NPCA CUP Awards Entry Form

	Safety Award Entry Form

Safety Awards logo Entry Deadline: Jan. 22, 2010

Publicity Agreement
NPCA has the right to publish the company name and plant location for each Safety Award winner. All
submitted data will remain confidential.

Send your completed entry forms to:

Liz Todd - Safety Awards
NPCA
1320 City Center Drive
Suite 200
Carmel, IN 46032

or via fax:

Attn: Liz Todd
(317) 571-0041

or fill in the fields below to submit your entry via email.

For more information contact Liz Todd at NPCA (800) 366-7731

All fields in the form below are required.

Reporting Period: Jan. 1, 2009 - Dec. 31, 2009

Company name as it should appear on award:

Contact Person:

Email Address:

Mailing Address:

Phone:

Fax:

By checking this box, I certify that the above information is true and accurate, and fairly reflects the safety performance of the submitting facility. Further, I hereby authorize NPCA to bill a $25 shipping and handling fee only if I am eligible for a plaque award. Awards will be shipped immediately after the winter conference.

Safety Representative:

Phone:

Note: This form must be received no later than Jan. 22, 2010. NPCA will contact the safety representative listed below to confirm any award received.

1.	Total hours worked during the reporting period for all personnel, including clerical, for the facility being reported on this form.
2.	Number of employees
3.	Number of injuries and illnesses that required the employee to miss at least one full shift from work (total of column H, OSHA 300 log) (If zero, please enter "00")
4.	Number of injuries and illnesses that involved a job transfer or restriction, but did not result in days away from work (total of column I, OSHA 300 log).
5.	Number of other injuries and illnesses not resulting in days away from work or days of restricted work (total of column J, OSHA 300 log)
6.	Number of days away from work due to injuries and illnesses during this reporting period (total of column K, OSHA 300 log) (If zero, please enter "00")
7.	Number of days of restriction or job transfer due to injuries and illnesses during this reporting period (total of column L, OSHA 300 log)