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2018 SAFETY EXCELLENCE AWARDS APPLICATION

DUE March 22, 2018 @ 5pm cst

* Indicates required field

Company Name: *

Contact Name: *

First

Last

Phone Number *

Email *

Title *

Corporate Address: *

Line 1

Line 2

City

State

Zip Code

Country

Facility Address: *

Line 1

Line 2

City

State

Zip Code

Country

Number of Facilities *

Additional Locations (Cities): *

NAICS: *

Awards & Certifications: *

VPP SHARP OHSAS 18001 ISO

BLS Rate: *

OTHER: *

AWARD CATEGORIES

Select one award category per application. MAM Safety Excellence Award Committee reserves the right to change the award category for any application.

Award Categories *

Safety Innovation Award (Corporate, Multi-site or Single-site) Most Improved (Corporate, Multi-site or Single-site) Safety Manufacturing Company of the Year (Corporate, Multi-site or Single-site) Leader of the Pack (Corporate, Multi-site or Single-site) Horizon Award (Individual –or– Corporate, Multi-site or Single-site) Safety Champion of the Year (Individual) Safety Professional of the Year (Individual)

Data represents (select one): *

Corporate (all facilities) Multi-site (two or more facilities) Single-site (one facility)

Full-time Employees *

Part-time Employees *

Percentage of Temporary Employees: *

Employees per Shift:

1st Shift *

2nd Shift *

3rd Shift *

Total hours worked (calendar year)

Number of recordable nonfatal work-related injuries and illnesses

Number of days away from work cases

Number of job transfer or restricted work activity cases

Experience Modification

2015 *

Untitled *

2016 *

Untitled *

2017 *

Untitled *

How many days/hours since last lost time injury? *

Choose One *

Option 1 Option 2 Option 3

Submit

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SPRINGFIELD, MO 65804
PHONE: 417-863-7262

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