The annual awards competition is sponsored by:

Awards20th Annual

Wisconsin Corporate Safety

2013 Application Form

www.wisafetycouncil.org

Celebrating Safety in Wisconsin

2013 Award TimelineApplication Forms Available: December 2013

Applications Deadline: Phase I: Statistical Data January 24, 2014

Finalists Notified: February 10, 2014

Phase II: Subjective Report February 28, 2014

Winners Notified: March 28, 2014

Awards Presented: April 29 & 30, 2014 Awards presented during the 72nd Annual Wisconsin Safety and Health Conference & Expo in Wisconsin Dells

The Awards Program is sponsored by:

Friends,

This year marks the 20th anniversary of the prestigious annual Wisconsin Corporate Safety Awards program; co-sponsored by the Wisconsin Safety Council and the Wisconsin Department of Workforce Development. This is an extraordinary opportunity for your organization to be acknowledged as a leader in the safety industry for unparalleled standards and efforts.

By participating in a joint effort with other Wisconsin employers, and sharing successful methods and programs with fellow Wisconsin workers, our great state will continue to be a desirable, safe and successful place in which to live and conduct business. I encourage you to apply for this respected award using the enclosed application. Presentations to celebrate these awards will be held on April 29 & 30, 2014.

As Governor of the state of Wisconsin, it is my privilege to honor those companies that make it a priority to ensure the safety of each member of our Wisconsin workforce every single day.

If you have questions regarding the Wisconsin Corporate Safety Awards program, please contact Janie Ritter, jritter@wisafetycouncil.org or (800) 236-3400.

Help Wisconsin’s economy continue on its path to growth and success by upholding the highest of safety standards.

Sincerely,

Scott Walker Governor

Honoring Wisconsin Employers Achieving Safety and Health Excellence

Special Awards

Special Awards may be awarded to companies experiencing a long history of zero lost time incidents.

These special award winners will be announced at the conference on April 29 & 30, 2014.

BenchmarkThe process of applying requires your organization to benchmark where you

have been, where you are, and where you are headed. It can be used as an opportunity to evaluate your current

situation, your prospects, and progress.

PrestigeOrganizations winning awards have been the subject of well-deserved press coverage in their local communities, as well as in statewide newspapers and business magazines. Award winners have used the Corporate Safety Award to promote their organization and products in their internal communication, marketing materials, websites, sales presentations, and publicity.

Morale BoosterMany winners of these awards cite their workers as deserving the majority of the credit for the award. Many winning organizations use the award as an opportunity to show appreciation to their associates for a job well done.

Why Apply?

Application Deadline: January 24, 2014

Application forms and past recipients can be found on our website: www.wisafetycouncil.org (Safety Award Programs)

Finalists announced: February 10, 2014

The list of finalists will be reviewed by OSHA and DWD.

EligibilityApplicants must be headquartered in Wisconsin or have a permanent physical facility with Wisconsin management.All applications submitted must pertain only to the corporation’s Wisconsin payroll. Divisions of corporations may submit a separate application for their facility if they can certify that:

• They operate in a separate location, and• Have a distinct line of business identity for the

division, and• Are managed independently from other

divisions of their corporate parent for safety and loss control (i.e., independent procedures and programs for safety).

• Multiple submissions from the same organization must be written locally. Multiple submissions will be reviewed for duplication and may be considered as one application.

• Finalists’ history of regulatory compliance will be reviewed by OSHA and DWD covering the award year, as part of Phase II.

ExclusionsWisconsin organizations with any work-related fatality to one of your employees, or have accepted a willful violation in 2013, are excluded from the 2013 Corporate Safety Awards.

AwardsThe 2013 Wisconsin Corporate Safety Awards will be based on size of organization AND type of organization. All award finalists receive a finalist certificate and publicity; those with zero incidence rates will receive certificates.

A. Size of OrganizationsSize is based on actual 2013 payroll hours (calendar year) which include office hours, but excludes vacation and holidays. You must include all full-time, part-time, seasonal and temporary contract employees who work under your organization’s supervision.

B. Types of OrganizationsCategory A: Manufacturing - NAICS Codes 31-33 Category B: Agricultural, Forestry, Transportation, Mining and Utilities - NAICS Codes 11-22Category C: Construction - NAICS Code 23Category D: Other/Public Agencies - NAICS Codes 42-92For assistance in determining your NAICS code, visit the Census Bureau NAICS webpage.

