Company Safety Program:
On separate pages, please answer the following questions:
1. Describe the various components of your safety program, such as how you identify hazards, investigate incidents, keep
track of records and manage your information. Perhaps your program includes indoor air quality, industrial hygiene, and
ergonomics. Please be as thorough as possible in your description.
2. What proactive changes have been made in your program from the previous year?
3. Please describe the role of top management in your safety program. What does top management do to support your
4. Why do you believe your company should receive award recognition? What distinguishes your company in safety?
All applicants please answer the following questions:
Yes No N/A Yes No N/A
1. u u u Has your company made a policy declaration on safety? 7. Does your program include the following?
First time applicants must attach. u u u a. Accident analysis or investigation
u u u b. Written injury/illness incident reporting policy
2. u u u Does your company have a written injury/illness preven- u u u c. Near miss reporting and review
tion plan as required under Nebraska law? u u u d. Method to measure results
First time applicants must attach.
8. Does your program include these OSHA required programs?
3. u u u Has your company assigned a management individual u u u a. First aid/CPR training
with specific responsibilities for safety? _______ u u u b. Hazard communication training
If so, who (name) __________________ u u u c. Bloodborne pathogens training
Percentage of time allocated to safety ____________ u u u d. Lockout/tagout program
u u u e. Hearing conservation
4. Is safety part of: u u u f. Eye protection
u u u a. Employee orientation u u u g. Respiratory protection program
u u u b. Annual performance appraisals
9. u u u Does your program include DOT drug and alcohol programs?
5. u u u Do you have disciplinary procedures for safety
rule violations? 10. Does your program include the following?
u u u a. Pre-placement health examinations
6. Does your safety program include the following? u u u b. Early return to work, light duty
u u u a. Regular safety committee meetings u u u c. Periodic health examinations/medical surveillance
u u u b. Regular environmental audits u u u d. Cumulative trauma disorder prevention program
u u u c. Regular safety/health inspections u u u e. Back injury prevention program
u u u d. Written safety belt policy u u u f. Break/job rotation practice
u u u e. Motor vehicle driver training
u u u f. Safety incentive programs 11. Does your program have any of the following?
u u u g. Facilities inspections u u u a. Safety rules
u u u h. Equipment purchase safety review u u u b. Health rules
u u u i. Engineering and design safety review u u u c. Wellness program
u u u j. Supervisor's safety responsibilities u u u d. Smoking Policy
u u u k. Safety training for supervisors u u u e. Off-the-Job safety program
u u u l. Safety training for workers
CHECKLIST: Receive the recognition your
First time applicants must include the following:
u YES u NO 2006, 2007, 2008 300A summary company deserves
or supporting documents if not
u YES u NO Safety policy declaration
u YES u NO Written injury/illness prevention plan 2009 Awards Luncheon
Re-applicants must include the following:
featuring Bruce S. Wilkinson, CSP
u YES u NO 2008 OSHA 300 Summary or Humorous, passionate, enthusiastic, authentic and
supporting documents if not brilliant in his delivery, Bruce Wilkinson will dazzle and
under OSHA impress your safety team as he motivates us all to
continued excellence in safety and health.
If you checked “NO” on any answers, please explain why:
__________________________________________________ 11620 M Circle, Omaha, NE 68137
fax: (402) 896-6331
Primary Contact Signature ____________________________ phone: (402) 896-0454
Join the ranks of CATEGORIES OF RECOGNITION FOR
Greater Omaha's Safest Companies! GREATER OMAHA'S 2009 SAFEST COMPANIES GREATER OMAHA’S 2009 SAFEST COMPANIES
Greater Omaha’s Safest Companies have
implemented an injury and illness preven-
tion program, a safety committee, employee
Most Improved Program Recognition
For the company with the most improved program
AWARDS RECOGNITION PROGRAM
training and other safety initiatives designed
to meet their unique needs. Small Business Award Covering the period of January 1, 2008 to December 31, 2008 Applications Due
For companies, with fewer than 20 employees, which have outstanding safety and health Please type or print and return no later than February 20, 2009. All questions must be answered February 20,
The results of those efforts and the chal- programs, results and achievements completely and all numbers must be provided in the Injury and Illness Record.
lenges in attaining success may have seemed 2009
Mail or bring completed application to:
mountainess at times, but your company Small Business Recognition -Years of Recognition National Safety Council – Greater Omaha Chapter, 11620 M Circle, Omaha, NE 68137
has succeeded and you are realizing reduced For consecutive years as a Small Business Award Recipient Awards recognition program criteria and form can be found at www.SafeNebraska.org.
