ASSP Award Nomination Form 2022 SOUTHERN OREGON OCCUPATIONAL SAFETY & HEALTH CONFERENCE

Safety Committee Champion Award .

Section 1	Submitter Information

Please share information about yourself, how you know the safety committee member being nominated:

Company	Name
Address	Relation to Business Leader Nominated
Phone	Your Title
Email	Fax

Section 2	Nominee Information

Please provide information about the safety committee member that you are nominating for this award:

Company	Name
Address	Job Title
Role on the Committee	Areas of Responsibility Within Company
Email

If you have questions or to arrange packet delivery: David Hanson davhan@saif.com (541)-857-4236 Shyra Vaughn shyvau@saif.com (541)-857-9692 Send your packets to: ASSP – Southern Oregon Chapter P.O. Box 1481 Medford, OR 97501-0110

Deadline: Applications must be received by August 26, 2022 at SAIF, Medford Office at 990 N. Phoenix Rd. Ste. 101, Medford, OR 97504. Incomplete Applications will not be accepted

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Safety Committee Champion Award.

Section 3	Application Checklist

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

Type written summary below describing specific accomplishments or on separate page as needed

Attach any Supporting Documentation

The Safety Committee Champion Award recognizes a safety committee member who has demonstrated an outstanding commitment to safety and health. This nomination will show how this cooperative member is a true champion for safety in their organization going above and beyond the minimum requirements based on a caring to keep coworkers safe. This nomination should explain the specific work performed and accomplishments this champion has realized.

Written Summary (Or attach a separate page as needed):

Persons eligible for this award may not be a senior manager or executive in the organization.

This award will be evaluated annually and presented on merit.

If selected, a photo will be requested.

Awards Committee Notes:________________________________________________________

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 If you have questions or to arrange packet delivery: David Hanson davhan@saif.com (541)-857-4236 Shyra Vaughn shyvau@saif.com (541)-857-9692 Send your packets to: ASSP – Southern Oregon Chapter P.O. Box 1481 Medford, OR 97501-0110 _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________