Submit 2021 Safety Award

Company Name *

Contact Person *

Choose One Category *

Total Employee Hours Worked in 2021 *

Total number of lost time cases (days away from work) *

Experience Modification Rate *

Do you have a written safety policy? *

Yes No

Is your safety policy signed by the company principal? *

Yes No

Does your safety policy give all field employees authority to "shut down" a job or operation because of a hazard that presents an imminent danger to employees? *

Yes No

Does your company currently have a designated safety person? *

Yes No

Are the responsibilities of the safety person clearly defined in writing? *

Yes No

Does your company conduct jobsite safety reviews? *

Yes No

Are jobsite reviews documented? If so please upload a jobsite below at the end of this application. *

Yes No

Are all incidents investigated promptly? *

Yes No

Does your company have a near miss reporting program? *

Yes No

Are near misses investigated? *

Yes No

Does your company provide new hires with a written copy of the company's safety policy? *

Yes No

Does your company provide a description of employees' responsibilities for job safety? *

Yes No

Do you train your employee on proper use and care of PPE? *

Yes No

Do you provide employees with clear procedures on how to report incidents and injuries? If so, please provide a brief description on what your procedure is. *

Yes No

Procedure Comment Box *

What has your company done in the last 12 months to improve its safety program? Why do you think your company should win a 2021 AGC Safety Award? *

Upload OSHA 300A Summary Form *

Max file size: 20MB

Upload Jobsite Review *

Max file size: 20MB

Upload Safety Meeting Sign-In *

Max file size: 20MB

Upload EMR Letter from Insurance *

Max file size: 20MB

​2021 Safety Awards application

2021 Safety Awards application