Safety Award of Excellence Nomination

Home / Annual Meeting & Safety Awards Ceremony / Safety Award of Excellence Nomination

For over 100 years, Chesapeake Region Safety Council has served our community by educating and influencing people to prevent accidental injury and death. In 2023 we added a new award to our Annual Awards Ceremony, the “Saving a Life Award”. This award was created as a thank you to individuals who have applied their safety and health training in a life threating emergency to save a life.

Nominations Closed

Thank you to our 2026 Nominators!

Register as an attendee and join us on June 12, 2026

2027 Nominations Will Open Soon!

Please enable JavaScript in your browser to complete this form.

Company Information – Step 1 of 4

Section 1 Section 2.1

Safety Performance Data

Refer to your OSHA FORM 300A for items (a) through (h)

definition Safety (i)

(a) Total number of DEATHS

line G on the OSHA 300A

(b) Total number of CASES with days away from work

line H on the OSHA 300A

line i on the OSHA 300A

(d) Total number of OTHER RECORDABLE CASES

line J on the OSHA 300A

(e) Total number of DAYS away from work

line K on the OSHA 300A

(f) Total number of DAYS of job transfer or restriction

line L on the OSHA 300A

(g) Annual average number of employees

as entered in your OSHA 300A

(h) Total hours worked by all employees

as entered in your OSHA 300A

(i) Experience Modification Rate

EMR or “mod factor”– call insurance company

(j) For 3 PRIOR YEARS have you had any employee fatalities?

If yes, number: *

Section 2.2

Transportation

(k) # of miles driven without a preventable vehicle accident

Attach your organization definition of preventable vehicle accident

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

(l) Do you have an accident review committee?

(m) Do you operate under the CDL/DOT regulations?

(n) Area in which your vehicles operate:

(o) During the 3 PRIOR YEARS have you had any employee fatalities?

If yes, number: *

2025 OSHA 300A Summary Report

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

You must attach the 2025 OSHA 300A Summary report

Save and Resume Later

Section 3

Key Components Safety Program

This information is to be completed for all submissions
Provide a copy of your safety program index page and any additional supporting documents related to section 3 responses.

(a) Length of safety orientation for new employees

in minutes

(b) Toolbox safety talks frequency:

Daily
Weekly
Bi-weekly
Monthly
Other

Other: *

Type of Testing: *

(d) Employer Involvement:

(e) Employer Policy Statement on Safety:

(f) Responsibility for Safety:

(g) Safety Program Goal Setting:

(h) Employer Supervisory Meetings on Safety Issues:

(i) Pre-planning for Job Safety:

(j) Employee Participation:

(k) Safety Rules:

(l) Inspections:

(m) Supervisory Training Topics:

(n) Incident Investigation:

(o) Use of Personal Protective Equipment (PPE):

(p) Safety Program Performance Review:

Safety Program Index Page

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Provide a copy of your safety program index page and any additional supporting documents related to section 3 responses.

Save and Resume Later

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.

Save and Resume Later

Heads up! Saving your progress now will store a copy of your entry on this server and the site owner may have access to it. For security reasons, sensitive information such as credit cards and mailing addresses, along with file uploads will have to be re-entered when you resume.

Go Back

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Download a PDF Copy of the Nomination Form

Email the completed nomination form and supportive
documentation to safety@chesapeakesc.org.

Download PDF