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All information is required, unless otherwise indicated.
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Please enter the name of your company as it would be inscribed on an award.
IMPORTANT: If you are submitting more than one application (e.g. one for each of several different divisions in your company) please enter a distinct company/division name for each application you submit.
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Please select your Reporting Code. Select a Category first;
then select a Code.
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*Must have ten or more employees
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If you answered NO to the question above (i.e. you did NOT submit a Governor's Award Application 2021), you must enter data for ALL years below. If you answered YES to the question above (you did submit a Governor's Award Application 2021), you may skip 2020 and 2021 and enter data for 2022 only. (We have your prior data on file.)
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Governor's Safety Award Program Evaluation Scorecard
Please rank how well your organization implements the following elements of a safety program:
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We have a written general safety and health program with clearly defined goals and objectives, and we review it annually. |
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| 2. |
Our organization budgets adequately for safety, including training, communication, hazard abatement, equipment and other tools needed to provide a safe and healthy workplace. |
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Our employees understand and support our safety goals and objectives. |
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Executives and managers are invested in the safety program and held accountable for safety performance.
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We have tools that measure safety performance and employee attitudes and perceptions of safety. |
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Employees wear appropriate personal protective equipment. |
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Our safety committee reviews workplace injury and illness reports, conducts area inspections, identifies hazards and addresses safety concerns raised by employees, supervisors, safety staff and management. |
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Executives, managers and all employees are aware of the results of data analysis and we document how that information is used to prevent future incidents. |
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Trained employees identify frequent and high risk areas and jobs, and any exposures responsible for OSHA recordable cases. |
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Equipment, tools, machinery, etc., are repaired, serviced or replaced promptly. |
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Our employees participate in job safety observations of their co-workers and results are analyzed and shared for follow-up action. |
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Employees are instructed to report all incidents including near misses to their supervisor right away. |
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We have established procedures to investigate OSHA-recordable injury and property damage incidents. Identified hazards are reduced or eliminated promptly. |
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Injury and illness logs and exposure records are kept correctly, and we use significant analytical findings to develop our prevention efforts. |
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We determine root cause for incidents. |
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Workplace safety is a part of new-employee orientation and our employees understand that working safely is a condition of employment. |
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All of our managers receive training in safety and health management. |
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Our employees can explain what their role is in maintaining a safe and healthy workplace. |
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Our managers and executives know their role and model it. |
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We have written plans and safety programs for all applicable OSHA regulations and provide employee safety training. |
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Certification Full Name is required. certify that our head of management
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Head of Management Full Name is required.
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Head of Management Title is required. has reviewed this application and agrees with this evaluation. |
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Please enter contact information for the person who should receive mail notification if your company receives an award.
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E-mail is required.E-mail is in an invalid format.
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(include Area Code)
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(optional)
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If the person named above is YOU, skip this section.
If you are not the person named above, please enter your own contact information below.
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(include Area Code)
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E-mail is in an invalid format.
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