Awards Application
Company Name (as it should appear on award)
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GA Location Name and Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
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First Name
Last Name
Contact Phone Number
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Please enter a valid phone number.
Contact Email
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example@example.com
Award Consideration
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Superior Safety or Environmental Performance
Workplace Innovations Award
Distinguished Safety, Health and/or Environmental Advocate
If applicable, name of nominated Distinguished Safety, Health and/or Environmental Advocate:
First Name
Last Name
Advocate Job Title
Type a question
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Yes
No
Supporting Information
Has there been a workplace fatality or any OSHA/EPA violations at the site within the past 5 years?
Does the company have comprehensive written environmental, safety & health programs that address the following key elements:
Management Commitment/Leadership
Employee Involvement
Worksite Analysis
Hazard Prevention and Control
Safety and Health Training
Has responsibility for developing and monitoring the safety, health or environmental program been delegated to a specific person or office?
Has responsibility for carrying out the safety, health or environmental program been assigned to all levels or the line organization (managers, supervisors, and employees)?
Is there an accountability system for ensuring safety, health and environmental responsibilities are completed?
Does the communication system include provisions to encourage employees to inform the employer of hazards or unsafe conditions at the work site without fear of reprisal?
Are periodic workplace inspections scheduled and completed?
Are unsafe or unhealthful conditions and work practices corrected immediately, with the most hazardous exposures corrected first?
Do employees know the environmental, safety, or health hazards specific to their job assignments?
Are training needs evaluated whenever new substances, processes, procedures, or equipment introduced to the workplace or whenever the employer receives notification of a new or previously unrecognized hazard?
Does the employer have a labor-management safety and health committee?
In a narrative form (no more than 500 words), please describe any success stories or best stories regarding your safety, health or environmental program in the past year. Items may include safety, health or environmental training programs, unique or innovative programs utilized at the facility, significant employee involvement, innovations, etc. Applicants may include details regarding a significant challenge the facility has overcome, programs, processes, equipment that were implemented or actions of an individual to warrant recognition.
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