Application form: Innovation in OSH

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1 Application form: Innovation in OSH AWARD CATEGORY Innovation Awards DESCRIPTION SUB CATEGORY (TICK THE CATEGORY APPLIED FOR) The award aims to recognize innovation in OSH (Occupational, Safety & Health) by organizations across all sectors listed below. Automobile Consumer Goods Logistics / Transportation Chemicals Industrial Goods Mining, Extraction & Power Generation Construction Films & Events SME Oil & Gas Others Please specify: ELIGIBILITY CRITERIA 1. Applications are open only for entities which have a registered presence and operations in India. 2. More than one application in an award category is permitted if the applications are for different initiatives. Please use a separate form for each application. IMPORTANT RULES FOR PARTICIPATION 1. Please complete the form in permanent ink (pencil applications will not be permitted) 2. All questions must be answered. Incomplete forms may not be considered. You may use additional sheets of paper, if required, however please ensure that you adhere to the word limit specified for each question. 3. The declaration (at the end of this form) must be signed by the safety head and the COO / Site Head / CEO of the participating entity. 4. The form may be submitted in any of the following ways: a. Download the application form from the website b. the completed application form to c. Send a hard copy of the completed application form via courier to: Mr. Debashish Sharma, UBM India Pvt. Ltd., Times Square, Unit No.1 & 2, B-Wing, 5 th Floor, Andheri Kurla Road, Marol,Andheri East, Mumbai , India T: +91 (22) ext M: F: +91 (22) The completed form must reach the Awards Management by 1 ST October Please maintain one copy of the form with you for your records. SECTION 1 APPLICANT INFORMATION (FOR CORRESPONDENCE) Name of applicant Contact number ID Page 1

2 SECTION 2 ENTITY INFORMATION Name of participating entity Corporate or other Group or Parent company to which the participating entity belongs, if any Postal address City: State: Pin code: SECTION 3 - OSH METRICS Does the organization Yes No have a written OSH policy? Top 3 hazards in your organisation OSH related facilities made available at the workplace No of employees Full time: Part Time : Contract: No of accidents in the past 3 years No of safety training hours provided in the organization in the past 3 years No of voluntary programmes for OSH No of personnel employed for overlooking / implementing the safety programmes OSH related certifications received (attach a copy for the jury s reference) OSH or safety related awards received (attach a copy for the jury s reference) Fatal: First aid cases: Full time: Reported (Non-fatal): Near miss incidents: Part time: (Attach the organization chart for safety management in section 5) Page 2

3 SECTION 4 - CASE STUDY (THE INITIATIVE IDEA THAT WORKED) OSH Innovation Awards 2017 UBM Q1. What were the circumstances or the unmet safety needs / challenges in the organization which led to the idea or initiative? (max 150 words) Q2. Describe the initiative undertaken by your organization in the area of occupational safety and health to address the above situation / need / challenges. (max 250 words) Would you like the initiative to be promoted by UBM - OSH India 2017? (Refer to rules and regulations for further details) Yes No Page 3

4 Q3. Describe the impact of the initiative on various stakeholders. Describe the short term and long term benefits of the initiative (max 75 words each) Stakeholder Participating Entity (E.g. Savings in man days lost, employee motivation, etc) Impact Employees (E.g. Higher morale, fewer accidents, etc) Industry (E.g. setting new benchmarks, pioneering best practices, etc) Other Please specify: SECTION 5 - SUPPORTING DOCUMENTS Please attach supporting documents to substantiate your initiative and its impact. E.g. OSH related certificates received, workplace design where ergonomics is applied, health program brochures, other images, etc. Sr No Document Name Description Organization chart for safety A chart describing the human resources of the organization responsible 1 management* for implementation of OSH related programs and initiatives *Mandatory for all applicants Page 5

5 SECTION 6 DECLARATION I declare that the information provided in this application form is correct, accurate and pertains to my business. I agree to abide by the rules and regulations of participation. Safety Head COO / Site Head / CEO Sign Date (DD-MM-YYYY) Name ID Sign Date (DD-MM-YYYY) Name ID Company Name & Stamp If you have any questions or require any clarifications, please contact Mr. Debashish Sharma (contact details above) Page 5

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