2010 SDA Nomination Form by O3L09H

VIEWS: 0 PAGES: 17

									          2010
ATA Safety Director Award
    Nomination Form




                                                                        Sponsored By:




   Note: Each section represents a tab to your nomination exhibit binder. Please place supporting
                    documentation behind the cover tabs. Deadline July 1, 2010.
 \all information and materials in the order specified in the application/nomination form. Please
                     ATA SAFETY DIRECTOR AWARD
       The Safety Director Award is presented annually to the motor carrier safety professional whose
job qualifications, achievements and ability to design and direct safety programs are deemed most
outstanding. The Award Program is administered by American Trucking Associations, Inc. (ATA)
through its Safety Management Council. The program is designed to promote high standards in the
qualifications and performance of those in the motor carrier safety profession.


Eligibility & Nominations
   Any person at the policy making level who is employed by a motor carrier of property for the full
time direction of its safety activities is eligible for the ATA Safety Director Award. The candidate must
be the individual:

      with the overall authority for policy decisions in the promulgation, inauguration, and adminis-
       tration of the carrier’s safety program;
      with day-to-day operational safety responsibilities;
      who has devoted his/her career to the field of highway and/or industrial safety for a period of
       not less than 10 years; and
      whose title is not necessarily “Director” but who has directed a safety program for at least 5
       consecutive years.

Candidates must be a member of:

      American Trucking Associations and
      ATA Safety Management Council.

   Nominations will be reviewed by the ATA Safety Director Award Committee and judging will be
conducted by government officials and law enforcement personnel.             Individuals may nominate
themselves or may be nominated by any other person or organization.

   The award winner is honored each year by the membership of the ATA Safety Mangement
Council at its National Conference & Exhibition in the Fall. The winner is announced at the Awards
Banquet and is presented with a $5,000 check and ring. The recipient is also honored with an award
plaque at ATA’s annual convention.

   In addition, please include a cover sheet listing the responsibilities of the person and reporting
structure of the company. Include your companies Safestat Scores as an attached exhibit; as well as
a recommendation and personal letter from the company president.

                                                    1
                   Corporate Organizational Chart
                               Section 1

Please include an Organizational Chart to your binder behind this page.




                                   2
                                            Nominee Information Sheet
                                                        Section 2

Name:


E-mail Address



Date of Birth:
      /           /

Current Company:


Current Company Address:


Telephone:                                                           Fax:
  (           )           -                              (       )     -

Home Address:


Social Security Number*:                                                    Ring Size:
          -           -


  * Social            Security number requested in order to present the winner with the award check and will
                                              remain strictly confidential.




                                                             3
                                 Employment History
                                         Section 3

              Please provide appropriate back up information where applicable.
List Current Position:
  Current Position                               Dates Held



List Current Employer:



Length of Time in Current Position:                    Number of Years in Safety:



Number of Years in Trucking:                           Number of Years with Overall
                                                       Safety Responsibility:



Provide a description of your company:



List of Previous Positions held with current company:
            Position                   Dates Held                   Supervisor




                                             4
List of Previous Employers and Positions Held:
 If more space is needed, please insert additional information in your binder.

                                                                                  Length of
         Employer                   Position Held                Supervisor        Service




Military Service:


                     Branch of Service                                    Dates Served




                                                   5
                                      Formal Education
                                             Section 4

Provide the following information for all non-safety related education:

                     High School                                  Dates              Graduation
                                                                 Attended               Year




            College/                          Degree              Dates              Graduation
        Technical School                     obtained            Attended               Year




Safety Curriculum: Provide the following information for all undergraduate and
postgraduate courses that contributed to your knowledge of the safety field:

           If more space is needed, please insert additional information in your binder.


                School                         Dates                   Course/Subject




                                                 6
                Fleet Accident Frequency for the Previous Five years
                                            Section 5

List your Accident Frequency Ratios:

      Year                Miles Traveled                All Accidents Frequency Ratio
      2008
      2007
      2006
      2005
      2004

Please provide the total number of units in your fleet:




Please provide the total number of drivers in your fleet:

   Total Drivers

Please provide the total number of terminals within your company:

   Total Terminals

Please provide the total annual mileage of your power units:

   City Miles
   Road Miles
   Total Miles

                 Please provide appropriate back up information where applicable.

                                                7
              Fleet Injury Frequency for the Previous Five Years
                                      Section 6


       Year              Number of Injuries           Fleet Injury Frequency Ratio
       2009

       2008

       2007

       2006

       2005

Please provide an explanation of your company’s overall fleet:




Please provide an explanation of your company’s safety department:




Please provide the total number of employees within your company:

Number of Employees:

Please provide the total number of hours worked by company employees in
2009:


Number of Hours Worked:

           Please provide appropriate back up information where applicable.




                                          8
                       Personal & Company Recognition
                                       Section 7

In the spaces provided, please list the past awards and recognition that you
or your company has received and the year in which it was presented (add
more lines as needed):

     Award or Recognition                Who presented the Award                  Year




Recognition Received as a Driver:

     Award or Recognition                Who presented the Award                  Year




         Please provide appropriate back up information to support your awards.

                                           9
                      Membership in Professional Organizations
                                             Section 8

Please provide a listing of current safety related organizations that you are
active in, including the dates that you have been active and offices held (if
applicable):

          If more space is needed, please insert additional information in your binder.

             Organization                     Years             Offices            Dates
                                              active             Held            Held Office




  Please provide appropriate back up information to support each Organization/Membership listed.


                                                10
     Safety Programs Designed, Developed and Implemented by Candidate
                                           Section 9

Please list all programs that were successfully designed, developed and
implemented by candidate and provide the page number for this particular
section that it appears on:

        Please provide appropriate supporting material in binder behind this page.
        If more space is needed, please insert additional information in your binder.

            Program                                Company                   Page number




                                              11
12
                                      Articles Published
                                            Section 10

List below each article written and published throughout your career.

   Please provide at least ten of those articles in binder behind this page.
   If more space is needed, please insert additional information in your binder.

               Article                       In-house or                 Publication
                Title                           public                    Printed In




                                                13
                                   Industry Presentations
                                            Section 11

As an industry representative, please list all presentations/lectures that you
have given in the industry.

   Please provide appropriate supporting documentation (i.e. conference program, letters of
    appreciation) in binder behind this page.
   If more space is needed, please insert additional information in your binder.

                                                                                Dates
       Presentation Subject                              Event                  Presented




                                                14
                   Attendance and Participation in Industry Events
                                            Section 12

As an industry representative, please list all presentations/lectures/conferen-
ces that you have attended in the industry.

   Please provide appropriate supporting documentation (i.e. conference program, letters of
    appreciation) in binder behind this page.
   If more space is needed, please insert additional information in your binder.

                             Conference/Event                                        Year




                                                15
                                  Check List
                                     Section 13

   Please ensure the following material is completed prior to submitting
                            nomination form.


Followed all directions precisely.

Submitted a cover sheet listing the responsibilities of the person and
reporting structure of the company.

Submitted information and materials in the order specified in the
application/nomination form.

The nomination packet is of a professional quality and appearance.

Safestat scores added to exhibit.

Presentation is no larger than the size of a 3’’ ring binder.

Recommendation and personal letter from the company president.

Deadline of July 1, 2010 met.




                                         16

								
To top