ZERO Incidents Program Award Application

Form 000.653.F0140

Zero Incidents Program Award Application

INSTRUCTIONS: Complete this form, attach any supporting material, and send to the appropriate
Regional or Business Unit Lead.
Project/Office Name (to be printed on plaque): / Date of Application:
Project Location (to be printed on plaque): / No. of Plaques Requested:
Actual Safe Work Hours Achieved: / Period of Achievement (to be printed on plaque):
Start Date: Through Ending Date: _
Date Plaque(s) Needed On Site: (allow 3 weeks after final approval)
Sponsoring Business Group: / Project No./Contract No.: / Billable (transbill) Project No.:
Site/Office Manager: / Site/Office HSE Representative:
Site/Office Shipping Address: / Street:
City/State/ZIP: / Country:
Telephone No.: / Email Address: / Fax No.:
AWARD CATEGORIES
Complete Appropriate Section Only
Note: Awards are based on total project or office performance, including contractor and subcontractor personnel. The project may be self-perform, construction management, or operations and maintenance.
Projects
AWARD / RECORDABLE CASE INCIDENCE RATE / SAFE WORK HOURS
One-Star / 0.43-0.55 / 100,000
Two-Star / 0.29-0.42 / 250,000
Three-Star / 0.15-0.28 / 500,000
Four-Star / 0.01-0.14 / 750,000
Five-Star / 0.00 / 1,000,000
Actual Recordable Case Incidence Rate: / Million
OfficesBecause office incident rate goals are zero, offices are eligible for the Five–Star award after completion of 5 million safe workhours or 3 years without a recordable incident.
AWARD / RECORDABLE CASE INCIDENCE RATE / SAFE WORK HOURS
One-Star / 0.12-0.15 / 100,000
Two-Star / 0.08-0.11 / 250,000
Three-Star / 0.04-0.07 / 500,000
Four-Star / 0.01-0.03 / 750,000
Five-Star / 0.00 / Million Hours (or)
Years
Achievement/Award Celebration Has Been Scheduled For (date) at (time)
ZERO Incidents PROGRAM AWARD APPLICATION APPROVALS
(For Use By Corporate HSE Only)
Regional or Business Unit HSE Lead:
Date Received: / Application Complete:
Yes No / Verification Audit Assigned To: / Date:
AUDIT
Verification of Information Provided / Date of Last Lost Workday Case:
Total No. Safe Work Hours:
Reviewer’s Name: / Qualifies For Award Requested: Yes No
Last HSE Audit Score: Auditor: Date:
Phone No.: / Onsite Verification Audit Required: Yes No
If “No” Explain:
Date:
Onsite Verification Audit / Scheduled Date: / Auditor:
Site Notified: Yes No / Site contact:
Date Audit Performed: / Verification Audit Score: / Passed Failed
Auditor’s Signature
Comments:
APPROVAL
Project/Site Manager / Application Status:
Approved Rejected / Signature / Date
Comments
Site HSE Representative / Application Status:
Approved Rejected / Signature / Date
Comments
Regional or BusinessUnit HSELead / Application Status:
Approved Rejected / Signature / Date
Comments
HSE Board Chair / Application Status:
Approved Rejected / Signature / Date
Comments:
HSE Awards Program Coordinator
Verification andTracking / Date Received: / Received: Approvals: Yes No
Backup Material: Yes No
Verification Audit: Yes No
Award Status:
Approved
Rejected / Award Approved For:
One-Star
Two-Star
Three-Star
Four-Star
Five-Star / Date Ordered:
Hours
Years / Date Approved:
Comments:
Date Award Shipped to Requestor: / Date Congratulatory Letter Sent: / Date Logged In Awards Database: / Date Billed:

Note: This form is referenced in Practice 000.653.1100.

Form Date: 01May2009