Workplace Safety and Health: Better OSHA Guidance Needed on Safety Incentive Programs
Published: 2012-04-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: OSHA relies on employer injury and illness records to target its enforcement efforts. Questions have been raised as to whether some safety incentive programs and other workplace safety policies may discourage workers' reporting of injuries and illnesses. GAO examined (1) what is known about the effect of workplace safety incentive programs and other workplace safety policies on injury and illness reporting, (2) the prevalence of safety incentive programs as well as other policies that may affect reporting, and (3) actions OSHA has taken to address how safety incentive programs and other policies may affect injury and illness reporting. GAO reviewed academic literature, federal laws, regulations, and OSHA guidance; surveyed a nationally representative sample of manufacturing worksites; and interviewed federal and state occupational safety and health officials, union and employer representatives, and researchers.
section_title: What GAO Found
paragraphs: Little research exists on the effect of workplace safety incentive programs and other workplace safety policies on workers' reporting of injuries and illnesses, but several experts identified a link between certain types of programs and policies and reporting. Researchers distinguish between rate-based safety incentive programs, which reward workers for achieving low rates of reported injuries or illnesses, and behavior-based programs, which reward workers for certain behaviors, such as recommending safety improvements. Of the six studies GAO identified that assessed the effect of safety incentive programs, two analyzed the potential effect on workers reporting of injuries or illnesses, but they concluded that there was no relationship between the programs and injury and illness reporting. Experts and industry officials, however, suggest that rate-based programs may discourage reporting of injuries and illnesses. Experts and industry officials also reported that certain workplace polices, such as post-incident drug and alcohol testing, may discourage workers from reporting injuries and illnesses. Researchers and workplace safety experts also noted that how safety is managed in the workplace, including employer practices such as fostering open communication about safety issues, may encourage reporting of injuries and illnesses.
In 2010, from its survey, GAO estimated that 25 percent of U.S. manufacturers had safety incentive programs, and most had other workplace safety policies that, according to experts and industry officials, may affect injury and illness reporting. GAO estimated that 22 percent of manufacturers had rate-based safety incentive programs, and 14 percent had behavior-based programs. Almost 70 percent of manufacturers also had demerit systems, which discipline workers for unsafe behaviors, and 56 percent had post-incident drug and alcohol testing policies according to GAOs estimates. Most manufacturers had more than one safety incentive program or other workplace safety policy and more than 20 percent had several. Such programs and policies were more common among larger manufacturers.
Although the Occupational Safety and Health Administration (OSHA) is not required to regulate safety incentive programs, it has taken limited action to address the potential effect of such programs and other workplace safety policies on injury and illness reporting. These programs and policies, however, are not addressed in key guidance such as OSHA's field operations manual for inspectors. OSHA has cooperative programs that exempt employers with exemplary safety and health management systems from routine inspections. One such program prohibits participants from having rate-based safety incentive programs, but guidance on OSHAs other cooperative programs does not address safety incentive programs. Similarly, OSHA inspectors and outreach specialists provide information to employers about the potential benefits and risks of safety incentive programs, but the guidance provided to inspectors in its field operations manual does not address these programs.
section_title: What GAO Recommends
paragraphs: GAO recommends that OSHA provide guidance about safety incentive programs and other workplace safety policies consistently across the agency's cooperative programs, and add language about safety incentive programs and other workplace safety policies to the guidance provided to inspectors in its field operations manual. OSHA agreed with the recommendations, and noted its plans to address them.

section_title: Letter
paragraphs: In March 2005, 15 workers died and 180 others were injured during an  explosion at the BP Texas City refinery. The refinery had a safety incentive  program that tied workers’ bonuses to achieving low rates of injuries and  illnesses. A January 2007 study conducted by an independent panel after  the explosion found, among other issues, that workers feared reprisals for  reporting potentially risky conditions at the refinery. In October 2009, we  reported that safety incentive programs can provide disincentives for  workers to report injuries and illnesses to their employers.
The Department of Labor’s (Labor) Occupational Safety and Health  Administration (OSHA) uses employer data on occupational injuries and  illnesses to, among other purposes, target its efforts in enforcing  workplace safety and health regulations, including selecting worksites for  inspection. OSHA relies on workers to report work-related injuries and  illnesses to their employers, and on employers to accurately record and  report this information to OSHA. Accurate injury and illness data also help  employers and others identify patterns of work-related injuries and  illnesses and try to prevent them. For example, many insurance  companies use employers’ injury and illness rates among other factors to  set their workers’ compensation insurance premium rates.
According to some workplace safety and health experts, certain safety  incentive programs and other workplace safety policies may discourage  workers from reporting workplace injuries and illnesses. Because of  ongoing concerns that injuries and illnesses are not always reported, you  asked us to examine the following questions: (1) What is known about the  effect of workplace safety incentive programs and other workplace safety  policies on injury and illness reporting? (2) How prevalent are workplace  safety incentive programs, as well as other workplace safety policies that  may affect injury and illness reporting? (3) What actions has OSHA taken  to address how workplace safety incentive programs and other policies  may affect injury and illness reporting?
To learn what is known about the effect of safety incentive programs and  other workplace safety policies on injury and illness reporting, we  interviewed OSHA and state occupational safety and health agency  officials, union and employer representatives, and researchers; and  identified and analyzed 26 studies that appeared in peer-reviewed journals  from 2001 to 2011. To describe the prevalence of workplace safety  incentive programs and other policies, we surveyed a nationally  representative sample of manufacturing worksites about their safety  incentive programs and workplace safety policies and analyzed the  results. To identify the actions OSHA has taken to address safety  incentive programs and policies that may affect injury and illness reporting,  we reviewed relevant federal laws, regulations, and OSHA program  guidance; analyzed OSHA inspection data; and interviewed OSHA and  state occupational safety and health agency officials and experts.
