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					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
   program?
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
                                                                                                           at the
                     under OSHA
 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
                                                                                                web: www.SafeNebraska.org
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
                                                                                                                  Dave Pfeffer
                                                                                                                  Vice President, Human Resources,              1. Average number of employees
                                                                                                                  Goodwill Industries
     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.