Owner (Member) Awards Application Form

OSHA & Safety Information
Has your organization had a fatality in the past year?*

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

YesNo
Information:

Enter your entire Contractor Community’s OSHA injury/illness statistical data for the past 3 years in the table below:

(Total cumulative for Indiana counties including Lake, Porter, LaPorte, Newton, Jasper, Starke, and St. Joseph).
Total Number of Fatalities:*
Total Number of Cases with DAFW:*
Total Number of Cases with Job Transfers/Restrictions:*
Total Number of Other Recordable Cases:*
Total Number of 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)

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

Describe your company’s Contractor Safety Management System including the following criteria (do not include safety manuals, booklets, etc.):
A. Describe your management accountability and commitment (attach policy below).*
Contractor Safety Policy:

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B. How do you select contractors?*
C. Do you review your contractor’s Safety Manual?*
D. Describe your initial and refresher site safety orientation for contractor employees and include how you determine the effectiveness of your orientation.*
E. Do you hold contractor safety meetings, pre-job meetings? (Include frequency, duration, who conducts, attends, and how meetings are documented).*
F. Does your organization ensure contractor conformance to safe work practices? (Include accountability for safe and unsafe behavior).*
G. Describe incident reporting/investigation and how you use incident statistics to improve contractor safety performance.*
H. How are unsafe conditions/behaviors to be reported and resolved?*
I. What innovations to improve contractor safety have been implemented in the last year?*
J. What future initiatives are planned to influence project safety?*
Prepared by:*

First NameLast Name
Title:*
Date*

MonthDayYear
Date
Preparer's Signature*

Clear
Site/Plant Manager Name:*

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

Clear
Should be Empty:

Owner Part 1