2017 SAFETY AWARD APPLICATION

Select Category (one per company) *

More Than 1 Million Annual Man-Hours in 2016 500,000 - 1 Million Annual Man Hours in 2016 250,000 - 500,000 Annual Man Hours in 2016 125,000 - 250,000 Annual Man Hours in 2016 Fewer Than 125,000 Annual Man Hours in 2016

Incident Summary Data
If none, type "0" in the box

Experience Modifier Information
Input the workers' compensation Experience Modification Rate (EMR) from the insurance company

Number of years company has had an Injury and Illness Prevention Program (IIPP) *

How many foremen, supervisors and managers received OSHA's 10 hr training? *

How many foremen, supervisors and managers received OSHA's competent person training? *

How many EMPLOYEES have received OSHA's 10 hour training? *

Name, phone, email of person officially responsible for safety & health in company *

How many foremen, supervisors and managers received OSHA's 30 hour training? *

How many employees work for your company? *

How many employees have received OSHA's 30 hour training? *

What methods are used to familiarize employees with the safety program? (check all that apply) *

What makes your safety program effective? Please type a brief statement in the box below that addresses:
A) The full involvement of employees, supervisors and management
B) Does it provide opportunities to identify specific workplace hazards to which employees are exposed?
C) Is effective training provided to all employees?

SAFETY AWARD APPLICATION

Incident Summary Data​If none, type "0" in the box

Incident Summary Data
If none, type "0" in the box