TOPS Award Application

TOPS Application Form - Part 1

Company Demographics & Statistics
Company Name
Corporate Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Submitted Project Name & Location
Project Name
Project Location
Brief description of the submitted project, approximately 25 words, which can be used at the award ceremonies to introduce your company as the award is received,
File Upload (If needed)

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Category 1 (under 60K work hours)Category 2 (60K-250K work hours)Category 3 (250K-750K work hours)Category 4 (over 750K work hours)
NOTE: Statistical Data Weighting Factor 20%

Provide the following Statistics for the Overall Company/Organization: Data to be taken from OSHA 300/300A data (upload copies of OSHA 300/300A data). *

Rows	2020	2019	2018
(A) Total Hours Worked**
(B) # Fatalities
(C) # Lost Workday Cases
(D) # Restricted Day Cases
(E) # Other Recordable Cases
(F) # Total Recordable Cases (Sum C thru E)
Experience Modification Ratio (EMR)

Entry required in all fields*

Rows	2020	2019	2018
Recordable Incident Rate (TRIR) F x 200,000 / A
Lost Workday Case Rate (LWCR) C x 200,000 / A
Days Away/Restricted or Transfer Rate (DART) (C + D) x 200,000 / A

North American Standard Industry Classification (NASIC)
** Corporate Fatalities considered in score weighting but do not result in disqualification unless experienced within the TOPS submission year.
Upload any necessary files for this section

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Application Form - Part 2 - Project Statistics

Provide the following Statistics for the Submitted Project (Most recent three years): Provide work hours and statistical data for all personnel managed by the applicant Company inclusive of subcontractors for the applicable years.
Submitted Project Start Date
Submitted Project Completion Date
NOTE: Statistical Data Weighting Factor 80%

Entry required in all fields*

Rows	2020	2019	2018
Total Hours Managed (Inclusive of subcontractors)
# Fatalities (Inclusive of subcontractors) ** Immediate disqualification
# Recordable Cases (Inclusive of subcontractors)
Recordable Incident Rate (TRIR) (Inclusive of subcontractors)
# OSHA/MSHA Citations*** (Inclusive of subcontractors)

*** Upload documents providing details of each OSHA/MSHA citation. Emphasis on why the citation event occurred, contributing factors and actions taken to reduce the potential for future occurrence. (MSHA citations will be weighted differently from OSHA citations)

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Submittal Endorsements:
Prepared By:*
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Signature*
Corporate Officer / Designate Certification

I certify that information contained herein has been verified and is accurate.
Signature*
Date*

MonthDayYear
Date
Name*
Title*
Should be Empty:

Rows	Your Personnel Only	Inclusive of all Sub-trades
Pre-Project Risk Assessment / Mitigation Plan
Daily JSA / Task Planning
High Hazard Activity Preconstruction Conferences
Other (provide description below)

Rows	Your Personnel Only	Inclusive of all Sub-trades
Daily JSA / Task Planning
Project-Wide Safety Meetings
Flex & Stretch Program
“Good Catch” Program
Behavioral Based Processes (Worker Observation)
Project Celebrations / Luncheons
Incentive / Reward Program(s)
Other (provide description below)

Rows	Your Personnel Only	Inclusive of all Sub-trades
Corporate Management
Project Management
Site Supervision
Crew Foremen
Designated Safety Representative

Rows	Your Personnel Only	Inclusive of all Sub-trades
First Aid Cases
Property Damage Cases
Near-hit Incidents
Vehicle/Mobile Equipment Incidents
Recordable Cases
Environmental Incidents

TOPS Application Form - Part 1

Submitted Project Name & Location

Application Form - Part 2 - Project Statistics

Application Form - Part 3 - Project Questionnaire

Vendor/Supplier Recognition

Submittal Endorsements:

Corporate Officer / Designate Certification