TCA Safety Awards Application

TCA Safety Awards Application

Alphonse Engelman Safety Awards
Company Name *
TCA Membership Required. Contractors with a fatlity in previous year are ineligible.
Contact for Award Application *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Contractor Type/Classification *

General Contractor, less than 205k work hours General Contractor, 250k - 749k work hours General Contractor, 750k work hours or greater Tilt-Up Contractor, less than 205k work hours Tilt-Up Contractor, 250k - 749k work hours Tilt-Up Contractor, 750k work hours or greater

Safety Record

Please enter the figures recorded on your previous year's OSHA 300 log.
Incident Rate (IR): Use the number from the previous year for the calculation below, which is a nationally recognized measure of safety that equalizes accident rates for all firm sizes.

N: number of lost workday cases plus recordable incidents and modified duty for both injuries and illnesses. This number should be the sum of the check marks in columns H, I and J of your previous year’s OSHA 300 log.

WH: number of work hours for the firm in the calendar year included all on your payroll: hourly, non-hourly, overtime.

(N x 200,000) / WH = IR
Total Work Hours *
Lost Workday Cases *
Incident Rate *

Safety Record

Please communicate records for the previous three years.

Injury and Illness Incident and Frequency Rate *

	2021	2020	2019
Totaly Employee Hours Worked
Total Number of Recordable Injury/Illness Cases
Total Number of Lost Workday Cases
Total Number of Restricted Duty Cases
Recordable Incidence Rate
Lost Workday Incidence Rate
Restricted Duty Rate
Worker's Comp Experience Modification Rate

Confirmed Citations Last 3 Years *
Number of confirmed citations during the past 3 years.
Citation Description

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If you have received a citation, use this button attach a brief description including the date and type of citation.
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TCA Safety Awards Application

Safety Record

Safety Record