Safety Excellence Award Application

safety excellence award application

The purpose of this award is to acknowledge and reward those companies who have implemented pro-active programs and goals to create safe and healthy work environments to better our industry.

The identity of each company's submission will be confidential and withheld from the award judges. For privacy purposes, upon submission the SEAA office will assign the company's application a unique number. Any data furnished in this application will not be made public at any time and will only be used as a metric to base award recognition.

* Indicates required field

Company Name *

Company Address *

Line 1

Line 2

City

State

Zip Code

Country

Contact Name *

First

Last

Phone Number *

1. List your company's Interstate Experience Modification Rate for the three most recent years. If EMR rate exceeds 1.00 in any of the three years (or is increasing), a letter of explanation, including proactive planning, will be required.

Year *

EMR *

Year *

EMR *

Year *

EMR *

2. Please use your OSHA 300A Summary Log to complete the following information:

A. Total number of recordables on OSHA 300A form:

2017 *

2018 *

2019 *

Recordable Incident Rate

Untitled *

B. Total number of Lost Time on OSHA 300A form

Untitled *

Lost Time Incident Rate

Untitled *

C. Total number of DART on OSHA 300A form

Untitled *

DART

Untitled *

D. Total number of OTHER on OSHA 300A form

Untitled *

E. Employee hours worked last year

Untitled *

F. Average number of employees

Untitled *

G. Were there any fatalities?

Choose One *

Yes No

If yes, how many?

# of fatalities *

Year of fatality *

Submit