Fields marked (*) are required

Contractor Name:*

Address:*

City:*      State:*      Zip Code:*

SIC/NAICSCode:*

Years Reported: (Report Last 3 years)	2007*	2006*	2005*
Total Site Hours Worked (in thousands) *
Number of: (From OSHA Log)
a. Fatalities *
b.(1) Lost Work Day Cases *
b.(2) Lost Work Day Rate *
c.(1) Total Recordable Cases *
c.(2) Total Recordable Rate *
d. Number of OSHA Citations *

Contractor:

Prepared By:*

Title:*

Phone:*       Fax:*

Email:*

President/CEO/Designee:*

Title:*

Phone:*       Fax:*

Email:*

Plant: (Owner Representative)

Complete Company Name:*

Representative Name:*

Title:*

Phone:*       Fax:*

Email:*

NOMINATION FORM - Part 1-B
(OWNER MEMBER MULTIPLE SITE HOURS - COMBINED)
(Separate application must be completed for GNOIEC & MGCSC Locations)

The following fields are optional and to be filled out only if you are applying for multiple sites:

Contractor Name:

Address:

City:      State:      Zip Code:

SIC/NAICSCode:

Years Reported: (Report Last 3 years)	2007	2006	2005
Total Site Hours Worked (in thousands)
Number of: (From OSHA Log)
a. Fatalities
b.(1) Lost Work Day Cases
b.(2) Lost Work Day Rate
c.(1) Total Recordable Cases
c.(2) Total Recordable Rate
d. Number of OSHA Citations

Contractor:

Prepared By:

Title:

Phone:       Fax:

Email:

President/CEO/Designee:

Title:

Phone:       Fax:

Email:

Owner Location 1:  
Owner Location 2:  
Owner Location 3:  
Owner Location 4:  
Owner Location 5:  
Owner Location 6:  
Owner Location 7:  
Owner Location 8:  
Owner Location 9:  
Owner Location 10:

NOTES:

• OWNER MEMBER assigned personnel Only (Omit headquarters and regional offices)
• If there are mitigating circumstances, please feel free to present details surrounding the case.
• OSHA Classification “Lost Workday Case - Away From Work”
• OSHA Total Recordable Injuries/Illness.

 ^ back to top ^

NOMINATION FORM  - PART 2 

Attach a general synopsis (limited to five (5) pages) of your Construction Safety Management Program and Policies/Procedures that address:

• Management accountability and commitment
• Written safety and health programs
• Orientation of new employees
• Site safety meetings
• Disciplinary action for unsafe work practices
• Safety work permit systems for hazardous areas/work & confined spaces
• Incident reporting/accident investigation & maintenance of accident statistics
• Program for monitoring subcontractor safety programs

**DO NOT ATTACH YOUR SAFETY MANUAL IN PLACE OF THE ABOVE GENERAL SYNOPSIS REQUIREMENT.


Safety Management Program Synopsis: *
(If you will be sending this in with the other required files, please type "sending with other files" in the field below)

^ back to top ^

Appendix 1

GNOIEC/MGCSC SAFETY AWARDS PROGRAM
GENERAL GUIDELINES

All nominations must be submitted to the GNOIEC Office by the March 7, 2008 DUE DATE.
(MUST BE RECEIVED AND COMPLETED TO BE CONSIDERED)

The Safety Awards Committee will evaluate nominations, to determine if contractor members are eligible to participate in the award program based on eligibility and criteria for nomination evaluation.

Contractors will only be nominated for one award classification, based on applicable SIC/NAICS Code listed in Appendix II, page 11 and OWNER MEMBER MULTIPLE SITE WORKHOURS COMBINED category.

In the event of a tie, nominees must ensure that the appropriate personnel are available for interviews at the time of the audit.   A list of current regional employees and nominating site employees must be provided prior to the scheduled audit date.  If time is not allocated the application becomes void.  If interview scheduling becomes a problem due to the audit schedule, additional time for these interviews may be granted.

Nomination audits will serve to validate the information supplied in the nomination form. The nomination site work hours and combined site work hour statistics for the multiple site categories will be checked... Key elements in the Contractors Safety Management program will be reviewed with the nominee. Pertinent records, documentation, program reviews and interviews will be used to substantiate the elements of the Contractors safety program. The audit will be conducted at the nominee work/worksites.

The audit format will be consistent for all applicants where applicable.

No final information regarding the Contractor Safety Excellence Award audits will be discussed with any contractors.  All findings are strictly reserved for the Contractor Safety Excellence Award Selection Committee.  Results will only be made with the announcement of the winners in each category at the Safety Excellence Awards Banquet on June 10, 2008.

^ back to top ^

Appendix 2

STANDARD INDUSTRIAL CLASSIFICATION (SIC)/
North American Industry Classification System (NAICS) CODES
Select the appropriate classification code for the type of work your company performs and insert the number (i.e., 15, 16, 17) or (236,237,238) into the SIC/NAICS Code space on the nomination form.

I hereby certify that all information submitted in this application is correct, and is submitted with the permission of all parties involved. *