Workplace Safety Innovation Award Nomination Form
Nominate an individual, team, or organization for outstanding contributions to workplace safety innovation.
Nominee Information
Please provide details about the person, team, or organization being nominated.
Full Name of Nominee (or Team/Organization Name)
*
First Name
Last Name
Nominee's Job Title or Role
*
Nominee's Organization/Company
*
Nominee's Email Address
*
example@example.com
Nominee's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Nominator Information
Please provide your details as the person submitting this nomination.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Relationship to the Nominee
*
Please Select
Colleague
Supervisor/Manager
Direct Report
HR/Health & Safety Officer
Other
Innovation Details
Describe the workplace safety innovation and its impact.
Title of the Innovation/Initiative
*
Describe the workplace safety innovation, including the problem it addresses, the solution implemented, and any unique features.
*
What were the results or impact of this innovation? (e.g., improved safety, reduced incidents, increased awareness)
*
When was this innovation implemented?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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of
Evaluation (for review panel only): Please rate the following aspects of the innovation.
Rows
Originality/Creativity
Impact on Safety
Sustainability/Long-term Effect
Scalability/Applicability
Excellent
1
2
3
4
Good
5
6
7
8
Satisfactory
9
10
11
12
Needs Improvement
13
14
15
16
Submit Nomination
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