2020 Corporate Safety Award Application Form Step 1 of 4 25% Company Name*Contact Person* First Last Title*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone Number*Email* Year Established*Primary North American Industry Classification Code (NAICS)*When possible, please use at least a 4-digit NAICS code. For assistance in determining your NAICS code, visit: http://www.census.gov/eos/www/naics/Reporting as:*Entire Wisconsin OrganizationSeparate Division/Operations Unit 1. Were there any fatalities within your organization in 2020?*YesNoWisconsin organizations with any work-related fatality to any employees or temporary/contract employees in 2020 are excluded from the 2020 Corporate Safety Awards. Temporary/Contract EmployeesAverage Number of temporary/contract employees in 2020*Please enter a value greater than or equal to 0.Number of temporary/ contract employee hours worked*Please enter a value greater than or equal to 0.Number of temporary/contract employee recordable cases*Full Time Employees (whole numbers only) 2018 2019 2020 Average number of employees on Payroll in 2018*Please enter a value greater than or equal to 0.Average number of employees on Payroll in 2019*Please enter a value greater than or equal to 0.Average number of employees on Payroll in 2020*Please enter a value greater than or equal to 0.Total number of hours worked in 2018*Please enter a value greater than or equal to 0.Total number of hours worked in 2019*Please enter a value greater than or equal to 0.Total number of hours worked in 2020*Please enter a value greater than or equal to 0.[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.]Total number of recordable cases (from OSHA form 300): 2018 2019 2020 Column H (days away from work) 2018*Column H (days away from work) 2019*Column H (days away from work) 2020*Column I (job transfer or restriction) 2018*Please enter a value greater than or equal to 0.Column I (job transfer or restriction) 2019*Please enter a value greater than or equal to 0.Column I (job transfer or restriction) 2020*Please enter a value greater than or equal to 0.Column J (other recordable cases) 2018*Column J (other recordable cases) 2019*Column J (other recordable cases) 2020*Total Column (H, I and J) 2018*Total Column (H, I and J) 2019*Total Column (H, I and J) 2020*If your answer above to Column H (Days away from work) is zero, how far back does this record go?Date Hours WorkedPlease enter a value greater than or equal to 0.Incidence Rate (Recordable):Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2018)*Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2019)*Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2020)*Incidence Rate (Lost Workday Case):Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2018)*Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2019)*Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2020)*Severe Injury ReportingTotal Number of Worker Amputations in 2020*Please enter a value greater than or equal to 0.Total Number of Worker Loss of Eye Injuries in 2020*Please enter a value greater than or equal to 0.Total Number of Worker In-Patient Hospitalization in 2020*Please enter a value greater than or equal to 0.Did OSHA conduct a safety and health inspection at your location(s) in 2020?*YesNo I hereby certify that the information included in this application form is factual and accurate.* Agree Application Must be Received By Friday, Feb. 5, 2021 at 11:55AM.Completed by*NameThis field is for validation purposes and should be left unchanged.