Safety Award Application

Member (Company) Name:

Contact

Address

City

State

Zipcode

Phone Number

Fax Number (optional)

Email Address

Client (Company) Name

Contact

Address

City

State

Zipcode

Phone Number

Fax Number (optional)

Email Address

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.