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Governor's Award Application for Year 2022
All information is required, unless otherwise indicated.
 Company Information

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.

Please select your Reporting Code. Select a Category first; then select a Code.

*Must have ten or more employees
Did you submit a Governor's Award Application for 2021 to the South Dakota Safety Council last year?      
 Reporting Data
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.)
      2020 2021 2022
1.   Average number of employees on your payroll           

2.   Total number of hours worked           

3.   Total number of recordable cases (Count the total number of cases on your OSHA form 300)           

4.   Count number of cases with column H or I checked on Form 300 (These are D.A.R.T. cases, ie, cases with Days Away, Restrictions, and/or Transfers)           

5.   Total number of fatal incidents/amputations in entire organization         

6.   Date (mm/dd/yy) of last incident involving day(s) away from work (NOT restricted work activity)         

7.   Has this reporting entity received citations/fines for willful/repeat violations within the last three years?     

Governor's Safety Award Program Evaluation Scorecard
Please rank how well your organization implements the following elements of a safety program:

  Responsibilities and Accountabilities  
5 = Extremely well · 4 = Very well · 3 = Moderately well · 2 = Somewhat well · 1 = Not well · 0 = Not part of our program
1. We have a written general safety and health program with clearly defined goals and objectives, and we review it annually.
2. Our organization budgets adequately for safety, including training, communication, hazard abatement, equipment and other tools needed to provide a safe and healthy workplace.
3. Our employees understand and support our safety goals and objectives.
4. Executives and managers are invested in the safety program and held accountable for safety performance.
5. We have tools that measure safety performance and employee attitudes and perceptions of safety.
  Identifying, Controlling and Analyzing Hazards  
5 = Extremely well · 4 = Very well · 3 = Moderately well · 2 = Somewhat well · 1 = Not well · 0 = Not part of our program
1. Employees wear appropriate personal protective equipment.
2. 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.
3. 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.
4. Trained employees identify frequent and high risk areas and jobs, and any exposures responsible for OSHA recordable cases.
5. Equipment, tools, machinery, etc., are repaired, serviced or replaced promptly.
6. Our employees participate in job safety observations of their co-workers and results are analyzed and shared for follow-up action.
  Incident Investigation  
5 = Extremely well · 4 = Very well · 3 = Moderately well · 2 = Somewhat well · 1 = Not well · 0 = Not part of our program
1. Employees are instructed to report all incidents including near misses to their supervisor right away.
2. We have established procedures to investigate OSHA-recordable injury and property damage incidents. Identified hazards are reduced or eliminated promptly.
3. Injury and illness logs and exposure records are kept correctly, and we use significant analytical findings to develop our prevention efforts.
4. We determine root cause for incidents.
  Communication and Training  
5 = Extremely well · 4 = Very well · 3 = Moderately well · 2 = Somewhat well · 1 = Not well · 0 = Not part of our program
1. Workplace safety is a part of new-employee orientation and our employees understand that working safely is a condition of employment.
2. All of our managers receive training in safety and health management.
3. Our employees can explain what their role is in maintaining a safe and healthy workplace.
4. Our managers and executives know their role and model it.
5. We have written plans and safety programs for all applicable OSHA regulations and provide employee safety training.
I Certification Full Name is required. certify that our head of management , Head of Management Full Name is required. , Head of Management Title is required. has reviewed this application and agrees with this evaluation.
 Reported By
Please enter contact information for the person who should receive mail notification if your company receives an award.


E-mail is required.E-mail is in an invalid format.
(include Area Code)

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.

(include Area Code)

E-mail is in an invalid format.

Contact the South Dakota Safety Council at
or phone 605-361-7785 or 1-800-952-5539.