Safety Awards Application For 2017 Reporting Period

Transcription

1 Safety Awards Application For 2017 Reporting Period 1505 E. Colonial Drive Orlando, FL Phone: Fax: Awards to be presented at: The United Safety Council 65 th Annual Safety Awards Banquet Citrus Club 255 Orange Ave Suite 1800 Orlando, Florida March 23, 2018 ~ official invitation to follow ~

2 General Instructions The achievements we are looking for are those that have occurred between January 1, 2017 and December 31, This application may be completed and returned by the following methods: U.S. Mail: Glenn Victor, Director Occupational Safety Institute United Safety Council 1505 E. Colonial Drive Orlando, FL Fax: Online: Click on the Awards Application link at All applications must be received by 5:00pm on March 1, 2018 Corporate Safety Awards include both Public and Private Sector companies and agencies. Applications will be divided into the following categories: Level I: Employees Level II: Employees Level III: Over 2000 Employees Note: Applications must have the name of the individual making the submission on behalf of the company or agency, as well as the person that will accept any awards. The following pages include forms for each award category. You may apply for as few or as many awards as you choose.

3 Company Information Company Name: (Exactly as it should appear on award) Address: City: State: Zip: Phone: Ext: Number of Full Time Employees: Years in Operation: Brief description of company:

4 United Safety Council Certified Occupational Safety Specialist (COSS) Scholarship Application The United Safety Council COSS Scholarship provides for one fully paid registration in any United Safety Council Open Enrollment session of the COSS course during the 2016 calendar year. Applications for the United Safety Council COSS Scholarship are open to employees of United Safety Council member companies and agencies, as well as their family members. Candidates should provide an essay of between words to include the following: A narrative of the candidate s educational background The candidate s current employment status and future career goals How the COSS scholarship will benefit the candidate personally How the candidate intends to utilize the education provided for the benefit of others Name of Candidate: Please attach essay to this document upon submission.

5 Lost Time Prevention Award Date of last lost time incident: Recognizes companies or agencies that have achieved at least 12 consecutive months without incurring an occupational injury or illness resulting in lost time. All submissions will receive Certificates of Recognition at the discretion of the awards selection committee. Name of person accepting award: Company Name:

6 Outstanding Lost Time Prevention Award Date of last lost time incident: Recognizes companies or agencies that have achieved at least three consecutive years without incurring an occupational injury or illness resulting in lost time. The top three selected will receive Gold, Silver, and Bronze awards and all other submissions will receive Honorable Mention certificates at the discretion of the awards selection committee. Name of person accepting award: Company Name:

7 Vehicle Fleet Safety Award The top three selected will receive Gold, Silver, and Bronze awards and all other submissions will receive Honorable Mention certificates at the discretion of the awards selection committee. Company Name: Total annual mileage: Number of business/agency owned vehicles: Types of vehicles: Number of drivers: Number of employees: Number of preventable (at-fault) accidents in the past 12 months: Please attach a brief narrative to include the types of vehicles driven, the primary purpose for the travel, any potentially hazardous materials being transported, and any other fleet circumstances that you feel should be taken into consideration in the selection process. Name of person accepting award:

8 Corporate Safety Award Company Name: The application will be considered based on size of the business or agency, the hazard potential, and a review of the submitted essay describing safety achievements during the reporting period. The top three selected in each level will receive Gold, Silver, and Bronze awards and all other submissions will receive Honorable Mention certificates at the discretion of the awards selection committee. Please check the applicable level: Level I (1-500 employees) Level II ( employees) Level III (Over 2000 employees) Number of recordable incidents during the reporting period: Please submit a typewritten essay of approximately 500 words, to include any information available on the following topics: Safety Committees Inspection Programs Written Safety & Health Program(s) Management Involvement Employee Involvement Mishap Investigation Programs Name of person accepting award:

9 COSS Excellence in Safety Award The COSS Excellence in Safety Award is open to all current Certified Occupational Safety Specialist (COSS) graduates from the United Safety Council. This Award recognizes an outstanding COSS graduate for their accomplishments since graduating from the COSS program. Nominees are to provide an essay of between words describing how the COSS program has improved the COSS graduate s company or agency safety & health program. Submissions should also address how completion of the COSS program played a role in the graduate s efforts to make those improvements. Any other information the graduate feels is relevant may also be included in this submission. Name of Nominee: Please attach essay to this document upon submission.

10 Safety Leadership Award Awarded to an individual whose influence positively affects corporate, community, and/or personal safety and health. Based on the criteria referenced above, Please submit a typewritten essay of up to 500 words. State the nominee s complete name, title or position, description of responsibilities, and their specific act or actions that have resulted in a lasting contribution. Name of Nominee: Please attach essay to this document upon submission.