We conducted this performance audit from September 2010 to April 2012  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. For more information on our  scope and methodology, see appendix I.
subsections: section_title: Background
paragraphs: OSHA administers the Occupational Safety and Health Act of 1970 (OSH  Act), which was enacted to assure so far as possible safe and healthful  working conditions for the nation’s workers. OSHA helps ensure the safety  and health of 106 million private sector workers at approximately 8.7 million  worksites in the United States by operating over 80 area offices that report to  1 of 10 regional offices. OSHA sets occupational safety and health standards  and is responsible for enforcing them. The agency directly enforces these  standards in about half the states; the remaining states have been granted  authority by OSHA to set and enforce their own workplace safety and health  standards under a state plan approved by OSHA.
subsections: section_title: OSHA’s Recordkeeping Requirements
paragraphs: The OSH Act and OSHA’s regulations generally require employers to  prepare and maintain records of work-related injuries and illnesses  sustained by their workers and make them available to OSHA upon  request. These requirements are referred to as OSHA’s recordkeeping  requirements. OSHA has established definitions and guidelines to assist  employers in determining which injuries and illnesses must be recorded.  Employers are required to maintain a log of recordable injuries and  illnesses incurred at each worksite. OSHA requires employers to post  summaries of these injury and illness logs annually at each worksite and  provide them to OSHA if requested. In addition, under a section of the OSH  Act referred to as the whistleblower protection provision, employers are  prohibited from retaliating against employees for taking certain protected  actions, including reporting work-related injuries or illnesses, and OSHA is  responsible for investigating workers’ complaints of retaliation.
To help ensure compliance with federal occupational safety and health  standards and OSHA’s recordkeeping requirements, OSHA conducts  enforcement activities such as on-site inspections of worksites. OSHA  conducts these inspections in response to fatalities, serious injuries,  complaints from workers, and referrals. In addition, OSHA targets  industries and employers with a high number of workplace injuries and  illnesses for inspection. When inspecting worksites, OSHA inspectors  identify hazards that could lead to workers’ injuries or illnesses, review  worksites’ injury and illness records, evaluate employers’ safety and  health management systems, and meet with employers and worker  representatives to discuss their findings and possible courses of action to  correct hazards and improve their systems. Employers that fail to comply  with the safety and health standards may face sanctions, such as paying  penalties for violations. In its field operations manual, OSHA provides  guidance to inspectors, employers, and workers on compliance with  safety and health standards, inspections, and penalty assessments.
section_title: OSHA Cooperative Programs, Outreach, and Training
paragraphs: To help employers comply with safety and health standards and  recordkeeping requirements, OSHA supplements its enforcement efforts  with voluntary cooperative programs, outreach, and training in which  OSHA invites employers to collaborate with the agency and uses a  variety of methods to encourage employers to adopt practices designed  to foster safer and healthier working conditions. For example, OSHA’s  Voluntary Protection Programs (VPP) recognize employers with  exemplary safety and health systems and relatively low injury and illness  rates, and exempts them from routine inspections. Small employers that  request on-site consultation services may be recognized through OSHA’s  Safety & Health Achievement Recognition Program (SHARP), which  exempts those with exemplary safety and health management systems  from routine inspections for up to 3 years.
OSHA also trains employers and workers on how to comply with its  standards and other regulations by, for example, providing online materials  and reaching out directly to employer and worker groups. For example,  each OSHA area office typically has one outreach specialist who serves as  a resource to a variety of groups including businesses, trade associations,  unions, and community groups.on OSHA’s cooperative programs, training resources, and tools available  on the agency’s website. In addition, during inspections, OSHA’s inspectors  provide information to employers on the strengths and weaknesses of their  safety and health management systems.
section_title: Workplace Safety and Health Management Systems
paragraphs: OSHA encourages employers to take a multifaceted approach to  preventing and controlling hazards and creating an effective safety and  health management system or a positive safety culture.OSHA, the four elements of an effective safety and health management  system are as follows:  (1) Management commitment and employee involvement  Employers should develop a safety and health policy, communicate it to all  employees, and demonstrate commitment to it by, for example, instilling  accountability for safety and health and ensuring an open exchange of  information about safety issues. Employees should be involved in safety-  and health-related activities such as accident investigations.  (2) Worksite analysis  Employers should have a thorough understanding of all hazardous  situations to which employees may be exposed, as well as the ability to  recognize and correct these hazards. Accurate injury and illness records  can be used to identify and prevent work-related injuries and illnesses.  (3) Hazard prevention and control  Employers should have clear procedures for preventing and controlling  hazards identified through worksite analysis, such as a hazard tracking  system and a written system for monitoring and maintaining workplace  equipment.  (4) Safety and health training  Training is necessary to reinforce and complement management’s  commitment to safety and health and to ensure that all employees  understand how to avoid exposure to hazards.
As part of their safety and health management systems, many employers  use safety incentive programs to encourage safety in the workplace.  These programs provide workers with rewards for achieving certain safety  goals. Examples of these rewards include cash, meals, tangible goods,  and public recognition. Employers can provide such rewards on the basis  of individual or group performance depending on the program’s design.
There are two types of safety incentive programs: rate-based programs,  which reward workers for achieving low rates of reported injuries or  illnesses, and behavior-based programs, which reward workers for certain  behaviors such as recommending safety improvements (see fig. 1). Rate- based programs provide workers or groups of workers with rewards such  as bonuses and prizes for having no or a low number of work-related  injuries and illnesses during a specified period. For example, an employer’s  rate-based program may reward workers with $100 bonuses for having no  reported work-related injuries or illnesses in a given year. Behavior-based  programs provide workers or groups of workers with rewards for  demonstrating safe behaviors but are not tied to low injury and illness rates.  For example, an employer’s behavior-based program may reward workers  with gift cards for identifying hazardous conditions and suggesting safety  improvements. Some experts we interviewed used the term behavior- based safety programs to describe an approach to workplace safety that  focuses on worker behavior as the cause of work-related injuries and  illnesses. However, in this report, we use the term behavior-based program  to define a type of safety incentive program that is a component of an  employer's safety and health management system. These systems may  include other workplace safety policies such as demerit systems that  discipline workers for failing to follow safety procedures.
