OSHA Challenge Applications and Instructions

Administrator Application and Instructions

OMB Control Number: 1218-0239 Expires 08-31-2027

Public reporting burden for this collection of information is estimated to average 5 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Cooperative and State Program U.S. Department of Labor, 200 Constitution Ave., Suite N3700 NW, Washington, DC 20210-4537 and reference the OMB Control Number 1218-0239.

Complete the Challenge Administrator Application (DOC). If you intend to use a Challenge Coordinator to assist you as you work with Challenge participants, please complete a Challenge Coordinator Application for each proposed Coordinator.
Write and sign a Challenge Administrator letter of commitment. A sample letter of commitment is at the end of this application.
To submit electronically, attach the completed Challenge Administrator Application (and, if applicable, any completed Challenge Coordinator Applications) and a scanned copy of the signed Challenge Administrator letter of commitment to an email and send it to Rick Harris.

To submit via hard copy, send the completed Challenge Administrator Application (and, if applicable, any completed Challenge Coordinator Applications) and the signed Challenge Administrator letter of commitment to:

If you have questions about OSHA Challenge or the Challenge Administrator application Process, please contact Office of Partnerships and Recognition at 202-693-2213.

Rick Harris
Program Analyst
Directorate of Cooperative and State Programs
Occupational Safety and Health Administration
200 Constitution Avenue, NW, Room N3700
Washington, DC 20210

Challenge Administrator Application
Contact Information
Organization Name:
Organization Type (e.g., private company, federal agency, association, etc.)
Administrator Name within Organization:
Administrator Title within Organization:
Administrator Work Address:
Administrator Phone Number:
Administrator Fax Number:
Administrator Email Address:
Knowledge and Experience
In 400 words or less, please describe your organization's knowledge and experience with developing, implementing, and evaluating safety and health management programs. Experience may include involvement in other OSHA cooperative programs such as the Voluntary Protection Programs, the OSHA Strategic Partnership Program, and/or experience in administering and evaluating corporate-wide safety and health programs.
Resources
In 100 words or less, please confirm the availability of resources (e.g., time and personnel) to administer OSHA Challenge and guide the Challenge participants through the Challenge stages.
Data Collection
In 250 words or less, please provide a description of what your process will be for collecting progress reports and baseline and quarterly/annual data from each of your Challenge participants and ensuring that the data obtained is accurate.

Note: Although it is not required, Challenge Administrators may select Challenge Coordinators to assist them in managing their Challenge participants. If the Challenge Administrator chooses to have a Challenge Coordinator, please complete this form. If the Challenge Administrator chooses to have more than one Challenge Coordinator, please complete a separate application for each prospective Challenge Coordinator.

Challenge Coordinator Application
Contact Information
Organization Name:
Organization Type (e.g., private company, federal agency, association, etc.)
Coordinator Name within Organization:
Coordinator Title within Organization:
Coordinator Work Address:
Coordinator Phone Number:
Coordinator Fax Number:
Coordinator Email Address:
Name of Challenge Administrator:
Knowledge and Experience
In 200 words or less, please describe the prospective Challenge Coordinator's knowledge and experience in safety and health management programs.
Training and Certifications
In 150 words or less, please describe any relevant safety and health training completed (e.g., OSHA Special Government Employee training) and certifications that the prospective Challenge Coordinator has completed.
Evaluation Experience
In 200 words or less, please describe any relevant experience the prospective Challenge Coordinator has with evaluating safety and health management programs.

Challenge Administrator Application Sample Letter of Commitment

Mr. Sherman R. Williamson
Director, Office of Partnerships and Recognition
Directorate of Cooperative and State Programs
Occupational Safety and Health Administration
200 Constitution Avenue, NW, Room N3700
Washington, DC 20210

Dear Mr. Williamson:

I am writing to inform you of the intent of <organization name> to participate in OSHA Challenge and serve as a Challenge Administrator. We have reviewed the OSHA Challenge requirements and believe <organization name> meets the necessary criteria. We assure you that <organization name> is committed to assisting Challenge participants progress through the Challenge stages and achieve an effective safety and health management program and to fulfilling the responsibilities inherent in being a Challenge Administrator.

Attached please find our Challenge Administrator Application which includes the Challenge Coordinator Information form (if applicable). Should you have any questions or need additional information, please contact me at <organization representative telephone number> or <organization representative email address>.

Sincerely,

Participant Application and Instructions

OMB Control Number: 1218-0239 Expires 08-31-2027

Complete the Challenge participant application (DOCX).
Write and sign a Challenge participant statement of commitment. A sample letter of commitment is at the end of this application.
To submit electronically, attach the completed Challenge participant application and a scanned copy of the signed Challenge participant statement of commitment to an email and send it to your Challenge Administrator.

To submit via hard copy, send the completed Challenge participant application and the signed Challenge participant statement of commitment to your Challenge Administrator. All Challenge Administrators' addresses can be found on the OSHA Challenge page under the Program Information sub-header.

If you have questions about OSHA Challenge or the Challenge participant application process, please contact the Office of Partnerships and Recognition at 202-693-2213.

Challenge Participant Application
Challenge Participant Applicant:
Site Address:
Site Manager Name:
Site Manager Title:
Company/Corporate Name (if different from above):
Challenge Participant Applicant Contact Name:
Challenge Participant Applicant Contact Title:
Challenge Participant Applicant Contact Phone Number:
Challenge Participant Applicant Contact E-mail Address
Union Name and Local #:
Union Representative's Address (if different from above):
Union Representative's Name:
Union Representative's Phone Number:
Union Representative's Fax Number:
Union Representative's E-mail Address:
Number of Employees:
Number of Contract Employees:
SIC:
NAICS:

Baseline Injury and Illness Information
Challenge Participant Applicant						OSHA 300 Log Totals for Calendar Year

G	H	I	J	K	L	M:1	M:2	M:3	M:4	M:5	M:6

Total Hours Worked

Total # of Employees

TCIR

DART

To Calculate TCIR:

(Columns H +I + J) x 200,000 = TCIR
Total Hours Worked

To Calculate DART:

(Columns H + I) x 200,000 = DART
Total Hours Worked

Challenge Participant Applicant Statement of Commitment

(Date)

In our mission to produce high quality products and services, we, <Challenge Participant Applicant>, value our employees as our greatest assets and we are committed to providing a safe workplace for them. We assure you that <Challenge Participant Applicant> is committed to successfully completing OSHA Challenge and developing an effective safety and health management program. We will provide the necessary data and documentation to our challenge Administrator, <organization name>, and keep them informed of our progress. We also will involve our employees in OSHA Challenge. We are excited to be involved in voluntary efforts with OSHA and look forward to reaching our goals.

Attached please find our Challenge participant application. Should you have any questions or need additional information, please contact me at <Challenge Participant Applicant telephone number> or <Challenge Participant Applicant email address>.

Signature