPROVAL. A systematic review process exists that ensures the following:

1. A Regional record shall be established.

2. Applicants are informed within 5 workdays of the receipt of its application.

3. Copy of the application is sent to the National Office, as soon as possible.

4. Application review is conducted within 30 days from date received.

5. The six basic criteria for participation in the VPP "Star" program are met by the applicant organization. They include the following:

a. Management Commitment and Planning.

b. Hazard Assessment.

c. Hazard Correction and Control.

d. Safety and Health Training.

e. Employee Participation

f. Safety and Health Evaluation. 6. The six basic criteria of "Star" are used in the evaluation of "Merit" program applicants with leeway provided on the requirements within the elements.

7. Any verbal requests for additional information were followed up in writing.

8. The Area Office provided inspection history and conducted a 11(c) review on the applicant.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

9. The on-site review for initial approval includes the following:

a. The "Requirements Checklist" from Appendix E, of OSHA Instruction TED 8.1. is used in the evaluation. If not, the criteria that is used is delineated.

b. The injury records are reviewed.

c. Illness and injury rates are recalculated. The rates meet the requirements.

d. Employees are interviewed.

e. The following documents are reviewed:

(1) Management statement of commitment to safety and health;

(2) The OSHA 200 log;

(3) Safety and health manual(s);

(4) Employee notification of safety and health problems;

(5) Safety rules, emergency procedures, and examples of safe work procedures;

(6) The system of enforcing safety rules;

(7) Self-inspection procedures, reports and correction tracking;

(8) Accident investigation;

(9) Safety committee minutes;

(10) Employee orientation and safety training programs and attendance records;

(11) Industrial hygiene monitoring records;

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

(12) Other records which provide documentation of the qualifications for these programs.

10. The justification for any waiver of the safety and health plan is in the file.

11. Revisits are made to those applicants who are deferred approval to verify that appropriate actions are taken to meet the application criteria. The necessary action is taken within the 90-day guideline.

12. The pre-approval report is completed within 20 workdays after the completion of the on-site review.

13. When necessary, the participant has made use of the OSHA contact person during the operational year between evaluations, discussing problems and other related subjects. On-site visits for assistance are documented.

14. The documents that are required to be maintained by the FEDERAL REGISTER, July 12, 1988, Vol. 53, No. 133, pages 26339-26348, are on file (public file) at the Regional Office. Those documents include the following:

a. VPP application and amendments;

b. Pre-approval report and subsequent evaluation reports;

c. Transmittal memorandum to the Assistant Secretary;

d. Assistant Secretary's approval letter; and

f. Notification memorandum to the RA.

B. EVALUATIONS.

1. If an evaluation was necessary prior to the 3-year interval for the Star program and one year for the Merit program, it is documented in the file.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

2. Injury incidence and lost-day injury case rates are still below the industry specific levels.

3. The February 15 deadline for the participants to submit information on their worksites injury incidence and lost workday case rates is met.

4. The documents outlined in OSHA Instruction TED 8.1, Page VI-4, Figure VI-1, are reviewed.

5. The on-site report is completed and filed.

6. Evaluations are completed no later than 30 days following the approval anniversary.

ADMINISTRATIVE PROGRAMS

A. EQUAL EMPLOYMENT OPPORTUNITY (EEO). A systematic review process exists that ensures the following:

1. The Regional Administrator has established EEO goals for the Region. A plan was developed to reach the goals.

a. The goals are consistent with departmental and National Office goals.

b. The goals were transmitted to the Area Offices and the Regional staff.

c. The Regional staff and the Area Directors have implemented the plan to reach the EEO goals.

2. Followup has been conducted on previous year's goals and accomplishments by the appropriate staff to determine program effectiveness.

3. The appropriate EEO reports have been completed and submitted on a timely basis.

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OSHA Instruction PAE 2.1C November 18, 1991 Office of Field Programs

B. EQUIPMENT. A systematic review process exists that ensures the following:

1. A physical inventory is done at least once a year. Discrepancies are handled in accordance with Departmental Property Management System (DPMS) guidelines.

2. The disposal of excess property is handled in accordance with the DPMS guidelines.

3. The Regional Office maintains control over the use, calibration and maintenance of safety and health equipment.

C. TIME AND ATTENDANCE. A systematic review process exists that ensures the following:

1. Time and attendance records are up to date, with restricted access to the records.

2. Before their submission to the payroll office timecards are reconciled to sign-in sheets.

3. "Time and Leave Records" are reconciled to payroll records per Department of Labor Manual Series 6-3, Timekeepers Guide.

D. FREEDOM OF INFORMATION ACT (FOIA) AND PRIVACY ACT (PA).

1. The region has a designated FOIA/PA officer.

2. The FOIA/PA logs are maintained in a timely manner; an accurate record of fees collected and forwarded to the Regional Office of the Assistant Secretary for Administration and Management is maintained.

3. Training has been provided to employees responsible for FOIA release.

4. The Regional Office monitors the Area Offices on their FOIA/PA activity.

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