2023 Safest Company Award Nomination Safety Award Nomination General Company Information Applicant Name * Company Name * Company Address * Company Address Company Address Company Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Industry/Products * Number of Employees * Number of Domestic Sites * Number of EHS Professionals * Safety Performance Lost-Time Injury Rate * Industry Average Lost-Time Injury Rate * Experience Modification Rating * Is your firm self-insured for workers compensation claims? * Yes No OSHA Data - reference OSHA forms 300A from the selected years Number of Fatalities 2019 * 2020 * 2021 * Number of Lost Work Day Cases 2019 * 2020 * 2021 * Number of Job Transfer or Restricted Work Day Cases 2019 * 2020 * 2021 * Number of Other Recordable Cases 2019 * 2020 * 2021 * Number of Days Away From Work 2019 * 2020 * 2021 * Total hours worked by all employees last year 2019 * 2020 * 2021 * Total Recordable Incident Rate (TRIR) 2019 * 2020 * 2021 * Lost Work Day Case Rate 2019 * 2020 * 2021 * Days Away, Restrictions, or Transfers Rate (DART) 2019 * 2020 * 2021 * Safety Policies, Programs, and Procedures Has your company been cited by OSHA in the past three years? * Yes No If yes, were any of the citations classified as willful or repeat? * Yes No Does your company have a written safety and health management program? * Yes No Does your safety and health program contain the following?: Affirmative Action Plan * Yes No Confined Space Entry Program (if applicable) * Yes No N/A Disciplinary Program * Yes No Do you have a vehicle? * Yes No If yes, do you do DOT required drug testing? * Yes No Fall Protection Program * Yes No If yes, how are unprotected sides or edges 4 feet (general industry) or 6 feet (construction industry) or higher above lower level protected? * Hazard Communication Program * Yes No If yes, do you have a list of all hazardous materials? * Yes No Do you have a safety data sheet for each chemical? * Yes No Hazard Recognition and Control * Yes No If yes, when was the last Job Hazard Analysis performed? * Does your company conduct a Job Safety/Hazard Analysis before each work shift/task? * Yes No If yes, are they written and recorded for your records as well as reviewed by management? * Yes No Hearing Conservation Program (if applicable) * Yes No N/A Do you have highly hazardous chemicals at your facility? * Yes No If yes, have you implemented a process safety management program? * Yes No Injury and Illness Reporting * Yes No Lockout/Tagout Program * Yes No If yes, do you have lockout procedures for each piece of equipment? * Yes No When was the last periodic inspection conducted? * Management Commitment Statement * Yes No Personal Protective Equipment Program (PPE) * Yes No If yes, have you conducted a PPE hazard assessment and do you have a written certification of hazard assessment? * Yes No Proper Portable Electrical/Power Tools Use * Yes No Pre-Employment Drug & Alcohol Screening * Yes No Random Reasonable Suspicion and Post Accident Drug Testing * Yes No Respiratory Protection Program * Yes No Substance Abuse Program * Yes No Does your company have an accident investigation procedure? * Yes No If yes, who is on the accident investigation team? * Does senior management participate? * Yes No When are accidents reported? * How are accidents recorded? * How often are accident records and summaries reported? * How often are accidents totaled for the entire company? * How often are accidents totaled by project? * Does your company conduct site safety inspections? * Yes No Do you have a safety observation program for both management and hourly employees? * Yes No Do you have a safety committee? * Yes No Do these inspections include housekeeping? * Yes No How often do these inspections take place? * Do you have a program to insure that PPE is inspected and maintained? * Yes No Do you conduct inspections on operating equipment (cranes, forklifts, etc.)? * Yes No Safety Training and Orientation Part 1 Do you have a safety orientation program for new hires? * Yes No 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? * Yes No Are safety trainings offered to your employees per subject matter and the hazards associated with all tasks at hand? * Yes No If yes, which topics do you offer to train your employees on and is it on yearly basis? * Accident Reporting / Investigation Procedures * Yes No Aerial Lift Platforms * Yes No Assured Grounding / GFCI * Yes No Bloodborne Pathogens * Yes No Compressed Gas * Yes No Confined Space * Yes No Electrical Safety * Yes No Emergency Procedures (including Evacuation Plan) * Yes No Environmental / Spill Procedures * Yes