"Job Applications in Northwest Indiana"
N W I B R T NORTHWEST INDIANA BUSINESS ROUNDTABLE (NWIBRT) 2009 SAFETY AWARDS APPLICATION Welcome to the 2009 Safety Award Application, We are looking forward to receiving your application and seeing you at this year’s banquet. There are several changes from last year’s application. We would like to specifically note the changes on page 6, which lists the criteria for the written portion of the application. However, be sure to read each page carefully. The Roger Walters Memorial Award was added in recognition of the life and work of Roger Walters. Please go to the end of this award application for full details on this award and the application process. Thank you and work safely, NWIBRT Safety Subcommittee 6 CRITERIA FOR APPLICATION EVALUATION 1. Submission of your three most recent Experience Modification Ratings (Submit a photocopy of your Insurance Company documentation to validate your application information.) If the photocopy of the Insurance Company documentation is not included, the application will not be accepted by NWIBRT). 2. Part 1: OSHA injury/illness (total cumulative for all locations) statistical data for the past 3 years. (Submit photocopies of the OSHA 300-A log summary sheets for the past 3 years to validate your application. If the photocopies of the summary sheets are not included, the application will not be accepted by NWIBRT). 3. Part 2: A typewritten synopsis of your safety management system (see page 6). (Parts #1 & #2 must be completed for consideration) 4. NWIBRT review of Applicant’s safety performance at NWIBRT sites. 5. Finalists are to be subject to a selected work site audit by NWIBRT. 6. Submit (2) two copies of the application packet. ELIGIBILITY 1. All subscribers to the Northwest Indiana Business Roundtable are eligible to participate. 2. Any company that experienced a work-related fatality in the past year will only be eligible for the Innovation and the Roger Walters Memorial Awards. 3. Subscriber dues must be up-to-date 1 AWARD CATEGORIES RECOGNITION 1. The Company’s (OSHA) Total Recordable Incident Rate and Days Away from Work (DAFW) must be below the most current national industry average for the company’s NAICS code as established by the Bureau of Labor Statistics. Those averages are: NAICS 238* NAICS 541* NAICS 236* NAICS 237* (Old SIC 17) (Old SIC 87) (Old SIC 15) (Old SIC 16) Days Away From Work (DAFW) 2.7 .5 2.1 2.2 Total Recordable Incident Rate 5.1 1.1 4.0 4.2 (TRIR) *Your NAICS code must reflect the majority of your work. For information regarding the SIC to NAICS code conversion refer to: http://www.naics.com/search.htm. Use the first 3 numbers of the NAICS code. Call Jim Arendas at CAF, 219-764-2883, if you have questions. 2. In addition, the company must have a continuously improved EMR for the last 3 years, or have an EMR of .9 or less for the past year. ACHIEVEMENT The Company must first meet the criteria for Recognition Level. 1. The company’s TRIR and DAFW Rate must be below the averages for our NWI Regional Contractor Community for the company’s NAICS code. This is determined by averaging the rates submitted during the annual statistics review of subscriber companies. 2. In addition, the company must have an EMR of .9 or less for the past year. 3. The company must demonstrate its safety management system by addressing the questions in Part 2 of the application. EXCELLENCE The Company must first meet the criteria for Achievement Level. 1. The company’s TRIR and DAFW as well as EMR must be below the averages of our NWI Regional Contractor Community for the company’s NAICS code. 2 ADDITIONAL AWARD CATEGORIES Progress Award Any subscriber can submit an application to be considered for this award. The company does not have to meet any of the criteria for the other award categories to submit an application for the Progress Award. The subscriber must show an improving DAFW and TRIR Rate for the past 3 years. If you are applying for this award, fill out Part 1 completely and Part 2 of this application to the best of your ability. Innovation Award NWIBRT Member Companies will have an opportunity to nominate a contractor that performs work on its site for this award, by submitting a letter describing the innovation. As a contractor (subscriber) you also have the opportunity to submit a letter explaining your innovative contribution that would qualify you for this award. Your company must have played a proactive role in developing a new safety initiative at that site. You must include a contact name and number for the Member Company that benefited from the innovation. Companies being considered do not have to meet any of the criteria for the other listed awards. Contractor of the Year Each contractor who meets the Excellence Award criteria will be considered for this award. One Contractor of the Year award will be presented. The winner will be selected by the NWIBRT Member Companies based on application evaluation, overall contributions to the safety culture in Northwest Indiana and open discussion among the Member Companies. Roger Walters Memorial Award This award will be presented to the safety representative that has demonstrated extraordinary contributions to the safety of the workers in Northwest Indiana. The last two pages of this application describe the award in detail along with the application process. 3 NAICS CODES The eligible NAICS Code Groups are listed below: Group #1: NAICS 238 (Old SIC 17) – Specialty Trade Contractors Group #2: NAICS 541 (Old SIC 87) – Professional, Scientific & Technical Services Group #3: NAICS 236 (Old SIC 15) – Construction of Buildings Group #4: NAICS 237 (Old SIC 16) – Heavy & Civil Engineering Construction Notes: Your NAICS code must reflect a majority of your work. For information regarding the SIC to NAICS code conversion refer to: http://www.naics.com/search.htm. Use the first 3 numbers of the NAICS code. Call Jim Arendas at CAF, 219-764-2883, if you have questions. 4 NWIBRT Part 1 SAFETY AWARDS APPLICATION COMPANY NAME: _____________________________________________________ ADDRESS: ___________________________________________________________ CITY: ____________________________ STATE: ____________ ZIP: ___________ TELEPHONE NUMBER: _______________ FAX NUMBER: _______________ NAICS Category: _______________________ (Refer to page 4 for NAICS Information) EMR Information: Submit Your Most Recent Three Years Workers Compensation Experience Modification Rates. **ATTACH COPIES OF INSURANCE COMPANY DOCUMENTATION. 2007 2008 2009 Interstate Experience Modification Rate OSHA 300 Log Information: **ATTACH COPIES OF OSHA 300 Log Summary Sheets. 