2023 Safest Company Award Nomination

Safety Award Nomination

General Company Information

Company Address
Company Address

Safety Performance

Is your firm self-insured for workers compensation claims?

OSHA Data - reference OSHA forms 300A from the selected years

Number of Fatalities
Number of Lost Work Day Cases
Number of Job Transfer or Restricted Work Day Cases
Number of Other Recordable Cases
Number of Days Away From Work
Total hours worked by all employees last year
Total Recordable Incident Rate (TRIR)
Lost Work Day Case Rate
Days Away, Restrictions, or Transfers Rate (DART)

Safety Policies, Programs, and Procedures

Has your company been cited by OSHA in the past three years?
If yes, were any of the citations classified as willful or repeat?
Does your company have a written safety and health management program?
Does your safety and health program contain the following?:
Affirmative Action Plan
Confined Space Entry Program (if applicable)
Disciplinary Program
Do you have a vehicle?
If yes, do you do DOT required drug testing?
Fall Protection Program
Hazard Communication Program
If yes, do you have a list of all hazardous materials?
Do you have a safety data sheet for each chemical?
Hazard Recognition and Control
Does your company conduct a Job Safety/Hazard Analysis before each work shift/task?
If yes, are they written and recorded for your records as well as reviewed by management?
Hearing Conservation Program (if applicable)
Do you have highly hazardous chemicals at your facility?
If yes, have you implemented a process safety management program?
Injury and Illness Reporting
Lockout/Tagout Program
If yes, do you have lockout procedures for each piece of equipment?
Management Commitment Statement
Personal Protective Equipment Program (PPE)
If yes, have you conducted a PPE hazard assessment and do you have a written certification of hazard assessment?
Proper Portable Electrical/Power Tools Use
Pre-Employment Drug & Alcohol Screening
Random Reasonable Suspicion and Post Accident Drug Testing
Respiratory Protection Program
Substance Abuse Program
Does your company have an accident investigation procedure?
Does senior management participate?
Does your company conduct site safety inspections?
Do you have a safety observation program for both management and hourly employees?
Do you have a safety committee?
Do these inspections include housekeeping?
Do you have a program to insure that PPE is inspected and maintained?
Do you conduct inspections on operating equipment (cranes, forklifts, etc.)?

Safety Training and Orientation Part 1

Do you have a safety orientation program for new hires?

If your answer is "Yes," does the orientation program include documented instruction for each of the following?
Are new employees allowed to start work before completing orientation program?
Are safety trainings offered to your employees per subject matter and the hazards associated with all tasks at hand?
Accident Reporting / Investigation Procedures
Aerial Lift Platforms
Assured Grounding / GFCI
Bloodborne Pathogens
Compressed Gas
Confined Space
Electrical Safety
Emergency Procedures (including Evacuation Plan)
Environmental / Spill Procedures
Eye Protection
Fall Protection / Tie-off Requirement
Fire Protection & Prevention
First Aid
Forklift Training
Hazard Communication
Head Protection
Hearing Protection
Heat Stress
Highly Hazardous Chemicals (PSM)
Hostile Work Environment
Job Hazard Analysis
Ladder Safety
Lockout / Tagout
Material Safety Data Sheets (MSDS)
Perimeter Guarding (Floor & Roof)
Powered Industrial Vehicles (Cranes, Forklifts, etc.)
Respiratory Protection
Rigging and Crane Safety
Safe Work Practices
Safety Intervention
Safety Supervision
Sanitation / Housekeeping
Sexual Harassment
Signs, Barricades, & Flagging
Small Tool & Equipment
Storage & Use of Flammable Liquids
Suspended Work
Tool / Equipment Inspection
Toolbox Meetings
Trenching and Excavation
Walking & Working Surfaces
Workplace Violence

Safety Training and Orientation Part 2

Do your training records include the following?:
Employee Name (identification)
Date of the Training
Name of the Trainer
Is the Trainer certified or qualified?
Method used to Verify Understanding
How do you verify that employee understands the training?
If you use aerial lifts and forklifts, are the operators currently certified?
If yes, are all power operators certified within the last 3 years and current on their certifications?
Do you hold "toolbox" safety meetings?
Do you have a safety program for newly hired or promoted foremen/supervisors?

If your answer was "Yes," does it include instruction on the following?
Accident Investigation
Disciplinary Procedure
Emergency Procedure
Fire Protection & Prevention
First Aid Procedures
New Worker Orientation
OSHA 10-hour Course
Safe Work Practices
Safety Intervention

Safety Training & Orientation for Construction Companies

Is your company a construction company?
Do you use the OSHA Construction Safety courses?

Safety Program

Fatality Disclosure

Please indicate whether your company - including all locations and contractors, etc. - experienced a work-related fatality in the last five years.*

Company Representative Information

By signing this application, I certify that all of the information on this application is correct and complete. I understand that any misrepresentation can result in disqualification. By signing below, I'm also confirming that my company is able to send at least one representative to the Florida Chamber Safety Council's Southeastern Conference on Safety, Health, and Sustainability to accept the award.
Additional Contact (Optional):
Silhouette of men working