Employers’ safety and health management systems often include other  workplace safety policies. For example, some employers require the  participation of frontline workers and management in safety committees to  help foster communication and address safety-related issues and  encourage workers to promptly report injuries or illnesses and address  safety hazards. Other workplace safety policies are designed to prevent  injuries and illnesses by holding workers accountable for using safe work  practices. Demerit systems discipline workers for unsafe work practices  such as failing to follow safety procedures. For example, some employers  have policies that discipline workers for not wearing protective gear or for  other unsafe practices linked to reported injuries. In addition, some  employers have drug and alcohol testing policies, which provide for the  testing of workers (1) prior to employment, (2) at random intervals for  some or all workers, (3) at scheduled times for all workers, (4) when there  is evidence that suggests a worker may have used drugs or alcohol, or  (5) after a workplace incident, such as an injury, occurs.
section_title: Safety Incentive Programs and Policies May Affect Injury and Illness Reporting
subsections: section_title: Research on the Effect of Safety Incentive Programs Is Inconclusive, but Several Experts Agree Certain Programs and Policies May Discourage Reporting
paragraphs: Little conclusive academic research exists on whether safety incentive  programs and other workplace safety policies affect workers’ injury and  illness reporting, but several experts stated that rate-based programs may  discourage injury and illness reporting. Of the 26 studies of workplace  safety we reviewed, we identified 6 that evaluated the effect of safety  incentive programs on workplace safety, but only 2 of these studies  specifically evaluated the programs’ effect on reporting of injuries. Each  of the six studies, however, had methodological limitations that prevent  generalizing the effects of these programs on injury and illness reporting  for all workers.
The six studies that evaluated safety incentive programs reached different  conclusions about their effect on workplace safety. Three studies— including the two that specifically evaluated the programs’ effect on  reporting of injuries—focused on one type of safety incentive program  and found that their effect on workplace safety was inconclusive or that  the programs had no effect. For example, one study in which nurses were  surveyed to determine how often injuries and illnesses were reported in  their workplaces found that rate-based safety incentive programs had no  effect on injury reporting. reporting which may differ from actual reporting due to, for example, faulty  memories, and thus its results are not definitive. The three studies that  did not focus on only one type of safety incentive program found that the  programs reduced injuries; however, these studies did not quantify the  programs’ effect on injury and illness reporting. The authors of these  studies acknowledged that, when the programs provide incentives for not  reporting an injury—such as providing a monetary reward for having a low  injury and illness rate—workers may underreport injuries. For example,  the authors of one study noted that workers may “intentionally fail to  report injuries in an effort to preserve potential bonuses for their work  groups.” Information on the six studies is summarized in table 1.
Jean Geiger Brown, Alison Trinkoff, Kenneth Rempher, Kathleen McPhaul, Barbara  Brady, Jane Lipscomb, and Charles Muntaner, “Nurses Inclination to Report Work-Related  Injuries: Organizational, Work-Group, and Individual Factors Associated with Reporting,”  AAOHN Journal, vol. 53, no. 5 (2005): 213-217.
The study analyzed workers’ perceptions of reporting behavior which may differ from actual reporting  behavior; therefore, the results are not definitive.
In addition to reviewing existing studies, we interviewed over 50 experts  and industry officials from academia, employer associations, a law firm, a  consulting firm, unions, and state and federal safety and health agencies  to obtain their opinions about the effect of safety incentive programs and  other workplace safety policies on injury and illness reporting. Several of  them told us that an unintended consequence of rate-based programs  may be discouraging workers from reporting injuries and illnesses. For  example, when workers’ injuries are relatively minor or easy to hide, and  if the rewards provided under the program are relatively large, workers  may not report their injuries to preserve their rewards. Potential  underreporting of injuries and illnesses is even greater when an incentive  creates peer pressure on workers to not report injuries. For example,  when all workers on a team get a reward only if no one on the team has  an injury, there may be pressure on all members of the team to not report  injuries. According to some experts we interviewed, it is difficult to  quantify the effect safety incentive programs may have on injury and  illness reporting partly because researchers do not have access to  workers’ medical records. Without such access, workers who do not  report their injuries cannot be identified and this information cannot be  used to explore whether workers’ decisions to not report their injuries  were linked to their employers’ safety incentive programs.
Several experts and industry officials we interviewed also mentioned that,  along with safety incentive programs, some workplace safety policies may  discourage workers from reporting injuries and illnesses. For example,  policies that punish workers for unsafe practices that are linked to injuries  may—depending on the nature of the injury and the policy—inhibit them  from reporting injuries. Such policies include demerit systems that have  consequences for workers who report injuries or illnesses, such as giving  workers warnings, demotions, or terminating them for recurrences.  However, some employers use demerit systems to discipline workers who  engage in unsafe practices such as not wearing protective gear, and such  demerit systems may have no effect on workers’ reporting of injuries and  illnesses. According to officials from a union, workplace safety policies  that single out workers who report injuries or illnesses by, for example,  requiring them to wear identifying clothes such as an orange vest, may  also discourage them from reporting. In addition, according to several  experts, policies that require drug and alcohol testing after an injury is  reported—compared to those that are applied on a routine basis to all  workers—may deter workers from reporting injuries. We found only one  study that evaluated the effect of these other workplace safety policies  mentioned by experts and industry officials as having a potentially  adverse effect on injury and illness reporting. This study evaluated the  effect of post-incident drug testing on injury and illness reporting and  found evidence that such testing may discourage reporting of relatively  minor injuries that are easy to hide.
section_title: How Employers Manage Safety Can Affect Injury and Illness Reporting
paragraphs: While some safety incentive programs and other workplace safety  policies may discourage injury and illness reporting, research we  reviewed indicated that how employers manage safety has a greater  influence on workers’ actions, including whether they are likely to report  injuries and illnesses, than any one program or policy. Among the 26  studies we reviewed, most found that employers that promote a positive  safety culture may encourage workers to use safe behaviors, report  injuries and illnesses, or reduce the incidence of injuries and illnesses.  We identified 21 studies that evaluated the effect of an employer’s safety  culture on workplace safety. Of these studies, 16 indicated that having a  good safety culture has a positive effect on workers’ use of safe  behaviors, injury and illness rates, or reporting of injuries and illnesses,  and 5 indicated that a good safety culture had a mixed or inconclusive  effect.
According to the studies we reviewed, workplaces with a positive safety  culture placed a strong emphasis on safety by, for example, encouraging  open communication about safety issues, placing a high priority on safety  training, and having procedures that prevented breakdowns in workplace  safety. Some researchers concluded that in such environments, workers  felt that they could report injuries and illnesses without fear of reprisal or  blame from management or fellow workers. Of the four studies we  reviewed that evaluated the effect of a positive safety culture on reporting  of work-related injuries or accidents, safety culture increased the likelihood of injury and illness reporting. three found that having a positive  Policies that help employers create a positive safety culture and keep  workers safe and healthy were generally perceived as being proactive  versus reactive. For example, employers with proactive policies that  require workers to report near-miss incidents to help identify hazards and  other safety concerns before an injury takes place were more likely to  have a positive effect on injury and illness reporting.
