Safety Awards

Safety Awards
General Information
Facility Type: *

Water Treatment Water Distribution System Wastewater Treatment Wastewater Collection System
Facility Name and Owner: *
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? *

Yes No
Does your facility have a safety committee? *

Yes No
Does your facility have a designated safety officer/representative? *

Yes No
Does your facility have a safety awards program? *

Yes No
Does your facility have a formal program for disciplinary action of safety infractions? *

Yes No
Does your facility have a formal training program for safety related topics? *

Yes No
Does your facility conduct routine inspections to identify safety concerns? *

Yes No
Does your facility have a working relationship with the local emergency service agency? *

Yes No
Additional Comments:
Safe Work Practice Information (Applies to Full Calendar Year)
Number of full time employees:
Number of part time employees (if any please answer next question):
Man-Hours per year for part time employees :
Number of accidents that resulted in time off or restricted duty:
Number of work days lost, include restricted duty :
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