Awards Nomination Form. Corporate Safety. 18 th Annual. Celebrating Safety in Wisconsin

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1 18 th Annual Wisconsin Corporate Safety Celebrating Safety in Wisconsin 2011 Nomination Form The annual awards competition is sponsored by:

2 2011 Award Timeline Nomination Forms Available: December 2011 Applications Deadline: Phase I: Statistical Data January 20, 2012 Finalists Notified January 31, 2012 Phase II: Subjective Report February 15, 2012 Winners Notified: March 15, 2012 Ceremony: April 17, 2012 presented during the 70 th Annual Wisconsin Safety and Health Conference & Expo in Wisconsin Dells The Program is sponsored by: Friends, As Governor of the state of Wisconsin, I am proud to honor the workers and employers of this great state! For the 18th consecutive year, the Wisconsin Department of Workforce Development and the Wisconsin Safety Council have co-sponsored the annual Wisconsin Corporate Safety program. This is a unique opportunity for your organization to be recognized for its exceptional safety standards. By working together to share best practices with other employers in our state, Wisconsin can continue to lead the way by maintaining the highest of safety standards. I encourage you to apply for this prestigious award using the enclosed application. A ceremony to celebrate these awards will be held on April 17, If you have questions regarding the Wisconsin Corporate Safety program, please contact Janie Ritter at (800) , or by at jritter@wisafetycouncil.org. Thank you for your investment in Wisconsin! Together, we will work to let everyone know that Wisconsin is open for business! Sincerely, Scott Walker Governor

3 Why Apply? Benchmark The process of applying requires your organization to benchmark where you have been, where you are, and where you are headed. It can be used as an opportunity to evaluate your current situation, your prospects, and progress. The 18th Annual Wisconsin Corporate Safety Prestige Organizations winning awards have been the subject of well-deserved press coverage in their local communities, as well as in statewide newspapers and business magazines. Award winners have used the Corporate Safety Award to promote their organization and products in their internal communication, marketing materials, websites, sales presentations, and publicity. Morale Booster Many winners of these awards cite their workers as deserving the majority of the credit for the award. Many winning organizations use the award as an opportunity to show appreciation to their associates for a job well done Award Programs Corporate Safety Safety Hall of Fame Award Lifetime Achievement Award Nomination Deadline January 20, 2012 Nomination forms and past recipients can be found on our website (award programs) Special Special may be awarded to companies experiencing a long history of zero lost time incidents. These special award winners will be announced the night of the program. Sponsored by Wisconsin Safety Council, the Wisconsin Department of Workforce Development and Wisconsin Manufacturers & Commerce Honoring Wisconsin Employers Achieving Safety and Health Excellence

4 2011 Wisconsin Corporate Safety Eligibility Applicants must be headquartered in Wisconsin or have a permanent physical facility with Wisconsin Management. All applications submitted must pertain only to the corporation s Wisconsin payroll. Divisions of corporations may submit a separate application for their facility if they can certify that: 1) they operate in a separate location, 2) have a distinct line of business identity for the division, 3) are managed independently from other divisions of their corporate parent for safety and loss control (i.e., independent procedures and programs for safety), 4) Multiple submittals from the same organization must be written locally. Multiple submittals will be reviewed for duplication and may be considered as one application. Exclusions Wisconsin organizations with any work-related fatality to one of your employees or temporary/contract employees in 2011 are excluded from the 2011 Corporate Safety. The 2011 Wisconsin Corporate Safety will be based on size of organization AND type of organization. All award finalists receive a finalist certificate and publicity; zero incidence rates will receive certificates. A. Size of Organizations Size is based on actual 2011 payroll hours (calendar year) which include office hours, but excludes vacation and holidays. You must include all full-time, part-time, seasonal and temporary contract employees who work under your organization s supervision. B. Types of Organizations Category A: Manufacturing - NAICS Codes Category B: Agricultural, Forestry, Transportation, Mining and Utilities - NAICS Codes Category C: Construction - NAICS Code 23 Category D: Other/Public Agencies - NAICS Codes For assistance in determining your NAICS code, visit The 2011 Wisconsin Corporate Safety are based on two phases: statistical data and subjective questions. Phase I: Statistical Data are first judged based upon the organization s incidence rates for the complete calendar years: 2009, 2010 and 2011 (primary consideration will be given to the 2011 recordable and lost workday incidence rates). Note: Applicants will be notified by January 31, 2012 whether or not they are finalists in the statistical phase of the Corporate Safety Award process, and thus asked to participate in Phase II of the awards process. Phase II: Subjective Questions Questions will be asked only to finalists in each category. Possible subjective topics that may be asked to finalists could include: Leadership and Participation Safety and Health Program Implementation Safety and Health Training Goals and Successes Presentation will be presented during a dinner at the Wisconsin Safety Council s 70th Annual Wisconsin Safety & Health Conference/Exposition, Tuesday, April 17, 2012 in Wisconsin Dells. Along with the Dinner, the Wisconsin Safety Council will announce the 11th inductee into the Wisconsin Safety Hall of Fame, and the Lifetime Achievement Award winner. Formal invitations and registration information will be mailed in March. Judges A panel of safety and health professionals has been assembled to judge application papers. Applications Application forms should be sent to: Wisconsin Safety Council, ATTN: Janie Ritter, PO Box 352, Madison, WI , or fax to (608) or jritter@wisafetycouncil.org. Confirmations of receipt will be ed to the contact listed on the application. Due Date Phase I applications must be received by the Wisconsin Safety Council no later than Friday, January 20, All information provided will be kept in strict confidence; however, WSC and DWD reserve the right to publicize the names of award winners. Nominations Must Be Submitted By JANUARY 20, The Application Form is on the next panel and can be found online at

5 2011 Wisconsin Corporate Safety Phase I Statistical Data Form The information will only be used by the Wisconsin Safety Council and judges of the 2011 Wisconsin Corporate Safety Award Send to: WISCONSIN SAFETY COUNCIL Wisconsin Corporate Safety Award PO Box 352, Madison, WI FAX: (608) jritter@wisafetycouncil.org Company (as you would like it to appear) Contact Person Title Street Address City State Zip Code Phone Number Fax Number Year Established Primary North American Industry Classification Code (NAICS) (see list on back) Reporting as: Entire WI Organization Separate Division/Operations Unit (see eligibility section) Worker fatalities in 2011 (see eligibility section) 2. Average number of temporary/contract employees in a. Number of temporary/contract employee hours worked 2b. Number of temporary/contract employee recordable cases (yes or no) 3. Average number of employees on payroll 4. Total number of hours worked [WH are the number of paid work hours for the calendar year (including office hours). PLEASE NOTE: Work hours (WH) are the actual payroll hours worked, excluding vacation and holidays. You must include all fulltime, part-time, seasonal and temporary/contract employees that work under your organization s supervision.] 5. Total number of recordable cases (from OSHA form 300) 5a. Column H (days away from work) 5b. Column I (job transfer or restriction) 5c. Column J (other recordable cases) 5d. Total Column (H, I and J) 6. If your answer to question #5a is zero, how far back does this record go? Date Hours worked INCIDENCE RATE: Enter Line 5d (above) x 200,000 = Rate (RECORDABLE) Enter Line 4 INCIDENCE RATE: Enter Line 5a (above) x 200,000 = Rate (LOST WORKDAY CASE) Enter Line 4 I hereby certify that the information included in this application form is factual and accurate. Completed by: (Please print or type name and title) APPLICATION MUST BE RECEIVED BY Friday, January 20, 2012.