Owner (Member) Awards Application Form

OSHA & Safety Information
Has your organization had a fatality in the past year?
Has your organization received any OSHA violation that was "willful" or greater in the past year?
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
2 digit month, 2 digit day, 4 digit yearDate
Preparer's Signature
Site/Plant Manager Name:

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

Owner Part 1