2022 SOUTHERN OREGON OCCUPATIONAL SAFETY & HEALTH CONFERENCE ASSP Award Application

Safety Committee Recognition Award In Honor of ~ Frank J. Bertak

Best of the Best Safety Committee Award _

Section 1	Company Information

Company	Contact Person
Division	Number of Employees
Address	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 Recordable Injuries
300 A Summary	employees for the year	Times 200,000 / Exposure hours
2019
2020
2021

Section 3	Application Checklist

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

Attach 1-page type written summary describing specific accomplishments

Attach Copy of a Safety committee agenda

Attach a list of current safety committee members

Attach copies of safety committee minutes from past 12 months (July 2019 through June 2021)

Attach quarterly inspection findings for this same period. (You must have at least one inspection for each quarter of the year.)

Deadline: Applications must be received by August 26, 2022 at SAIF-Medford Office at 990 N. Phoenix Rd. Ste. 101, Medford, OR 97504 (Questions: David Hanson davhan@saif.com 541.857.4236 or Shyra Vaughn shyvau@saif.com (541)-857-4217) Incomplete Applications will not be accepted

Safety Committee Recognition Award

The Safety Committee Recognition Award identifies safety committees, its members and activities that have made a significant contribution towards the company’s overall success. Businesses of qualifying safety committees must not have experienced a fatality or catastrophic accident in the past twelve months prior to the award presentation.

Please submit a written summary of not more than one (1) type written page of safety committee accomplishments, and also include:

Example of the safety committee agenda

A list of current members

Copies of safety committee minutes from the past 12 months (July 1 to June 30)

Quarterly inspection findings from this same time period

Note: The safety committee minutes and inspection reports must meet the requirements of

OAR 437-001-0765 http://www.orosha.org/pdf/rules/division_1/437-001-0765.pdf

Best of the Best Safety Committee Award

One Safety Committee Recognition Award winner will be selected by the awards committee that demonstrates a superior safety committee effort during the award period. The Best of the Best Award will be given to the committee who outshines the rest in preventing harm to workers, promoting the cause of safety and health and making safety fun and engaging for all employees.

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

Awards Committee Notes:________________________________________________________

If you have questions or to arrange packet delivery: Shyra Vaughn shyvau@saif.com (541)-857-4217 Michael Hill michil@saif.com (541) 857-4229 or David Hanson davhan@saif.com (541)-857-4236 Deadline: Applications must be received by August 26, 2022 at SAIF, Medford Office at 990 N. Phoenix Rd. Ste. 101, Medford, OR Incomplete Applications will not be accepted _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________