No Eye Protection * Yes No Fall Protection / Tie-off Requirement * Yes No Fire Protection & Prevention * Yes No First Aid * Yes No Forklift Training * Yes No Hazard Communication * Yes No Head Protection * Yes No Hearing Protection * Yes No Heat Stress * Yes No Highly Hazardous Chemicals (PSM) * Yes No Hostile Work Environment * Yes No Job Hazard Analysis * Yes No Ladder Safety * Yes No Lockout / Tagout * Yes No Material Safety Data Sheets (MSDS) * Yes No Perimeter Guarding (Floor & Roof) * Yes No Powered Industrial Vehicles (Cranes, Forklifts, etc.) * Yes No Respiratory Protection * Yes No Rigging and Crane Safety * Yes No Safe Work Practices * Yes No Safety Intervention * Yes No Safety Supervision * Yes No Sanitation / Housekeeping * Yes No Scaffolding * Yes No Sexual Harassment * Yes No Signs, Barricades, & Flagging * Yes No Small Tool & Equipment * Yes No Storage & Use of Flammable Liquids * Yes No Suspended Work * Yes No Tool / Equipment Inspection * Yes No Toolbox Meetings * Yes No Trenching and Excavation * Yes No Walking & Working Surfaces * Yes No Workplace Violence * Yes No Safety Training and Orientation Part 2 Do your training records include the following?: Employee Name (identification) * Yes No Date of the Training * Yes No Name of the Trainer * Yes No Is the Trainer certified or qualified? * Yes No Method used to Verify Understanding * Yes No How do you verify that employee understands the training? Written Test Performance Test Oral Test Job If you use aerial lifts and forklifts, are the operators currently certified? * Yes No If yes, are all power operators certified within the last 3 years and current on their certifications? * Yes No Do you hold "toolbox" safety meetings? * Yes No If you answered "Yes," how often do these take place? * If you answered "Yes," what topics are covered in one year? * Do you have a safety program for newly hired or promoted foremen/supervisors? * Yes No If your answer was "Yes," does it include instruction on the following? Accident Investigation * Yes No Disciplinary Procedure * Yes No Emergency Procedure * Yes No Fire Protection & Prevention * Yes No First Aid Procedures * Yes No New Worker Orientation * Yes No OSHA 10-hour Course * Yes No Safe Work Practices * Yes No Safety Intervention * Yes No Explain any other special safety training: Safety Training & Orientation for Construction Companies Is your company a construction company? * Yes No Do you use the OSHA Construction Safety courses? * Yes No How many employees have taken the 10-hour Construction Safety course? * How many employees have taken the 30-hour Safety course? * Safety Program Please name any other safety or environmental awards received by your company: * What is your company/management philosophy regarding safety? * Please offer at least one example that is indicative of management's dedication/commitment to workplace safety during the COVID-19 pandemic. * How are employees encouraged to participate in the safety process? Please offer at least two examples. * What are some of the key elements of your company's occupational safety and health program? * What makes these elements important o your company's safety process? * What role, if any, does safety play in how your company does business? How does your company make the business case for safety? * What methods do you use to track and verify the efficacy of your safety process? Do you use specific leading indicators? Please elaborate. * Are there unique elements to the safety process at your company? If so, please describe those efforts here. * Can you share an example or examples of where your company's safety policies and procedures go above and beyond OSHA standards? Above ANSI voluntary standards? Above accepted industry standards? * Why does your company deserve to be named one of Florida's Safest Companies by the Florida Chamber Safety Council? * Please include any addition information you feel is pertinent here. Fatality Disclosure Please indicate whether your company - including all locations and contractors, etc. - experienced a work-related fatality in the last five years.* Yes, we've had one or more fatalities in the last five years. (Please elaborate below) No, our company, including all locations, divisions, and contractors, has not had a work-related fatality in the last five years. Please elaborate below: Initial Here signature keyboard Clear 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. Full Signature * signature keyboard Clear Today's Date Name * Job Title * Phone * Email * Additional Contact (Optional): Name Job Title Phone Email If you are human, leave this field blank. Submit
