2017 Safety Awards Program Entry Form

Instructions

Entries for the NCMA/ICPI Safety Awards program must be received no later than March 16, 2017. Multiple facilities may be listed on this form for ease of entry. If additional entries are needed, please fill in the available fields below and submit; then fill out an additional entry form. There is NO ENTRY FEE and no need to submit additional documentation at this time other than this form. Fees will be charged only for those companies wishing to receive an award plaque for those award(s) for which they are eligible. The Safety Representative listed on this form will be notified by April 3, 2017 of awards won with the option to purchase physical awards/plaques. Confirmation of plaque(s) purchase must be received no later than April 17, 2017. Program guidelines are available on our website (www.ncma.org). If you have any questions in the submission process, please contact Ella Krupa at ekrupa@ncma.org or 703-713-1900.

Question Title

* 1. Company Information:

Name of Safety Representative *

Name of Company *

Safety Representative Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Safety Representative Email Address *

Safety Representative Phone Number *

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* 2. How many facilities are being entered?

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* 3. Facility #1

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 4. Facility #2

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 5. Facility #3

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 6. Facility #4

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 7. Facility #5

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 8. Facility #6

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 9. Facility #7

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 10. Facility #8

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 11. Facility #9

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 12. Facility #10

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 13. Facility #11

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 14. Facility #12

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 15. Facility #13

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 16. Facility #14

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

Question Title

* 17. Facility #15

Facility Name:

Street Address, City, State, Zip:

Total Number of Hours Worked (All Personnel):

Total Number of Recordable Injuries/Illnesses (Sum of G, H, I and J on OSHA 300A):

Total Number of Cases of Days Away from Work (H on OSHA 300A):

Total Number of Cases of Job Transfer or Restriction (I on OSHA 300A):

Total Number of Deaths (G on OSHA 300A):

If for Milestone, Enter the Number of Consecutive Years Without Incident:

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* 18. Please Select Your Membership Category:

NCMA Producer

ICPI Producer

NCMA Associate

ICPI Associate

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* 19. I am interested in receiving an award plaque for eligible facilities. You will be contacted separately with additional information and an order form.

Yes

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* 20. Please specify where you would like the plaques to be shipped:

Only the Safety Representative's address

Ship each award to the individual plant addresses provided above

Other (please specify)

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* 21. I acknowledge that NCMA reserves the right to require additional documentation to verify information submitted. (Such as OSHA 300 Logs or Canadian Equivalent)

Yes

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* 22. By typing your name and entering the date below, I certify that the information provided on this form is true and accurate.

Signature:

Date: