2021 SOUTHERN OREGON OCCUPATIONAL SAFETY & HEALTH CONFERENCE ASSP Award Application

Outstanding Safety & Health Program Award

In Honor of ~ Randall M. Lundberg

Section 1	Company Information

Company	Contact Person
Address	Number of Employees
North American Industrial Classification System Code
Phone	To Look Up NAICS Code: https://www.naics.com/search/
Email	Fax

Section 2	Injury and Illness Statistics

Provide Injury and Illness statistics for each year:

Year	Total Number of Recordable	Number of regular and	Incident Rate:
Injuries & Illnesses on OSHA	overtime hours for all	Equals Number of Recordables
300 A Summary	employees for the year	Times 200,000/Exposure hours
2020
2019
2018

Section 3	Application Checklist

Complete form Sections 1 & 2 by typing in each shaded field and printing

Type written summary describing specific accomplishments (See pg. 2 for topics)

Attach any Supporting Documentation relevant to an Outstanding Safety & Health Program.

If you have questions or to arrange packet delivery: David Hanson davhan@saif.com (541)-857-4236 Send your packets to: ASSP – Southern Oregon Chapter P.O. Box 1481 Medford, OR 97501-0110

Deadline: Applications must be received by August 27, 2021 at SAIF, Medford Office at 990 N. Phoenix Rd. Ste. 101, Medford, OR 97504. Incomplete Applications will not be accepted

Outstanding Safety & Health Program Award

In Honor of ~ Randall M. Lundberg

The Outstanding Safety & Health Program Award recognizes companies of all sizes that excel in addressing seven major elements of an effective occupational safety and health program along with an effective safety committee.

The company must demonstrate the effectiveness of their activities by showing how the company has systematically controlled hazards to reduce the risk of injury to employees. The company must not have experienced a fatality or catastrophic accident in the past twelve months prior to the award presentation.

Please submit a summary from one (1) to three (3) type written pages explaining the accomplishments of your company in addressing the elements of your safety and health program and fill out the information on the reverse side of the form and submit it to the Awards Selection Committee. The summary will be evaluated on your explanation and examples of success in these areas:

●	Management Commitment

●	Labor & Management Accountability

●	Employee Involvement

●	Hazard Identification and Effective Control

●	Periodic Plan Evaluation

●	Worker Training and Engagement

●	Incident / Accident Analysis, including root causes and recommendations

(Provide 3 of your most complete examples)

●	Successful Safety Committee Activities

If selected, a photo will be requested. Incomplete applications will not be accepted!

Awards Committee Notes:________________________________________________________

Deadline: Applications must be received by August 27, 2021 at SAIF, Medford Office at 990 N. Phoenix Rd. Ste. 101, Medford, OR 97504. Incomplete Applications will not be accepted If you have questions or to arrange packet delivery: David Hanson davhan@saif.com (541)-857-4236 Send your packets to: ASSP – Southern Oregon Chapter P.O. Box 1481 Medford, OR 97501-0110 ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________