Workplace Safety Award Application Form

Workplace Safety Award

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Step 1 of 4

Company Name(Required)

Contact Person(Required)

First Last

Title

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Year Established(Required)

Primary North American Industry Classification Code(Required)

PLEASE use SIX digit NAICS code; four digit is acceptable. (do not submit SIC code). For assistance in determining your NAICS code, visit: https://www.census.gov/naics/

Reporting as(Required)

Entire Wisconsin Organization

NEW! ONE Separate Division/Operations Unit

AGAIN THIS YEAR! If reporting separate division/operating unit, you may only apply with 1 division (not multiple divisions/units).

Temporary/Contract Employees

Average Number of temporary/contract employees in 2025(Required)

Please enter a value greater than or equal to 0.

Number of temporary/contract employee hours worked(Required)

Please enter a value greater than or equal to 0.

Number of temporary/contract employee recordable cases(Required)

Please enter a value greater than or equal to 0.

Full Time Employees (whole numbers only)

2023

2024

2025

Average number of employees on Payroll in 2023(Required)

Please enter a value greater than or equal to 0.

Average number of employees on Payroll in 2024(Required)

Please enter a value greater than or equal to 0.

Average number of employees on Payroll in 2025(Required)

Please enter a value greater than or equal to 0.

Total number of hours worked in 2023(Required)

Please enter a value greater than or equal to 0.

Total number of hours worked in 2024(Required)

Please enter a value greater than or equal to 0.

Total number of hours worked in 2025(Required)

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):

2023

2024

2025

Column H (days away from work) 2023(Required)

Column H (days away from work) 2024(Required)

Column H (days away from work) 2025(Required)

Column I (job transfer or restriction) 2023(Required)

Please enter a value greater than or equal to 0.

Column I (job transfer or restriction) 2024(Required)

Please enter a value greater than or equal to 0.

Column I (job transfer or restriction) 2025(Required)

Please enter a value greater than or equal to 0.

Column J (other recordable cases) 2023(Required)

Please enter a value greater than or equal to 0.

Column J (other recordable cases) 2024(Required)

Please enter a value greater than or equal to 0.

Column J (other recordable cases) 2025(Required)

Please enter a value greater than or equal to 0.

Total Column (H, I and J) 2023(Required)

Total Column (H, I and J) 2024(Required)

Total Column (H, I and J) 2025(Required)

Incidence Rate (Recordable):

Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2023)(Required)

Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2024)(Required)

Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2025)(Required)

Incidence Rate (Lost Workday Case):

Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2023)(Required)

Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2024)(Required)

Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2025)(Required)

Brief description of job tasks performed at your location.*(Required)

Why do you feel you should move on to Phase II?

Application Must be Received By Monday, Feb. 2, 2026 at 11:55AM.