Application
Awards of Merit and Honor
Name of Company Applying: _____________________________________________________________________________
Mailing Address: ______________________________________________________________________________________
City: ________________________________________________________ State: __________ Zip: __________________
Phone: ___________________________________________
Email: ___________________________________________
Type of Operation: _____________________________________________________ Number of employees: ____________
Your SIC/NAICS Code: ___________
Entry cannot be processed without your SIC/NAICS Code.
Name of company as you would like it inscribed on the award:
____________________________________________________________________
Is your company exempt from maintaining an OSHA 300 Log?
q Yes
q No
(If yes, an insurance certification is required. See entry form instruction “D”)
2013
2014
2015
Data Sources (a copy of each years’ OSHA forms must be
OSHA Form 300
OSHA Form 300
OSHA Form 300
attached to application)
Reporting Periods (must be the same each year
____/____/____
____/____/____
____/____/____
from
and reported on a calendar year basis)
thru
____/____/____
____/____/____
____/____/____
1. Average number of employees on payroll (See instruction E)
2. Total number of employee hours worked (See instruction E)
3. Total number of cases involving days away from work
(See instruction E)
4. Total number of recordable cases (See instruction E)
Safety Program Summary
In order to qualify, all answers must be answered affirmatively.
YES
NO
Do you have a safety committee that meets at least quarterly, has established a system for safety suggestions
q
q
from employees, reviews workplace injury and illness reports and makes recommendations to management?
Do you have and follow a written general safety and health program that has been formally reviewed during
q
q
the last year?
Do you have a written plan that helps prepare your employees for workplace emergencies
q
q
Does your organization perform periodic safety and health inspections?
q
q
Does your organization provide employee safety training on all applicable OSHA-required topics
q
q
Your organization has NOT sustained any work-related fatalities during the time periods covered in this
q
q
application?
All information must be complete and accurate to ensure a proper evaluation of incidence rates. Incomplete entry forms will not
be considered. Membership with the Utah Safety Council is required to participate in the Workplace Safety Awards Program.
I certify that this organization is a member in good standing of the Utah Safety Council and that the information contained in this
application is accurate and correct.
Reported by:
___________________________________
__________________________________________
Print Name
Signature
___________________________________
__________________________________________
Title
Date
LOCAL CHAPTER