Each of the studies had a methodological issue that may limit the generalizability of the  findings. For example, three of the four studies included nonrandom samples and the  results may be affected by selection bias.
In contrast, according to the studies we reviewed, workplaces with a  negative safety culture do not place a strong emphasis on safety. These  employers do not encourage open communication about safety issues or  prioritize safety training. According to two experts we interviewed, some  employer safety programs focus on workers' behaviors as the cause of  work-related injuries and illnesses, and have policies that discipline  workers for failing to follow safety procedures. As a result, workers in  these environments may be less likely to report injuries or illnesses  because, if they lack safety training, communication is poor, or they are  not encouraged to report injuries and illness, they may not know how to  report them, or may fear being disciplined.
section_title: Three-Quarters of U.S. Manufacturers Had Safety Incentive Programs or Other Workplace Safety Policies
paragraphs: According to our survey, in 2010, an estimated 116,000 of about 153,000  manufacturers in the United States (75 percent) had safety incentive  programs or had other workplace safety policies that, according to several  experts, may affect workers’ reporting of injuries and illnesses.  However, we estimated that safety incentive programs were less  prevalent than other workplace safety policies, such as demerit systems,  that discipline workers for unsafe work practices.a quarter of manufacturers had some type of safety incentive program  and most had a demerit system or post-incident drug and alcohol testing   We also estimated that  policy. Demerit systems were the most common policy reported, followed  by post-incident drug and alcohol testing policies (see fig. 2).
Very few manufacturers had only one type of safety incentive program, and  few had only one type of other workplace safety policy. Most  manufacturers had more than one safety incentive program or other  workplace safety policy, and more than 20 percent had several, according to  our estimates. For example, one manufacturer who participated in our  survey had a program that rewarded workers with a luncheon for having no  injuries that resulted in lost time on the job, and provided a separate reward  to the worker who submitted the best safety suggestion during the month.  Manufacturers with multiple types of programs or policies were more than  twice as likely to have a demerit system or conduct post-incident drug and  alcohol testing than they were to have a rate-based or behavior-based  program (see fig. 3).
Large manufacturers were more likely to have safety incentive programs  and demerit systems than smaller manufacturers. We estimated that  large manufacturers were more than three times as likely to have safety  incentive programs compared with small manufacturers. Although safety  incentive programs and other workplace safety policies were less  common among small manufacturers, most small manufacturers had  demerit systems and many had post-incident drug and alcohol testing  policies (see fig. 4).
Companies sometimes request information on manufacturers’ injury and  illness rates before signing a contract with them to manufacture goods.  According to some workplace safety experts, such contractors may feel  pressure to lower injury and illness rates to avoid the risk of losing bids for  contracted work. Manufacturers whose injury and illness rates were  requested by potential contracting companies were more than twice as  likely to have rate-based safety incentive programs than manufacturers  whose rates were not requested. We estimated that 31 percent of U.S.  manufacturers performed contractual work in 2010. Contracting  companies requested injury and illness rate data from nearly a third of  these manufacturers prior to signing a contract with them. Thirty-eight  percent of these manufacturers that had their injury and illness rates  requested reported having rate-based programs in 2010. In contrast, 13  percent of the manufacturers that had did not have their injury and illness  data requested by potential contracting companies prior to signing a  contract reported having rate-based programs in 2010.
U.S. manufacturers provided incentives to workers for a variety of safety  goals and behaviors. Nearly three-quarters of manufacturers with rate- based programs, according to our estimates, rewarded workers for having  no reported injuries and illnesses. Forty percent rewarded workers for  having a low number or rate of injuries and illnesses during a specific time  period, and 23 percent of them rewarded workers for reducing the  number or rate of reported injuries and illnesses. Nearly 70 percent of  manufacturers with behavior-based programs rewarded workers for  recommending workplace safety improvements and 37 percent rewarded  them for wearing protective gear.
The criteria for providing rewards differed between rate-based and behavior- based programs, but the types of rewards manufacturers provided and the  types of workers targeted by both of these safety incentive programs were  similar. For both types of programs, monetary awards, meals, and other non- monetary awards, such as gift cards, were more commonly offered than time  off work or a token of recognition, such as a plaque. Manufacturers used  safety incentive programs to target various levels of workers and worker  groups, including entire workplaces, work teams such as department or  shifts, supervisors, and frontline workers. However, the percentage of  manufacturers that rewarded individual frontline workers through either rate- based or behavior-based safety incentive programs was twice as high as  those that rewarded supervisors.
section_title: OSHA Has Taken Limited Actions to Address Safety Incentive Programs and Other Workplace Safety Policies
subsections: section_title: OSHA’s Enforcement Efforts Address Safety Incentive Programs and Other Workplace Safety Policies to a Limited Extent
paragraphs: OSHA can use its enforcement authority to address certain aspects of  safety incentive programs and other workplace safety policies, but the  effectiveness of these activities is limited. Although the OSH Act does not  mandate that OSHA regulate safety incentive programs, OSHA officials  told us the agency could potentially issue a regulation to address safety  incentive programs and other workplace safety policies. However, OSHA  has not done so because, according to OSHA officials, it has focused its  regulatory resources on other priorities such as projects that address  exposure to serious safety and health hazards. Some of OSHA’s  enforcement tools can be used to address certain aspects of safety  incentive programs and other workplace safety policies, but these tools  are not designed to systematically address these programs. For example,  a worker may file a whistleblower protection complaint if the worker  reports an injury and, under the rules of the employer’s safety incentive  program, is subsequently excluded from receiving a reward, such as a  bonus. However, such claims may only address the adverse action  experienced by an individual worker and not address the potential overall  negative impact a safety incentive program may have on the workplace.
Under its recordkeeping regulations, OSHA can address recordkeeping  violations that occur as a result of safety incentive programs and other  workplace safety policies, but it cannot address potential disincentives to  injury and illness reporting associated with the policies. For example,  OSHA can cite employers for failing to properly record injuries or illnesses  under its recordkeeping regulations,  but the relationship between a  safety incentive program and potential underreporting of injuries and  illnesses is not directly addressed in these requirements. To find evidence  of underreporting, inspectors must interview workers, review their medical  records, and compare these records to employers’ injury and illness logs  to determine whether an injury or illness occurred but was not reflected  on the log.
