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2018 JOINT POULTRY INDUSTRY SAFETY AWARD

Application Questionnaire

Section 1 - General Information

1.Company:

FacilityName:

Address:

City/State/ZIP:

2.Facility Name and Location as you would like it to appear on award (ex., ABC Poultry Company, Ajax AL Feed Mill):

3.Person Completing this Application:

Name:

Position/ Title:

Company:

Street:

City/State/ZIP:

Phone:

Email:

4.Type of Facility:

Broiler Processing TurkeyProcessing Hen Processing

Further Processing Egg Production /Processing Hatchery

Rendering Feed Mill

5.Has this facility been recognized for any other safety and health awards in the last three years?

Yes No

If yes, please identify the award sponsor and nature of award(s):

Section 2 - Occupational Injury and Illness rates

Instructions

Obtain data from OSHA 300 Logs for the years 2015-2017. Prior years’ data must be provided in order to evaluate your facility for all possible awards. However, if this facility was recently opened, enter data beginning with the first complete calendar year of operation.

Note: If there has been arecordable workplace fatalityduring 2015-2017, the facility is ineligible for award consideration.

Complete the appropriate Injury Illness Spreadsheet for the type of facility:

2018 Poultry Slaughter & Further Processing Injury & Illness Rates

2018 Feed Manufacturing Injury & Illness Rates

2018 Egg Processing & Hatchery Injury & Illness Rates

2018 Rendering Injury & Illness Rates

  1. Enter the identifying facility data (name, address, etc.)
  2. Enter the Annual Employee Hours in the yellow blocks in the spreadsheet
  3. Enter the following data directly from the OSHA 300 log in the yellow blocks in the spreadsheet for years 2017, 2016 and 2015:
  1. Fatalities: (Directly from OSHA 300 Log Column G)
  2. Total Recordable Cases:(directly from OSHA 300 Log Columns G+H+I+J)
  3. Days Away, Restricted, Transfer: (directly from OSHA 300 Log Columns H+I)

See example:

If there has been a recordable workplace fatality or if a Total Recordable or DART rate exceeds the industry average over the last three years, you will receive an instruction to STOP. This facility will not meet the requirements to qualify for award consideration. Do not proceed to complete Section 3 of the application.

If all Responses indicate Proceed, SAVE the spreadsheet and PROCEED to complete the narrative responses in Section 3. You will submit the spreadsheet as part of your application.

Section 3 - Narrative Response

Please attach supporting documentation as needed.

  1. Describe safety and health training and educational programs provided at the facilitybeyond the required programs such as LOTO, HazComm, etc.These may include but are not limited to such topics as Risk Assessment and Hazard Control, S&H Communications, Emergency Preparedness, Incident Investigation and Auditing.
  1. Describe examples of strong safety culture, management commitment, and employee involvement in workplace safety and health.
  1. How does the safety committee activity contribute to the success of your safety programs?Do you have a Safety Steering/ Oversight Committee? Describe your safety committee(s) structure, processes and accountability.
  1. Describe any unique or innovative programs utilized at the facility. Describe howthey improve safety and health performance or community relations or how they allow greater efficiency in operation.
  1. Describe a significant safety challenge that the facility has/is experiencing and whatprocesses and/or initiatives have been implemented to drive safety performance improvement.

Submit Completed Application, Supporting Documentationand Accompanying Spreadsheet by E-mail to:

Matt Spencer

U.S. Poultry & Egg Association

ENTRY DEADLINE: 04/20/2018

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