Protocol for DOE-VPP Star Site Re-certification Reviews
This document provides the overall policy and the procedural protocols that
will be utilized by the Office of Environment, Safety and Health in conducting
re-certification reviews of facilities participating in the Department of Energy
Voluntary Protection Program (DOE-VPP) at the Star recognition level.
I. Selection for Review
In the beginning of each Calendar year, the DOE-VPP Program Team will identify
those sites that need to undergo re-certification reviews for that year based
on the application criteria as provided in this protocol for Star level participants.
The DOE-VPP Program Team will determine the approximate review dates for the
selected sites based on the Frequency of Review criteria described in this document
and forward a recommendation to the DOE-VPP Program Administrator for approval.
II. Frequency of Review
The reevaluation frequency for recognized Star participants will be determined
based on a review of the information provided in the annual program evaluation
reports submitted by the participant, review of the participants reported
injury and illness data, and review of any available oversight data and information.
- DOE-VPP participants that have established injury and illness rates for
the past three years which show consistent rates or evidence a downward trend
may be scheduled for reevaluation at any time within an interval of 36 to
60 months of the last approval. Extended reevaluation interval recommendations
are based in part on the need for the DOE-VPP program to have greater latitude
in targeting resources. In addition, it will permit those worksites with effective
programs to continue refinements and improvements without undue review of
their programs and processes.
- DOE-VPP participants that are experiencing any upward injury/illness trend
should be scheduled for reevaluation within an interval of 36 to 42 months
from the date of the last evaluation. This will permit the DOE-VPP program
office to target technical resources to those participants where assistance
may be of the greatest value.
III. Site Notification
The participants selected by the DOE-VPP Program Team and approved by the DOE-VPP
Program Administrator for reevaluation and re-certification during the up-coming
year will be provided written notification at the start of the calendar year
in which a re-certification review is planned. The notification will include
an approximate time frame for the review and request that the site coordinate
planning for the reevaluation with the DOE-VPP Program Team.
IV. Re-certification Review Teams
The DOE-VPP Program Team will develop a list of qualified individuals who may
act as re-certification team leaders and team members for each of the scheduled
reevaluations and forward this list of the recommended candidates to the DOE-VPP
Program Administrator for concurrence and approval. Usually, candidates to lead
reevaluation teams will be qualified Federal personnel from the Office of Regulatory
Liaison or other qualifying Field Offices or Program Offices. Members of the
reevaluation teams other than the team leader will be selected from among the
available, qualified individuals, usually from other DOE-VPP sites. Team members
may include qualified contractor employees from other DOE-VPP participating
Generally, re-certification reviews are not as comprehensive as initial reviews.
Team members conducting re-certification reviews have from three to five annual
program evaluation reports for an individual site that can be used as a measure
of the site’s process, programs and procedures. Also available to the team is
internal documented reviews of the annual reviews and other reported data. Using
this material together with the initial comprehensive report on a worksite,
allows the team to emphasize key program areas and limit the focus of the reevaluation.
Accordingly, the number of employees on a reevaluation team may be limited.
Typically, when conducting a re-certification review the team will be comprised
of 3 to 4 professionals with one of those members acting as the team leader.
As with initial on-site evaluations, the physical size of the team size is dependent
on the physical size of the site, the number of employees and the team leader’s
anticipated need to conduct employee interviews and/or reviews of records, programs
and operations. However, only in rare circumstances will a team consist of more
than 4 members.
V. Team Responsibilities
The re-certification team leader is responsible for assembling, guiding and
leading the team, and for contacting the site to finalize scheduling and specific
on-site arrangements for the review. Additionally, the re-certification team
leader is responsible for:
- Providing each team member with a copy of the last on-site review report
and copies of the site’s annual program evaluations and subsequent internal
reviews covering the last three year period;
- Reviewing oversight information since the last on-site review and providing
team members with pertinent information;
- Developing a strategy for the on-site review and making assignments to the
- Acting as spokesperson for the team in all meetings including the opening
conference at the site and during the closing conference/out-briefing with
the site; and
- Drafting and submitting the re-certification review report to the DOE-VPP
Program Team for further processing.
The team members should be responsible and accountable for the completion of
all assignments including preparation of all necessary documentation. In addition,
team members are responsible for preparing the selected areas of the report
assigned to them and for furnishing copies of all documentation to the team
VI. Complexity and Depth of Report
The re-certification review report should generally address all current tenets
of the program, although it need not address all sub-elements of each of the
program tenets, especially, if the decision is that only a targeted review is
warranted. The report should provide sufficient detail and analyses to justify
a site’s continuing qualification for and participation in the DOE-VPP. However,
team members should rely only on information and data provided by the DOE-VPP
Program Team leader and liberally reference this information rather than duplicating
At a minimum, the re-certification review report should contain:
- Injury and illness rate information and a narrative describing any identifiable
- A general summary of performance as related to the program tenets;
- A summary of improvements and/or modifications made since the last approval;
- Specific description(s) of procedures considered by the team to be “best
- A summary highlighting the outreach activities conducted by the site;
- A statement by the team as to their technical finding regarding the site’s
continued qualification for participation in the DOE-VPP.
As the previous reports contain general information pertaining to the site,
the re-certification review team need not repeat that information in their report.
VII. Onsite Review Process
The length of the review should be between 2-3 days, which is sufficient to
gather information from employee and management interviews, conduct observations
of work activity and collect pertinent data. Generally, review of technical
information should be limited to a representative sampling. Overall, the re-certification
review should focus on four areas:
- Generally, whether the participant continues to meet and maintain a safety
and health program addressing the basic tenets of DOE-VPP.
- Strengths of the site’s safety and health program.
- Site specific “value added” aspects of DOE-VPP including injury/illness
rate or worker’s compensation data, outreach activities, and best practices.
- The level or degree of employee involvement and management commitment.
This page was last updated on June 06, 2012