29 U.S.C. §§ 657(c), 658(a). For OSHA’s recordkeeping regulations, see generally 29  C.F.R. part 1904. the accuracy of employers’ injury and illness logs and identify and correct  any mistakes or omissions. OSHA began this program in September  2009, and in February 2010 established a goal of auditing injury and  illness records at approximately 350 worksites nationwide over a 2-year  period. Inspectors compared employers’ injury and illness logs to workers’  medical records, and interviewed workers, managers, recordkeepers, and  first-aid providers. As part of these audits, OSHA directed inspectors to  consider the effect of safety incentive programs or other workplace safety  policies on injury and illness reporting, and when recordkeeping violations  were found, in assessing the severity of the violation. For example,  according to OSHA officials, if inspectors found underreporting of injuries  and illnesses and concluded that a safety incentive program was a  contributing factor, the inspector could classify the violation as willful,  which carries an increased penalty. However, the guidance provided to  inspectors did not specify how this assessment should be done and, in  our interviews with OSHA area office officials we found that OSHA  inspectors inconsistently considered safety incentive programs when  reviewing employers’ injury and illness records. For example, one area  office official said that the penalty assessment for a recordkeeping  violation would be the same regardless of the existence of a safety  incentive program. In addition, because OSHA did not select a nationally  representative sample of worksites for these inspections, OSHA cannot  use the results to determine the effect of safety incentive programs and  other workplace safety policies on injury and illness reporting  nationwide.
section_title: OSHA Has Guidance on Safety Incentive Programs for One of Its Cooperative Programs but Has Not Adopted Similar Guidance for Other Efforts
paragraphs: OSHA has developed policy guidance on safety incentive programs for  the VPP, but the guidance for its other cooperative programs and for its  enforcement efforts does not address safety incentive programs or other  workplace safety policies. For example, OSHA’s guidance on its SHARP  program, a voluntary cooperative program that focuses on smaller  employers, does not address safety incentive programs. Similarly,  OSHA’s field operations manual does not provide guidance to its  inspectors for addressing safety incentive programs during inspections.
In June 2011, OSHA issued a policy memorandum for the VPP program  that contains specific criteria for safety incentive programs, including the  types of programs that are encouraged for VPP sites and those that are  prohibited. Programs that promote accurate injury and illness reporting  are encouraged, while participants in the VPP are now prohibited from  having safety incentive programs that focus on the number of injuries and  illnesses, such as rate-based programs that reward workers for achieving  low injury and illness rates. This policy memorandum does not address  other workplace safety policies that might impact injury and illness  reporting. OSHA officials are required to ensure current VPP participants  are in compliance with this policy when participants are reevaluated to  determine whether they will be allowed to continue to participate in the  program, but the new policy is not included in the VPP manual. Officials  from one regional office estimated that almost 20 percent of its VPP  participants have safety incentive programs that are not in compliance  with this new policy.
In addition to providing guidance on its voluntary cooperative programs,  OSHA often provides safety information to employers during its on-site  inspections. In its guidance on conducting inspections, OSHA’s field  operations manual outlines the educational duties that inspectors have as  part of the inspection process. For example, inspectors are expected to  discuss the strengths and weaknesses of the employers’ safety and  health management system and advise the employer of the benefits of  effective systems during the closing conference of the inspection.  However, the field operations manual does not make any references to  safety incentive programs or other workplace safety policies.
Other OSHA resources lack guidance about safety incentive programs  and other workplace safety policies. Outreach specialists and materials  available on OSHA’s website are additional sources of information that  can educate employers and workers about how safety incentive programs  and other workplace safety policies may affect a workplace’s safety and  health management system. Although outreach specialists each develop  materials and approaches for addressing the needs of employers in their  particular geographic area, each has an opportunity to discuss the  potential risks and benefits of safety incentive programs and the potential  impact of workplace safety policies on injury and illness reporting during  discussions about recordkeeping, safety and health management  systems, and OSHA’s cooperative programs, among other topics. In  addition, many resources are available to employers through OSHA’s  website, including fact sheets about recordkeeping and best practices,  such as the Effective Workplace Safety and Health Management Systems  fact sheet. This fact sheet and several others do not discuss safety  incentive programs or other workplace safety policies, although some do  address aspects of a positive safety culture.
section_title: Conclusions
paragraphs: Safety incentive programs exist in the context of a workplace’s safety  culture. Some types of programs, particularly those that are tied to low  injury and illness rates, may discourage injury or illness reporting.  However, the same programs in workplaces with positive safety cultures  may have no effect with regard to reporting. Similarly, some workplace  safety policies, such as those that punish workers in some way for  reporting injuries or illnesses, may discourage workers from reporting  injuries and illnesses, especially when implemented in a workplace with a  negative safety culture.
Because OSHA relies heavily on accurate injury and illness reporting in  tailoring its programs and allocating its finite enforcement resources, it is  important for the agency to assess the impact of safety incentive  programs and certain workplace safety policies on injury and illness  reporting, particularly given their prevalence. Without accurate data,  employers engaged in hazardous activities can avoid inspections and  may be allowed to participate in voluntary programs that reward  employers with exemplary safety and health management systems by  exempting them from routine inspections.
OSHA can encourage employers to create positive safety cultures and  avoid safety incentive programs and workplace safety policies that may  have a negative effect on injury and illness reporting. However, because  safety incentive programs and certain workplace safety policies are not  addressed in OSHA guidance, including its field operations manual,  OSHA inspectors may not consider these programs and policies during  worksite inspections, even as they observe key aspects of the  workplace’s safety culture. As a result, inspectors may miss opportunities  to educate employers about the benefits of promoting a positive safety  culture and avoiding prevalent programs and policies that can discourage  accurate reporting of injuries and illnesses. In addition, in the absence of  consistent guidance on the potential benefits and risks of some safety  incentive programs and workplace safety policies, OSHA may recognize  some employers as having exemplary safety and health management  systems without considering the potentially negative effects of some of  their programs and policies.
section_title: Recommendations for Executive Action
paragraphs: To increase consistency across OSHA’s cooperative programs, the  Secretary of Labor should direct the Assistant Secretary of OSHA to  implement criteria on safety incentive programs and other workplace  safety policies across all of its cooperative programs such as VPP and  SHARP. The criteria should be consistent with the most recent VPP  guidance memorandum that prohibits employers with safety incentive  programs that focus on injury and illness rates from participating in the  program.