The 2013 Wisconsin Corporate Safety Awards are based on two phases: statistical data and subjective questions.

Phase I: Statistical Data Due Jan. 24, 2014Awards are first judged based upon the organization’s incidence rates for the complete calendar years: 2011, 2012 and 2013 (primary consideration will be given to the 2013 recordable and lost workday incidence rates).Note: Applicants will be notified by February 10, 2014 whether or not they are finalists and thus asked to participate in Phase II of the awards process. Finalists’ history of regulatory compliance will be reviewed by OSHA and DWD covering the award year, as part of Phase II.

Phase II: Subjective QuestionsDue Feb. 28, 2014Questions will be asked only to finalists in each category. Possible subjective topics that may be asked to finalists could include:

• Leadership and Participation • Safety and Health Program Implementation • Safety and Health Training • Goals and Successes

Awards PresentationAwards will be presented at the Wisconsin Safety Council’s 72nd Annual Wisconsin Safety & Health Conference/Exposition, April 29 & 30, 2014 in Wisconsin Dells. Along with the awards, the Wisconsin Safety Council will celebrate the 13th inductee into the Wisconsin Safety Hall of Fame, and the Lifetime Achievement Award winner.

JudgesA panel of safety and health professionals has been assembled to judge application papers.

ApplicationsApplication forms should be sent to: Wisconsin Safety Council, ATTN: Wisconsin Corporate Safety Award, PO Box 352, Madison, WI 53701-0352, or fax to (608) 258-3413, email jritter@wisafetycouncil.org, or apply online at www.wisafetycouncil.org.

Important Due DatesPhase I applications must be received no later than Friday, January 24, 2014.

Phase II applications must be received no later than Friday, February 28, 2014

Applications Must Be Submitted By January 24, 2014.The application form i can be found online at www.wisafetycouncil.org

2013 Wisconsin Corporate Safety Awards

2013

2013 Wisconsin Corporate Safety Awards

Phase I — Statistical Data Form

APPLICATION MUST BE RECEIVED BY FRIDAY, JANUARY 24, 2014.

1. Worker fatalities in 2013 (see eligibility section) 2. Average number of temporary/contract employees in 2013 2a. Number of temporary/contract employee hours worked 2b. Number of temporary/contract employee recordable cases

Temporary/Contract employees are defined as individuals who are under the direct supervision of the applying company.

3. Average number of employees on payroll _______ ______ _______4. Total number of hours worked _______ ______ _______

[Work Hours (WH) are the number of paid work hours for the calendar year (including office hours). PLEASE NOTE: WH are the actual payroll hours worked, excluding vacation and holidays. You must include all full-time, part-time, seasonal and temporary/contract employees that work under your organization’s supervision.]

5. Total number of recordable cases (from OSHA form 300) 5a. Column H (days away from work) _______ ______ _______ 5b. Column I (job transfer or restriction) _______ ______ _______ 5c. Column J (other recordable cases) _______ ______ _______ 5d. Total Column (H, I and J) _______ ______ _______6. If your answer to question #5a is zero, how far back does this record go? Date_____________________ Hours worked________________

INCIDENCE RATE: Enter Line 5d (above) x 200,000 = Rate ________ _______ _______ (RECORDABLE) Enter Line 4

INCIDENCE RATE: Enter Line 5a (above) x 200,000 = Rate _______ _______ ________ (LOST WORKDAY CASE) Enter Line 4

I hereby certify that the information included in this application form is factual and accurate.Completed by: ______________________________________________________________ (Please print or type name and title)

Company Name ______________________________________________________________Contact Person ____________________________Title _______________________________Street Address _________________________________________________________________Mailing Address _______________________________________________________________City __________________________________ State ______ Zip Code ___________________Phone Number _________________________ Fax Number __________________________E-mail ______________________________________________ Year Established __________Primary North American Industry Classification Code (NAICS) (see list online) ___________Reporting as: Entire WI Organization Separate Division/Operations Unit (see eligibility section)

The information provided will only be used by the Wisconsin Safety Council.

Send to: WISCONSIN SAFETY COUNCIL ATTN: Wisconsin Corporate Safety Award PO Box 352, Madison, WI 53701-0352 FAX: (608) 258-3413 Email: jritter@wisafetycouncil.org

Submit an application online www.wisafetycouncil.org

20122011

(yes or no)