2021 ESA APPLICATION

2021 EXCELLENCE IN SAFETY AWARD APPLICATION
Application Deadline: Friday, March 5, 2021
ELIGIBILITY AND GUIDELINES

Award winners will be recognized at the 2021 Construction Excellence Awards Show

SAFETY AWARD APPLICATION

* Indicates required field

Company Name *

Company Address *

Contact Name *

First

Last

Contact Phone *

Contact Email *

Number of Years Company Has Been in Business *

Select Category (one per organization) *

Over 1 Million Annual Hours in 2020 500,000 - 1 Million Annual Hours in 2020 250,000 - 500,000 Annual Hours in 2020 125,000 - 250,000 Annual Hours in 2020

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

# of Deaths *

# Cases with days away from work *

# Cases with job transfer or restriction *

# Other recordable cases *

Total # days away from work *

Total # days of job transfer or restriction *

Injury or Illness Data
If none, type "0" in the box

# of Injuries *

# Skin disorders *

# Respiratory conditions *

# of Poisonings *

# Cases of hearing loss *

# of All other illnesses *

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

2017 *

2018 *

2019 *

2020 *

Recordable Incident Rate
If none, type "0" in the box

2017 *

2018 *

2019 *

2020 *

Operations and Best Practices
If none, type "0" in the box

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) *

Has your safety program resulted in lower costs through reduced worker compensation premiums? *

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?

Please answer A, B & C below (note: selected summaries may be published in The Quarterly magazine): *

Submit

SAFETY AWARD APPLICATION

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

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