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 *

3. Have You had any OSHA citations for the calendar year 2019? *

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.

Select One *

Upload File *

Max file size: 20MB

5. Are the costs of individual accidents kept? Please answer yes or no. If yes, how are they reported?

Comment *

6. Do you have an orientation program for new hires? Please answer yes or no. If yes, describe the program briefly:

Comment *

7. Do you hold site safety meeting for field supervisors? Please answer yes or no. If yes, how often?

Comment *

8. Do you hold craft “tool box” safety meetings? Please answer yes or no. If yes, how often?

Comment *

9. Do you conduct project safety inspections? Please answer yes or no. If yes, how often?

Comment *

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

Untitled *

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

Untitled *

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

Untitled *

13. Do you have a Behavioral Based Safety Program? If yes, how are they reported? If yes, what do you do with the information?

Comment *

14. What are your Safety Training requirements?

Comment *

Submit