To help OSHA inspectors consistently educate employers about the  importance of safety culture, the Secretary of Labor should direct the  Assistant Secretary of OSHA to add language about key elements of a  positive safety culture—and the potential effect of different types of safety  incentive programs and other workplace safety policies—to its field  operations manual.
section_title: Agency Comments
paragraphs: We provided a draft of this report to Labor for review and comment.  Labor’s Assistant Secretary for OSHA provided written comments, which  are reproduced in appendix IV. OSHA agreed with our recommendations  and emphasized the agency’s concern about workplace programs that  appear to encourage safe work practices but actually discourage workers  from reporting injuries. OSHA also provided technical comments, which  we incorporated as appropriate.
In response to our recommendation that OSHA implement criteria on  safety incentive programs and other workplace safety policies across all  of its cooperative programs such as VPP and SHARP, OSHA stated that  it will provide policy guidance about safety incentive programs across the  agency’s cooperative programs. According to OSHA, this guidance will be  similar to the VPP policy prohibiting participants from using safety  incentive programs that have the potential to discourage workers from  reporting injuries. Establishing such criteria across all of its cooperative  programs will help OSHA accurately recognize employers with exemplary  safety and health management systems.
In response to our recommendation that OSHA add language about key  elements of a positive safety culture—and the potential effect of different  types of safety incentive programs and other workplace safety policies— to its field operations manual, OSHA stated that it has issued guidance for  its inspectors about safety incentive programs that underscores the  agency’s position that programs that discourage workers from reporting  injuries may violate whistleblower protection statutes and OSHA’s  recordkeeping regulations. OSHA issued this guidance to regional and  whistleblower program officials in March 2012 and published it on the  agency’s website, but it has not yet been incorporated into the agency’s  field operations manual.
As agreed with your offices, unless you publically announce the contents  of this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Labor, relevant congressional committees, and other  interested parties. In addition, the report will also be available at no  charge on GAO’s website at http://www.gao.gov.
If you or your staff have questions about this report, please contact me at  (202) 512-7215 or moranr@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Key contributors to this report are listed in appendix V.
section_title: Appendix I: Scope and Methodology
subsections: section_title: Literature Review and Expert Input on Safety Incentive Programs and Other Workplace Safety Policies That May Affect Injury and Illness Reporting
paragraphs: To determine what is known about the effect of workplace safety incentive  programs and other workplace safety policies on injury and illness  reporting, we conducted a literature search for relevant studies. We  sought studies that analyzed the effect of workplace safety incentive  programs; other workplace safety policies, such as post-incident drug  testing; or safety culture on workers’ use of safe practices; injury and  illness rates; or reporting of injuries and illnesses. To identify the studies,  we searched bibliographic databases covering scientific, safety, medical,  and economic literature, including ArticleFirst, CINAHL, EconLit,  Electronic Collections Online, EMBASE, MEDLINE, ProQuest, PsycINFO,  SciSearch, and Social SciSearch for relevant search terms and citations  of studies. We limited the searches to materials published in 2001 or  after. We performed these searches from August 2011 to October 2011,  and identified over 600 abstracts of studies. Among these studies, we  excluded those that did not satisfy our criteria that each study (1) be  published in a peer-reviewed journal and (2) contain relevant, primary  research conducted in the United States. We also excluded studies that  seemed duplicative or did not meet GAO’s methodological standards. To  assess the methodological quality of the studies, two GAO research  methodologists independently reviewed each study that satisfied our  criteria and excluded those that did not contain original research or lacked  rigor. Using this approach, we identified 26 methodologically sound  studies (see app. II for a list of the 26 studies).
To supplement our understanding of what is known about the effect of  safety incentive programs and other workplace safety policies on injury  and illness reporting, we interviewed experts and industry officials from  academia, employer associations, a law firm, a consulting firm, unions,  and state and federal occupational safety and health agencies. We spoke  with individuals from the University of Connecticut, Boston University,  Institute for Work and Health, United Steel Workers, United Mine Workers  of America, American Federation of Labor and Congress of Industrial  Organizations, National Association of Manufacturers, Mercer, Voluntary  Protection Programs Participants’ Association, Gibson, Dunn & Crutcher,  Occupational Safety and Health Administration (OSHA), Bureau of Labor  Statistics (BLS), National Institute for Occupational Safety and Health,  Chemical Safety Board, and state occupational safety and health  agencies in California, North Carolina, South Carolina, and Vermont. To  identify these experts and industry officials, we reviewed relevant trade  press and congressional transcripts and sought referrals from  interviewees. To ensure balance, we spoke with an array of experts and  industry officials with varying backgrounds and perspectives.
section_title: Survey of Manufacturing Worksites
paragraphs: To study the prevalence of workplace safety incentive programs as well  as other workplace safety policies that may affect injury and illness  reporting, we surveyed a nationally representative sample of  manufacturing worksites. We selected a systematic random sample of  1,000 manufacturers from a total of 26,552 included in our sample frame  of data. Our sample frame consisted of the set of manufacturers with 11  or more employees contained in a nationally representative BLS  establishment survey fielded in 2010. This list was a relatively complete,  current source of business names and addresses that had undergone a  strict refinement process to remove establishments that were out of  business, duplicates, or miscoded. We sorted the manufacturers by the  sample weight for the BLS survey prior to the systematic random  selection in order to ensure that a range of manufacturers was obtained.
We designed and implemented a dual mode survey (mail and web-based)  to obtain information from manufacturers on the types and characteristics  of safety incentive programs and policies used at their workplaces, and  the extent to which they performed contractual work for other companies.  To develop our survey questions, we drew on information we gathered  from interviews with occupational safety and health stakeholders and  from scholarly studies on occupational safety and health. We pretested  the survey with nine manufacturers that represented the three size  populations of manufacturers studied (small, medium, and large) and  submitted the questionnaire for an additional independent review by two  survey specialists within GAO and experts in OSHA and BLS. We then  made revisions based on their feedback prior to finalizing the survey. We  conducted the survey using a self-administered questionnaire, and  offered prospective respondents the option of completing and mailing a  hard copy questionnaire or completing the questionnaire online (see app.  III for a copy of the survey). To encourage participation, we mailed a  reminder postcard, a second questionnaire, and made follow-up phone  calls to all those who had not yet responded in regular intervals prior to  closing the survey. A total of 663 manufacturers responded, resulting in a  final weighted response rate of 62.4 percent.
