Chapter Safety Awards 2026

Chapter Safety Awards

2026 Application
From
Form Name
Company Name
Primary Safety Contact

First NameLast Name
Job Title
Phone Number

Area CodePhone Number
Email Address
example@example.com
Information Confirmed By (CEO Name):

CEO FirstCEO Last
2025 Safety Information
2025 Average # Employees
2025 Total Hours Worked
Total # Work Days Lost
Information available from the OSHA 300 Log.
Total # OSHA Recordable Cases
Information available from the OSHA 300 Log.
Lost Time Cases Incident Rate
Formula required. Click button below to view.
Total Recordable Cases Incident Rate
Formula required. Click button below to view.
2025 EMR
Experience Modifier Rate (EMR) is available from your Workers' Comp Policy or Insurance Agent.
2024 EMR
Experience Modifier Rate (EMR) is available from your Workers' Comp Policy or Insurance Agent.
2023 EMR
Experience Modifier Rate (EMR) is available from your Workers' Comp Policy or Insurance Agent.
# of Federal or State OSHA Inspections in 2025
# OSHA Citations Issued in 2025
$ Paid for OSHA Fines in 2025
Safety Evaluation
The following evaluation is provided to help you assess your firm’s safety program. Sixteen (16) key elements are addressed. Each element contains various descriptions. Mark (x) each description that most accurately describes your firm’s performance.
A. EXECUTIVE MANAGEMENT POLICY STATEMENT ON SAFETY
B. RESPONSIBILITY FOR SAFETY DEFINED
C. SAFETY PROGRAM GOAL SETTING
D. MANAGEMENT SUPERVISORY MEETINGS
E. PRE-PLANNING FOR JOB SITE SAFETY
F. EMPLOYEE PARTICIPATION
G. NEW EMPLOYEE ORIENTATION
H. SAFETY RULES
I. EMPLOYEE SAFETY TRAINING
J. SAFETY TOOLBOX MEETINGS
K. INSPECTIONS
L. SUPERVISORY SAFETY TRAINING
M. USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)
N. PERFORMANCE AUDIT
O. SUBSTANCE ABUSE
P. RECORD KEEPING - Records are kept on:
Total Score
Documentation

Please upload the following required documentation. A hard copy of your Company Safety Program and Policy manual is required. Soft copies are not accepted. Please deliver your hard copy to Lena McGuffin at ABC Mississippi, 5165 Old Brandon Road, Pearl, MS 39208. This is required to complete your application.
2025 OSHA 300A Summary Log (Combined For All Jobs)

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2025 Experience Modifier Rate (Indicated on Worker's Comp Policy or Insurance Statement)

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Substance Abuse Policy & Testing Procedures

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Would you like a follow-up evaluation of your safety program?
Payment

$125 Application Fee
Payment Type
Price
Calculation

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USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Chapter Safety Awards

2025 Safety Information

Safety Evaluation

Documentation

Payment

Pay Online