2007 2007 2008 2008 2009 2009 NWI National* NWI National* NWI National* Total No. of Fatalities Total No. of Cases with Days Away From Work Total No. of Cases with Job Transfer/Restriction Total No. of Other Recordable Cases Total Hours Worked + DART Incident Rate Total Recordable Incident Rate Total Recordable Incident Rate (TRIR) = ^Number of cases x 200,000 hours of exposure Total Hours Worked * All awards based on local frequencies. National numbers for reference only (other than fatalities). +"DART" stands for "Days Away, Restricted or Transferred". A DART case is a subset of OSHA recordable cases where the injury/illness is severe enough that the individual loses time away from his/her job by being away from work, on restricted duty, or is transferred to another job function because of the injury. ^Number of cases is the total of the first 4 rows. Prepared By and Title (print): ________________________________________ Signature: ________________________________________ Date:__________ CEO/President (Signature): ________________________________________ CEO/President (Printed): ________________________________________ 5 NWIBRT Part 2 SAFETY AWARDS APPLICATION 1. NAICS Code (You Must Select 1) ______________ Description of Contractor work/service provided: 2. List three clients from the Business Roundtable Member Companies to contact for a reference of your safety practices and performance: Name(s) Company Telephone No Email 3. Provide a maximum of (5) five double-spaced typewritten pages describing your safety management system including the following criteria (do not include safety manuals, booklets, etc.): a. Management accountability and commitment (include statement or policy) b. Written safety and health programs (include who maintains the program within your organization) c. Orientation for new employees and on-going safety training for all employees (include how you determine the effectiveness of your training) d. Site safety meetings (include frequency, duration, who conducts, attends, and how meetings are documented) e. Conformance to safe work practices (include accountability for safe and unsafe behavior) f. Incident reporting/investigation & use of incident statistics to improve safety performance (include how the statistics are used) g. How unsafe conditions are reported and resolved h. New program innovations that you implemented in the last year to improve your safety culture and reduce injuries & illnesses 4. If your firm is selected as a finalist, who is to be contacted to arrange a work site audit? Name: ____________________________________ Title: _____________________________________ Phone Number: ____________________________ Email: ____________________________________ 6 Instructions for Filing Application Send completed applications to NWIBRT c/o Jim Arendas The Construction Advancement Foundation 6050 South Port Rd., Suite A Portage, IN 46368 NOTE: Submit (2) two copies of the application packet. All award applicants are required to complete the application in full for acceptance, and have the application signed off by the Chief Executive Officer or President of the contractor firm. Deadline for Filing Application Applications must be postmarked before midnight March 19, 2010 Questions Any questions about the application process can be directed to: Jim Arendas - Construction Advancement Foundation - 219-764-2883 The awards will be presented at the Annual Recognition Ceremony Dinner Banquet at the Avalon Banquet Facility on Friday May 14th, 2010. 7 ROGER WALTERS MEMORIAL AWARD N N W W I I B B R R T T In recognition of Roger's service and dedication to the field of safety the NWIBRT would like to introduce the First Annual Roger Walters Memorial Award. The award will be presented to the safety representative that has demonstrated extraordinary contributions to the safety of the workers in Northwest Indiana. We are not looking for a single great act but a person whose everyday diligence and dedication to their field creates a working environment that mirrors the slogan “Never Give Safety A Day Off”. Roger Walters took safety seriously. It was not just a job to him, it was his life. He felt responsible for those who worked under his care and helped out other safety representatives by correcting situations at their site or letting them know of problems. I am sure that there are people out there who owe their lives to him, because they had him looking out for their well being and safety. He spoke up, even when in difficult situations, because he couldn't just “let it go”. It was just not in his constitution to walk away with an unresolved situation. He was always honest and truthful and fair. He always took the time to talk things over and earned the respect of all those who worked with him over the years. He was always looking out for everyone. He was the one you could always count on to know the answer or who could direct you to the right source. And, he didn't stop with safety at work, he lived it every day, at home, when out with his family, on vacation, and really in everything he did. Just listening to his stories made it real, he made you feel like you were there, and that you too could have the dedication and courage to do the things he took for granted. He was a selfless champion and a hero and he will be missed. We ask that the company manager take careful consideration when nominating a safety representative from their company. The nominee must have at least 3 years experience and at least 50% of his/her job must be dedicated to safety. We also require that the nominee work 3 years for a company located in Northwest Indiana. The application must include one typed page describing why this safety representative should receive this award. We require that you include at least 3 recommendations from hourly employees. Feel free to include non-work related activities that you feel would be relevant (EMT, volunteer, etc.).The next page contains the application. We ask that you fill it out and return it with your Safety Awards Application. The use of the form is not required but make sure all necessary information is contained on any separate sheets. Thank You, NWIBRT Safety Sub-Committee 8 ROGER WALTERS MEMORIAL AWARD APPLICATION Company: __________________________ Address: __________________________ Contact Name: __________________________ Contact Title: __________________________ Contact Phone No: __________________________ Nominee Name: __________________________ Nominee Title: __________________________ Years of Service with Company: __________________________ Years of Service in the Safety Field: __________________________ Attach the following to complete the application: o (1) One typed page describing why this award should go to the nominee o (3) Three recommendations from hourly employees Please mail your nominee’s application to the following: NWIBRT c/o Jim Arendas The Construction Advancement Foundation 6050 South Port Rd., Suite A Portage, IN 46368 9