Because we surveyed a sample of manufacturers, the survey results are  weighted estimates for a population of manufacturers and thus are  subject to sampling errors associated with samples of this size and type.  Our sample is only one of a large number of samples we might have  drawn. As each sample could have provided different estimates, we  expressed our confidence in the precision of our particular sample’s  results as a 95 percent confidence interval (e.g., plus or minus 10  percentage points). We excluded 29 of the sampled manufacturers  because we were able to determine that they were out of business at the  time of our survey or they indicated that they did not engage in  manufacturing. Therefore, all 29 of the manufacturers we excluded were  considered out of scope. All estimates produced from the sample and  presented in this report are representative of the in-scope population.
The practical difficulties of conducting any survey may introduce errors  resulting from the data collection procedures, commonly referred to as  nonsampling errors, which can introduce unwanted variability into the  survey results. There are four primary sources of nonsampling error:  1.  Measurement—error in responses recorded on the survey  instruments resulting from poorly worded, biased, or sensitive  questions; ambiguous instructions; or lack of information available to  respondents.  2.   Nonresponse—bias from failing to get responses from  establishments whose answers would have differed significantly from  those that did participate.  3.  Coverage—bias from failing to include all eligible establishments or  from including ineligible establishments in the list from which we  sampled.  4.  Data processing—error arising from faulty handling or processing of  the data.
We took extensive steps in developing the questionnaire, collecting the  data and analyzing the results to address the potential sources of  nonsampling error. To minimize measurement error, GAO staff with  subject-matter expertise collaborated with a survey design specialist to  develop the questionnaire. We pretested the instrument using cognitive  interviewing techniques and interviewed the pretest respondents to  ensure that (1) the questions and instructions were clear, unambiguous,  and in the correct order; (2) the terms we used were precise; (3) the  survey did not place an undue burden on the respondents completing it;  and (4) the survey was unbiased. To assess the risk of nonresponse bias,  we obtained answers over the phone to three survey questions from 19  nonrespondents. We statistically compared the answers from the  nonrespondents with those of our respondents on these three questions  and found no statistically significant differences. Our sample frame  minimized the risk of coverage error by drawing on a nationally  representative list of manufacturers that was thoroughly reviewed and  cleaned to remove ineligible establishments. Finally, we took several  steps to reduce processing errors: (1) Quality control measures were  implemented during preparation and mailout of survey packages to  ensure that the respondents would receive the package with the proper  login identification number and that the packages contained the correct  contents. (2) We contracted with an outside company to enter the data  from the paper questionnaires into a database, and we checked a 10  percent sample of the database as a quality control measure. (3)  Respondents who completed questionnaires online entered their answers  directly which eliminated the errors associated with a manual data entry  process. (4) After we analyzed the data, a second independent data  analyst checked all of the computer programs for accuracy.
section_title: Examination of OSHA’s Efforts to Address Safety Incentive Programs and Workplace Policies
paragraphs: To examine OSHA’s efforts to address safety incentive programs, we  reviewed relevant federal laws and regulations, OSHA’s policies and  procedures, and interviewed OSHA officials regarding the agency’s  activities. We interviewed selected OSHA officials from the agency’s  national office as well as several regional and area offices to learn about  (1) their efforts to address the potential impact of safety incentive  programs and workplace policies on injury and illness reporting, (2) the  recordkeeping enforcement initiative, and (3) their views on safety  incentive programs and the potential relationship between these  programs and injury and illness reporting. We interviewed officials from  three regional offices and five area offices representing 5 of the 10  different OSHA regions. In all of these interviews we attempted to meet  with regional and area office officials with experience in the recordkeeping  enforcement initiative and those that oversee cooperative programs and  other outreach and training efforts. We visited five OSHA offices and  spoke with officials from four state occupational safety and health  agencies. We selected these offices based on their geographic dispersal  and representation of OSHA regions.
To assess the results of OSHA’s recordkeeping enforcement initiative, we  analyzed data from the OSHA Recordkeeping Inspection Assistant  database, which contains records of the inspections OSHA conducted in  2009, 2010, and 2011. Prior to our analysis, we assessed the reliability of  the OSHA Recordkeeping Inspection Assistant database by reviewing  information obtained from OSHA about the database, and interviewing a  knowledgeable agency official. Where there were discrepancies in the  data, we worked with this official to clarify and, in some cases, correct the  data. For example, we found two records that were missing key  identifying information about the OSHA region in which the inspections  occurred. On the basis of our assessment, we concluded that the updated  data were sufficiently reliable for our reporting purposes.
We conducted this performance audit from September 2010 to April 2012  in accordance with generally accepted government auditing standards.  These standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Studies on the Effect of Safety Incentive Programs, Workplace Safety Policies, and Safety Culture on Workplace Safety
paragraphs: Alavosius, Mark, Jim Getting, Joseph Dagen, William Newsome, and Bill  Hopkins. “Use of a Cooperative to Interlock Contingencies and Balance  the Commonwealth.” Journal of Organizational Behavior Management,  vol. 29, no. 2 (2009): 193-211.
Brown, Jean Geiger, Alison Trinkoff, Kenneth Rempher, Kathleen  McPhaul, Barbara Brady, Jane Lipscomb, and Charles Muntaner. “Nurses  Inclination to Report Work-Related Injuries: Organizational, Work-Group,  and Individual Factors Associated with Reporting.” AAOHN Journal,   vol. 53, no. 5 (2005): 213-217.
Chowdhury, Sanjib K., and Megan Lee Endres. “The Impact of Client  Variability on Nurses’ Occupational Strain and Injury: Cross-Level  Moderation by Safety Climate.” Academy of Management Journal,   vol. 53, no. 1 (2010): 182-198.
DeJoy, David M., Lindsay J. Della, Robert J. Vandenberg, Mark G.  Wilson. “Making Work Safer: Testing a Model of Social Exchange and  Safety Management.” Journal of Safety Research, vol. 41, no.2 (2010):  163-171.
Evans, Demetrice D., Judd H. Michael, Janice K. Wiedenbeck, and  Charles D. Ray. “Relationships Between Organizational Climates and  Safety-Related Events at Four Wood Manufacturers.” Forest Products  Journal, vol. 55, no. 6 (2005): 23-28.
Fugas, Carla S., José L. Meliá, and Silvia A. Silva. “The “Is” and the  “Ought”: How Do Perceived Social Norms Influence Safety Behaviors at  Work?” Journal of Occupational Health Psychology, vol. 16, no. 1 (2011):  67-79.
