Safety Champion Nominations Form
Nominate an employee or team member who demonstrates outstanding commitment to safety awareness and safe practices. Please complete all sections below to help us recognize our Safety Champions.
Your Name
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First Name
Last Name
Your Email Address
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example@example.com
Nominee's Name
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First Name
Last Name
Nominee's Department or Team
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How would you rate the nominee's overall commitment to safety?
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1
2
3
4
5
Select the areas where the nominee has demonstrated exceptional safety practices.
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Identifying potential hazards
Encouraging safe behaviors in others
Reporting safety concerns promptly
Suggesting improvements to safety processes
Leading by example
Other
In your opinion, what impact has the nominee had on safety culture?
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Significant positive impact
Moderate positive impact
Some positive impact
Little to no impact
Please describe a specific example of how the nominee has promoted safety awareness or safe practices.
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Additional comments (optional)
Submit Nomination
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