injuries and illnesses; you’ve improved
employee relations; you’ve reduced your Award of Commendation Company or Organization ______________________________________________ NAICS Code ________________________
workers’ compensation costs and with the For companies with good safety and health programs, results and achievements
President/Senior Operations Official (name) ________________________________ (signature) ________________________
savings in indirect costs caused by injuries Award of Merit
you have increased the bottom line prof- Street Address ____________________________________________________________________________________________
For companies with outstanding safety and health programs, results and achievements
itability of your organization. City ________________________________________________________________ State ______ Zip Code ______________
Award of Honor
Let the National Safety Council, Greater Omaha For companies with superior safety and health programs, results and achievements
Chapter recognize your organization with: Contact or Safety Director __________________________________________________________________________________
• Greater Omaha 2009 Safest Company decals • Bronze Award of Honor
First year Award of Honor recipient Phone____________________________________________ Fax __________________ e-Mail __________________________
for your doors and logo for your use on let-
• Silver Award of Honor Web Address ____________________________________________________________________________________________
terhead, website and other materials/locations Second consecutive year Award of Honor recipient
you feel appropriate. • Gold Award of Honor with Distinction Classification:
• Recognition through the media, in the Third consecutive year Award of Honor recipient Please describe the organization’s operations:
Midlands Business Journal, SafetyPro, and on ________________________________________________________________________________________________________
www.SafeNebraska.org. Award of Honor with Distinction -Years of Recognition ________________________________________________________________________________________________________
For companies which have sustained superior safety and health programs, results and
• A template for you to release your informa- achievements for more than three consecutive years Is this application for: u Entire Organization u Division u Operations Unit
tion to the media, your industry magazine or Please list addresses of facilities included in this application:________________________________________________________
other appropriate organizations. Award of Honor Platinum -Years of Recognition ________________________________________________________________________________________________________
• An award to display as a reminder of your For companies which have sustained superior safety and health programs, results and
achievements for more than ten consecutive years
achievement. List the top 3 most common injuries for your company: 1.___________________________________________________________
• Recognition at the Awards Luncheon held at Double Honor Platinum Award 2._______________________________________________ 3. ______________________________________________________
the Safety and Health Summit, May 13, For companies which have sustained superior safety and health programs, results and
Were any injuries beyond your control or special circumstances? (i.e. rear-ended at stop sign) If so please describe: ___________
2009. achievements for twenty consecutive years
Jim Armstrong J. C. Moore, CHSP, CSSO ________________________________________________________________________________________________________
Safest Companies Senior Safety Technician, Metropolitan Utilities District Safety Officer, Methodist Health System
Please Describe the Operations of the Organization:
2008 2007 2006
(All numbers must be provided)
Awards Committee Bob Cook
Chief Operations Officer, Quality Living
Vice President, Human Resources, 1. Average number of employees
Craig Jacobs, Chairman Beth Fye 2. Total employee hours worked
Human Resource Manager, Henry Doorly Zoo Corporate Safety Manager, Omaha Steaks Kent Schroeder
Risk & Benefits Insurance Manager, 3. Total recordable cases
Crystal Anderson, CDS, ARM Glynda Grap Oriental Trading Company, Inc. (Total of OSHA 300 log columns G, H, I, J)
Risk Manager, Warren Distribution Safety & Marketing Leader, The Trane Company
4. Total number lost-time injury and illness cases involving days away from work
SAFEST COMPANIES AWARDS PROGRAM INFORMATION (OSHA 300 log column H)
1. Organizations must be a current member of OSHA 300 log summaries or equivalent for 7. Participating companies who do not
the National Safety Council, Greater Omaha 2005, 2006 and 2007. Re-applications sub- receive an award may have a helpful 5. Total number of cases involving away from work, days of restricted work
Chapter, or a National Safety Council mit 2008, however, be sure all numbers are "walk-through" inspection by the Greater activity, and/or job transfer (Total of OSHA 300 log columns H, I)
Member with a Greater Omaha Chapter provided on form. Omaha Chapter consulting staff.
Service Package. 6. Total Fatalities (OSHA 300A summary log column G)
4. Employee hours include only those on your 8. All award entries and documentation will
2. Organizations must have a written injury/ill- company payroll. Do not include any non- be held in confidence.
work time, even though paid, such as vaca-
Please enclose copies of your OSHA Log Summaries as requested below. If you are exempt, please provide
ness program or equivalent. If you have not 9. Applications must be received by the
received an award previously, please include tions, sick leave, holidays, etc. similar information to support information requested in 3, 4, and 5 above.
Greater Omaha Chapter of the National
a copy of your program with your awards Safety Council, 11620 M Circle, Omaha,
submission. Those who have received 5. Your application must be complete. First-time applicants: Are your OSHA log summaries or equivalent included for 2006, 2007, 2008? u YES u NO
NE 68137 by February 20, 2009.
awards previously need not submit unless Committee may call for additional information Re-applicants: Is your 2008 OSHA log summary or equivalent included? u YES u NO
they have made program changes. or if your application is incomplete. 10. If you have questions please contact If not, why? ______________________________________________________________________________________________
National Safety Council, Greater Omaha
3. New applicants must submit a copy of 6. The Awards Committee decision will be final. Chapter, 896-0454, ext. 407. Organizations will be notified of results by April 10, 2009. Awards will be presented May 13, 2009 at the
Annual Awards Luncheon, during the Safety and Health Summit at the Qwest Center in Omaha, Nebraska.
Go online at http://data.bls.gov/IIRC/calculate.do to review your rates and determine your NAICS code.