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.

Please ensure you have all necessary materials ready before beginning to fill out the form below. This will help you avoid losing any information if you're interrupted before submitting. Once you start the process, it is important to complete the form in one session to ensure your details are successfully captured.

* Indicates required field

Company Name *

Contact Name *

First

Last

Company Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

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 the data that will be used for 2024 OSHA 300A Summary Log to complete the following
information:*

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 Rate *

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? *

3. Have You had any OSHA citations for the calendar year 2024? *

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. (please redact your company name and logo from the document before sending) *

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 *

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

*Please provide a SSSP cover page & table of contents for a project in 2024. Points will be deducted if not submitted. (please redact your company name and logo from the document before sending) *

Max file size: 20MB

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

Please provide a safety related “write up” for the year 2024. Points will be deducted if not submitted. (please redact your company name and logo from the document before sending) *

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 2024. Points will be deducted if not submitted. (please redact your company name and logo from the document before sending) *

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. (please redact your company name and logo from the document before sending)

Upload File *

Max file size: 20MB

Upload File *

Max file size: 20MB

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Upload File *

Max file size: 20MB

Upload Current Company High-Res Logo *

Max file size: 20MB

Upload Team Photo (if you have one-- not required) *

Max file size: 20MB

If you're having trouble submitting this form, you can e-Mail your responses and supporting files to [email protected].

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