Gangwar, Manish, and Paul M. Goodrum. “The Effect of Time on Safety  Incentive Programs in the US Construction Industry.” Construction  Management and Economics, vol. 23, no. 8 (2005): 851-859.
Hinze, Jimmie. “Safety Incentives: Do They Reduce Injuries?” Practice  Periodical on Structural Design and Construction, vol. 7, no. 2 (2002):   81-84.
Hofmann, David A., and Barbara Mark. “An Investigation of the  Relationship Between Safety Climate and Medication Errors As Well As  Other Nurse and Patient Outcomes.” Personnel Psychology, vol. 59, no. 4  (2006): 847-869.
Hoonakker, Peter, Todd Loushine, Pascale Carayon, James Kallman,  Andrew Kapp, and Michael J. Smith. “The Effect of Safety Initiatives on  Safety Performance: A Longitudinal Study.” Applied Ergonomics, vol. 36,  no. 4 (2005): 461-469.
Huang,Yueng-Hsiang, Michael Ho, Gordon S. Smith, and Peter Y. Chen.  “Safety Climate and Self-Reported Injury: Assessing the Mediating Role  of Employee Safety Control.” Accident Analysis and Prevention, vol. 38,  no. 3 (2006): 425-433.
Lauver, Kristy J., Chris Quinn Trank, and Huy Le. “Information by Design:  How Employee Perceptions of Organizational Design Relate to Injury  Reporting.” Journal of Leadership and Organizational Studies, vol. 18,   no. 3 (2011): 344-352.
Lauver, Kristy J., and Scott W. Lester. “Get Safety Problems to the  Surface: Using Human Resource Practices to Improve Injury Reporting.”  Journal of Leadership and Organizational Studies, vol. 14, no. 2 (2007):  168-179.
Leiss, Jack K. “Management Practices and Risk of Occupational Blood  Exposure in U.S. Paramedics: Needlesticks.” American Journal of  Industrial Medicine, vol. 53, no. 9 (2010): 866-874.
Ludwig,Timothy D., Jay Biggs, Sandra Wagner, and E. Scott Geller.  “Using Public Feedback and Competitive Rewards to Increase the Safe  Driving of Pizza Deliverers.” Journal of Organizational Behavior  Management, vol. 21, no. 4 (2001): 75-104.
Mark, Barbara A., Linda C. Hughes, Michael Belyea, Yunkyung Chang,  David Hofmann, Cheryl B. Jones, and Cynthia T. Bacon. “Does Safety  Climate Moderate the Influence of Staffing Adequacy and Work  Conditions on Nurse Injuries?” Journal of Safety Research, vol. 38, no. 4  (2007): 431-446.
Michael, Judd H., Zhen George Guo, Janice K. Wiedenbeck, Charles D.  Ray. “Production Supervisor Impacts on Subordinates’ Safety Outcomes:  An Investigation of Leader-Member Exchange and Safety  Communication.” Journal of Safety Research, vol. 37, no. 5 (2006):   469-477.
Morantz, Alison D., and Alexandre Mas. “Does Post-Accident Drug  Testing Reduce Injuries? Evidence from a Large Retail Chain.” American  Law and Economics Review, vol. 10, no. 2 (2008): 246-302.
Morrow, Stephanie L., Alyssa K. McGonagle, Megan L. Dove-Steinkamp,  Curtis T. Walker Jr., Matthew Marmet, and Janet L. Barnes-Farrell.  “Relationships Between Psychological Safety Climate Facets and Safety  Behavior in the Rail Industry: A Dominance Analysis.” Accident Analysis  and Prevention, vol. 42, no. 5 (2010): 1460-1467.
Probst, Tahira M., and Armando X. Estrada. “Accident Under-Reporting  Among Employees: Testing the Moderating Influence of Psychological  Safety Climate and Supervisor Enforcement of Safety Practices.”  Accident Analysis and Prevention, vol. 42, no. 5 (2010): 1438-1444.
Probst, Tahira M., Ty L. Brubaker, and Anthony Barsotti. “Organizational  Injury Rate Underreporting: The Moderating Effect of Organizational  Safety Climate.” Journal of Applied Psychology, vol. 93, no. 5 (2008):  1147-1154.
Seo, Dong-Chul. “An Explicative Model of Unsafe Work Behavior.” Safety  Science, vol. 43, no. 3 (2005): 187-211.
Smith, Gordon S., Yueng-Hsiang Huang, Michael Ho, and Peter Y. Chen.  “The Relationship Between Safety Climate and Injury Rates Across  Industries: The Need to Adjust for Injury Hazards.” Accident Analysis and  Prevention, vol. 38, no. 3 (2006): 556-562.
Vredenburgh, Alison G. “Organizational Safety: Which Management  Practices are Most Effective in Reducing Employee Injury Rates?”  Journal of Safety Research, vol. 33, no. 2 (2002): 259-276.
Wallace, Craig, and Gilad Chen. “A Multilevel Integration of Personality,  Climate, Self-Regulation, and Performance.” Personnel Psychology,   vol. 59, no. 3 (2006): 529-557.
Zohar, Dov, and Gil Luria. “The Use of Supervisory Practices as Leverage  to Improve Safety Behavior: A Cross-Level Intervention Model.” Journal of  Safety Research, vol. 34, no. 5 (2003): 567-577.
section_title: Appendix III: Questionnaire Used for GAO’s Survey of Manufacturing Worksites
section_title: Appendix IV: Comments from the Department of Labor
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Gretta L. Goodwin, Assistant  Director, and Joel Green, Analyst-in-Charge, managed all aspects of this  assignment; James E. Lloyd III and Michelle Loutoo Wilson made  significant contributions to all phases of the work; Grace Cho made  substantial contributions to data analysis and message and report  development; Carl Barden and Pamela Davidson provided assistance in  designing the study, conducting data analysis, and developing the report;  Lorraine Ettaro, Stuart Kaufman, and Carl Ramirez helped with survey  administration; Delores Hemsley assisted in data collection; Catherine  Hurley assisted in data analysis; Ashley McCall provided literature search  assistance; Barbara Chapman, Cynthia Saunders, and Elizabeth Wood  assisted in the methodological review of studies; Susannah Compton  assisted in message and report development; James Bennett created the  report’s graphics; Sarah Cornetto provided legal advice; and Amber  Yancey-Carroll and Anna Bonelli reviewed the report to check the facts  presented.