Safety Awards

Safety Awards
General Information
Facility Type: *

Water TreatmentWater Distribution SystemWastewater TreatmentWastewater Collection System
Facility Name:*
Facility Owner: *
Please enter the official and exact name of the facility and its owner as you would like it to appear on the award. The information provided may be used directly for award printing, so ensure accuracy by using the official names. Any variations or typos in the entered names may be reflected on the award.
Facility Grade(s):*
Large or Small System:

Large (> 1MGD)Small (< 1MGD)
Safety Contact Person: *
Address:*
Phone:*
Fax:*
Email:*
Safety Program Information
Does your facility have a formal safety program? Only Facilities with formal written Safety Programs are eligible for an Award.*

YesNo
Does your facility have a safety committee?*

YesNo
Does your facility have a designated safety officer/representative?*

YesNo
Does your facility have a safety awards program?*

YesNo
Does your facility have a formal program for disciplinary action of safety infractions?*

YesNo
Does your facility have a formal training program for safety related topics?*

YesNo
Does your facility conduct routine inspections to identify safety concerns?*

YesNo
Does your facility have a working relationship with the local emergency service agency?*

YesNo
Additional Comments:
Safe Work Practice Information (Applies to Full Calendar Year)
Number of full time employees:
Number of full time employees:*
Number of part time employees Type "0" if applicable:
Number of part time employees Type "0" if not applicable: *
Man-Hours per year for part time employees Type "0" if not applicable:
Man-Hours per year for part time employees Type "0" if not applicable: *
Number of accidents that resulted in time off or restricted duty:
Number of work days lost, include restricted duty :
Number of work days lost, include restricted duty Type "0" if not Applicable: *
Number of treated injuries with ZERO lost workdays:
Disclaimer
By submitting the information in this entry form, you are certifying the following:

All information in this application is true and honest

Permission for the AZ Water Association Awards Committee to share the application materials for the purposes of selecting an award recipient

Please take the time to verify that all submitted information is correct.

A printable copy of the information submitted is available upon completion of the online form.
Should be Empty:

Safety Awards

General Information

Safety Program Information

Safe Work Practice Information (Applies to Full Calendar Year)

Disclaimer