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 *

Upload letter of explanation (if applicable) *

Max file size: 20MB

2. Please use your 2021 OSHA 300A Summary Log to complete the following information:
(please submit your summary logs for documentation)*

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

Recordable Incident Rate *

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

Lost Time Incident Rate *

C. Total number of DART on OSHA 300A form: *

DART *

D. Total number of OTHER on OSHA 300A form *

E. Employee hours worked last year *

F. Average number of employees *

G. Were there any fatalities? *

Yes No

If yes, how many fatalities? *

* Please submit copies of OSHA 300A Summary Log for 2019, 2020 & 2021. Points will be deducted if not submitted

Upload 2019 Summary Log *

Max file size: 20MB

Upload 2020 Summary Log *

Max file size: 20MB

Upload 2021 Summary Log *

Max file size: 20MB

3. Have You had any OSHA citations for the calendar year 2021? *

If so, what severity? *

4. Do you have a written safety program, including a Hazard Communication Policy? Please select yes or no. If yes, enclose a copy of Table of Contents. Points will be deducted if not submitted. *

Upload File *

Max file size: 20MB

5. When was the last revision of your Health & Safety Policy? *

6. Are the costs of individual accidents kept? Please answer yes or no. *

If yes, how are the costs reported? *

7. Do you have an orientation program for new hires? Please answer yes or no. Select One *

If yes, describe the orientation program briefly: *

8. Do you submit site specific safety plans? Please answer yes or no. Select One *

*Please provide a SSSP cover page & table of contents for a project in 2021. Points will be deducted if not submitted. *

Max file size: 20MB

If yes, how often do you submit site specific safety plans? *

Upload File *

Max file size: 20MB

9. Do you have a disciplinary program? Select One *

Please provide a safety related “write up” for the year 2021. Points will be deducted if not submitted. *

Max file size: 20MB

10. Do you conduct frequent project safety inspections? Please answer yes or no. *

If yes, how often do you perform project safety inspections? *

11. Do you have a 100% Fall Protection 6’ and above policy for all projects? Please answer yes or no. *

12. Do you have a daily Stretch & Flex program? Please answer yes or no. *

13. Do you require supervisors to perform daily JSA Job Safety Analysis or Pre-Task meetings? Please answer yes or no. *

Please provide a site pre task or JSA from 2020. Points will be deducted if not submitted. *

Max file size: 20MB

14. Do you have a Behavioral Based Safety Program? *

If you do have a behavioral based program, how are they reported AND what do you do with the information? *

If other, describe here: *

*Please provide supporting documentation. Examples are: Sign in sheets or employee training records

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

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