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 participant’s 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 sites.

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 team members;
• 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 leader.

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 previous work.

At a minimum, the re-certification review report should contain:

• Injury and illness rate information and a narrative describing any identifiable trends;
  
  
• 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 practices;” and
  
  
• 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:

1. Generally, whether the participant continues to meet and maintain a safety and health program addressing the basic tenets of DOE-VPP.
2. Strengths of the site’s safety and health program.
3. Site specific “value added” aspects of DOE-VPP including injury/illness rate or worker’s compensation data, outreach activities, and best practices.
4. The level or degree of employee involvement and management commitment.