Making our world a safer place.

22nd Annual Ozarks Corporate Safety Awards Application

The information will only be used by the sponsors and judges of the 2008 Ozarks Corporate Safety Award.

NORTH AMERICAN INDUSTRY CLASSIFICATIONS SYSTEM (NAICS)

Codes can be determined at the following U.S. Census Bureau site http://www.census.gov/epcd/naics02/

* denotes a required field
Full Name of Organization*
(will be inscribed on award certificate)
Contact Person *
Contac Person Title
Address*
City*
State*

Zip*
E-mail*
Telephone*
Fax
Year Established*
NAICS CODE *
Primary North American Industry Classification System Codes can be determined at the following U.S. Census Bureau site: http://www.census.gov/epcd/naics02/
Reporting As
You will need to mail or fax copies of your OSHA 300A for calendar years 2003, 2004, and 2005 with your application for purposes of verification and certification of the application.
  2005 2006 2007
1. Average number of employees on payroll
2. Total number of hours worked
[WH are the number of paid work hours for the calendar year (including office hours). PLEASE NOTE: Work hours (WH) are the actual payroll hours worked, excluding vacation and holidays. You must include all full-time, part-time, seasonal and temporary employees that work under your organization’s supervision.]
3. Total number or recordable cases _ _ _
(Count the total number of cases on your OSHA Form 300. Add columns H through J.)
4. Total number of cases involving days away from work
(Total of column H of OSHA 300.)
5. Total Case Injury and Illness Rate (TCIIR):
TCIIR = Enter line 3 (above) x 200,000 = Rate
                  Enter Line 2
6. TCIIR Rates for your NAICC Code for each year*
7. Days Away Case Rate (DACR)
DACR: Enter Line 4 (above) x 200,000 = Rate
                   Enter Line 2
8. DACR Rates for your NAICS Code for each year*
* Note on expanded data on the Internet: BLS has released two new web-based tools for analyzing occupational injury and illness data. Employers can compute their own injury and illness incidence rate for safety management purposes and compare their rate to their industry rate by visiting http://data.bls.gov/IIRC/.

* A second web tool, Profiles on the Web, allows anyone to access injury and illness data by industry, demographic characteristics, and case characteristics by visiting http://data.bls.gov/GQT/servlet/InitialPage.

9. Workers Compensation Mod rate
Experience modification rate MUST be provided. Even self-insured groups can get their experience. Modification rate by faxing a letter on company letterhead to NCCI.
Form Completed By
Name *
Title *

I hereby certify that the information included in this application form is factual and accurate.