Employee Health & Safety Recognition Program Nomination - 09/10

1. Nomination Form Instructions & Questions

Do you know a school district employee who has inspired or led others to be healthier or safer? Please let us know by taking a moment to complete the nomination form below. Examples of behaviors this employee may exhibit include:

-Consistently models healthy and safe behaviors both within
and outside of the workplace.

-Motivates other school district employees/students to
adopt healthy and safe practices in their daily lives.

-Demonstrates a personal commitment to health and safety.

-Advocates for employee health and/or safety programs within the workplace.

-Actively involved in initiating/coordinating an employee health and/or safety activity program at the workplace.

Nomination deadline: 5 PM on Wednesday, April 1, 2010

Question Title

1. (Required)

Person Making Nomination:

District:

Phone Number:

Email Address:

Question Title

2. (Required)

Nominee Name:

District:

Phone Number:

Email Address:

Question Title

3. Describe the nominee's contributions or achievements to employee health and safety efforts within the school district.

Thank you for taking the time to nominate this individual! CCCSIG will review the nominees and select the award recipients. Award recipients will be notified by April 15, 2010 and will be featured (with permission) in the May edition of Crossroads newsletter and on the CCCSIG website.

Any questions related to this nomination or the selection procedure should be directed to Abbie O'Toole at aotoole@cccsig.org.