Worker SAFEty Award Nomination Form

This award goes to an individual who is committed to safe work and is not a safety professional. Your nominee should be a safety champion who goes above and beyond to make others aware of workplace safety and health. Nominees should strive every day to make their workplace safer for themselves and their co-workers.

Nominations for the Worker SAFEty Award will be accepted from any other individual in the same workplace.

Please complete the following form to nominate a workplace for the Worker SAFEty Award.

Worker SAFEty Award Nomination Form

"*" indicates required fields

Who are you nominating?

First name*

Last name*

Job position*

Workplace name*

Workplace address*

City*

Postal code*

Phone number*

Email*

Nominator information:

First name*

Last name*

Job position*

Workplace name*

Workplace address*

City*

Postal code*

Phone number*

Email*

Why are you nominating this workplace for a Worker SAFEty Award?

Please answer these four questions to show how this individual meets the requirements for this award.

What has this worker accomplished to earn a nomination for the Worker SAFEty Award?*

(max. 200 words)

How does the nominee go above and beyond to improve safety and health in the workplace? Please provide at least one example.*

(max. 200 words)

How do co-workers and/or clients benefit from the nominee's commitment to safety and health? Please give at least one example.*

(max. 200 words)

How does this individual help ensure that safety and health activities in the workplace are carried out consistently and will be in place for years to come?*

(max. 200 words)

Worker SAFEty Award Nomination Form