Contractor Safety Awards Application Form

Contractor Safety Awards Application Form
Welcome to this year’s Safety Award Application. We are looking forward to receiving your application and seeing you at this year’s Safety Awards Banquet.

Please read the application in its entirety before submitting your company information.

BE SURE TO CLICK SAVE and Save The "Get Draft Link" Given to Return to your Form.

Reserve your tickets and sponsorship today at https://nwibrt.org/caf-nwibrt-safety-awards-banquet/ or call 219-226-0300.

Instructions for Filing Application

All award applicants are required to complete the application in full for acceptance, and have the application signed off by the chief executive officer or president of the contractor firm.

Deadline for Filing Application: Must be submitted before midnight February 14, 2025.

Questions: Direct any questions to (219) 226-0300.

Winners will be notified of their award status no later than: March 14, 2025.

The awards will be presented at the Annual Safety Awards Banquet at the Avalon Manor Banquet Center on May 8, 2025.

Criteria for Application Evaluation can be found at https://nwibrt.org/award-criteria/
Contractor Part 1
Company Name*
NAICS Category*
Contact Person*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Mobile Number
Please enter a valid phone number.
Email for Return Notification*
example@example.com

OSHA & Safety Information
Has your organization received any OSHA violation that was "willful" or greater in the past year?*

YesNo
Information:

Enter your OSHA injury/illness statistical data for the past three years in the table below.

(Total cumulative for Indiana counties including Lake, Porter, LaPorte, Newton, Jasper, Starke, and St. Joseph).
Please enter what type of accommodation services do you need.*
Total Number of Fatalities:*
Total Number of Cases with DAFW:*
Total Number of Cases with Job Transfers/Restrictions:*
Total Number of Cases of Other Recordable Cases:*
Total Hours Worked:*
To Calculate Rates:
DAFW =
Number of Cases (Row 2) x 200,000 hours / Total Hours Worked (Row 6)

DART =
Number of Cases (Row 2 + Row 3) x 200,000 hours / Total Hours Worked (Row 6)

TRIR =
Number of Cases (Rows 1+2+3+4) x 200,000 hours / Total Hours Worked (Row 6)
Please upload copies of your organization's OSHA 300-A summary for the past 3 years:*

Cancelof
Please upload copies of your organization's OSHA 300 Log with names redacted for the past 3 years:*

Cancelof

Contractor Part 2
Industry Type:*
NAICS Category (same as previous page)*
Describe the type of work/service you provide:*

List three clients from the NWIBRT Member Companies to contact for a reference of your safety practices and performance:*

	Name	Title	Company	Phone	Email
Reference one:
Reference two:
Reference three:

Describe in detail your safety management system including the following criteria (do not include safety manuals, booklets, etc.):
A. Describe your management accountability and commitment (include statement or policy).*
B. Provide written safety and health programs (include who maintains the program).*
C. What is your safety orientation procedure for new employees?*
D. What is your on-going safety training for all employees?*
E. How do you determine the effectiveness of your training?*
F. Describe site safety meetings (include frequency, duration, who conducts, attends, and how meetings are documented).*
G. Describe how you enforce safe work practices (include accountability for safe and unsafe behavior).*
H. Describe your incident reporting/investigation process?*
I. How do you use incident statistics to improve safety performance?*
J. How are unsafe conditions reported and resolved?*
K. What new programs, innovations or changes have you implemented in the last year to improve your safety culture and reduce injuries and illnesses?*
L. List all CAF safety classes and other recognized safety classes for its workforce?*
M. List the individuals in your company is active in NWIBRT Safety Subcommittee and Safety Sub Teams. How many meetings did each attend in 2024? (80% attendance is required to achieve Excellence Award status and Contractor of the Year consideration. If 80% is not achieved, companies will be eligible for Recognition and Achievement).*
If your firm is selected as a finalist, who is to be contacted to arrange a work site audit?
Name*

First NameLast Name
Title:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Prepared by:*

First NameLast Name
Title:*
Date*

MonthDayYear
Date
Preparer's Signature*

Clear
CEO/President Name:*

First NameLast Name
CEO/President Email Address:*
example@example.com
CEO/President Signature:*

Clear
I certify that the CEO of our company or division has reviewed this application:*

I agree
Should be Empty:

Contractor Safety Awards Application Form

Contractor Part 1

OSHA & Safety Information

Contractor Part 2