Governor’s Safety and Health Award Application

Information

To ensure submission of your application, please review the following checklist of required information:

* Name of Establishment

* Address

* City

* State

* Zip Code

* Contact Person

* Email Address

Ex: example@kentucky.gov

* Phone

* Number of Employees as of January 1

Union Representative

Local #

North American Industrial Classification System (NAICS, if known), or Standard Industry Code (SIC)

* Product or Services

* Hours worked without experiencing lost time

Date of last lost time Incident

Ex: 2/8/2003

Serious citations issued from KYOSH Compliance in the last 24 months?

Yes

Date of last KY OSH Compliance Inspection

Ex: 2/8/2003

* Upload Annual 300 Log and 300A Summary

Allowable file types: doc, pdf. Max file size 4mb. Click UPLOAD after selecting files.

Upon approval, the following information will be utilized to plan your award presentation:

* Company name to be printed on certificate

Union(s) if applicable

* Preferred location of the award presentation

At The Establishment

At Governor’s Safety and Health Conference

More information at kshn.net

If at the establishment, please indicate the preferred date(s)

Ex: 1/10/2019

Preferred time of day to begin award ceremony

Ex: 1:00PM

Will there be a tour of the facility?

Yes

If yes, estimated ending time of tour

Ex: 2:00PM

* Have you received a Governor’s Safety Award in the past?

Yes

If yes, when?