Project Safety Award Application

Member (Company) Name:*

Contact*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax (optional)

Email*

Client (Company) Name*

Contact

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax (optional)

Email*

How many on-site manhours did your company accrue on the project?*

Did your company have any OSHA recordable incidents during the project?*

Did your company suffer any property damage incidents valued in excess of $10,000 during the project?*

Does your company have a written Health and Safety Program?*

Did your company enforce a Site Specific Safety Plan?*

Does your company complete weekly safety meetings?*

Does your company have an on-site person trained in first aid/CPR?*

Do all of your workers have an OSHA 10 hour certification card?*

Do at least one of your supervisors have an OSHA 30 hour certification card?*

Briefly describe the scope of your company’s involvement on the project:*

In a short paragraph explain one safety lesson you’ve learned from this project:*

*

Check this box if you attest that the answers on this questionnaire are true and accurate.