Nomination Form

Nominations are now closed. Thank you to everyone who participated.


Winners will be featured in the November 2014 issue of Canadian Occupational Safety. See FAQ section for more information.



Nomination Process

Canada's Safest Employers recognizes Canadian companies that are making a difference in promoting the health and safety of their workers. If you are operating a safe and successful organization in Canada, we would like to hear from you.


Eligibility

TO BE ELIGIBLE FOR CANADA'S SAFEST EMPLOYERS AWARD, NOMINEES MUST MEET ALL OF THE FOLLOWING ELIGIBILITY CRITERIA:

  • Open to all companies that have been an employer in Canada for the last five years or more.
  • Must have NOT incurred any serious injuries or fatalities in the last five years, which resulted in investigation and subsequent charges under the Occupational Health and Safety Act and/or the Criminal Code.
  • Must have NOT been convicted of any charge under the Occupational Health and Safety Act and/or the Criminal Code, in the last five years.

Screening Process

  1. Completed nomination form.
  2. Completed Employee Safety Perception Survey. Only short-listed companies that pass the eligibility criteria and pre-screening process will be requested to proceed with the Employee Safety Perception Survey, provided by Canada's Safest Employers organizing committee.

Awards

Canada's Safest Employers gold and silver awards are available in the following categories:

  • Building and Construction
  • Health Care
  • Mining and Natural Resources (includes fish and forestry)
  • Transportation (land, sea and air)
  • Hospitality
  • Manufacturing
  • Oil and Gas
  • Public Sector / Non-profit
  • Retail and Services
  • Utilities and Electrical

Gold and silver awards are also available for two additional awards:

  • Wellness
  • Psychological Safety
CANADA’S SAFEST EMPLOYERS 2014 NOMINATION FORM »
Canada’s Safest Employers award – Wellness » Canada’s Safest Employers Psychological Safety Award »

Nomination Process

Canada’s Safest Employers recognizes Canadian companies that are making a difference in promoting the health and safety of their workers. If you are operating a safe and successful organization in Canada, we would like to hear from you. 

ELIGIBILITY


TO BE ELIGIBLE FOR CANADA’S SAFEST EMPLOYERS AWARD, NOMINEES MUST MEET ALL OF THE FOLLOWING ELIGIBILITY CRITERIA:

  • Open to all companies that have been an employer in Canada for the last five years or more.
  • Must have NOT incurred any serious injuries or fatalities in the last five years, which resulted in investigation and subsequent charges under the Occupational Health and Safety Act and/or the Criminal Code.
  • Must have NOT been convicted of any charge under the Occupational Health and Safety Act and/or the Criminal Code, in the last five years.

SCREENING PROCESS

  1. Completed nomination form.
  2. Completed Employee Safety Perception Survey. Only short-listed companies that pass the eligibility criteria and pre-screening process will be requested to proceed with the Employee Safety Perception Survey, provided by Canada’s Safest Employers organizing committee.
***Please note the nomination form times out after 3 hours and your information will not be saved. We encourage you to work in a Word document and then copy and paste your responses.

CANADA’S SAFEST EMPLOYERS 2014 NOMINATION FORM

Eligibility
Have you been an employer in Canada for the last five years or more?
Do you have more than 20 employees?
Are you willing to administer an employee safety perception survey provided by the Canada’s Safest Employers organizing committee to your workforce should you be shortlisted? (At least 20 per cent of employees must complete the survey within a prescribed time frame for your company to move on in the competition).
Note: If you answered No to any of the questions above, you are not eligible to participate in the selection process for Canada’s Safest Employers Award.
In the last five years, have any of your workers suffered any work-related injuries that resulted in prosecution under occupational health and safety, workers’ compensation and/or the Criminal Code legislation?
In the last five years, have you incurred any workplace fatalities?
In the last five years, has your company been convicted under the occupational health and safety, workers’ compensation and/or the Criminal Code legislation?
NOTE: If you have answered Yes to any of the questions above, you are not eligible to participate in the selection process for Canada’s Safest Employers Award.
Industry Category
To which industry does the company being nominated belong? Please check the box that applies (one answer only).









Contact Information
Employer Name
Telephone
Website
Street Address
City
Province
Postal Code
Contact Person (Person responsible for this application)
E-mail address
Telephone Number
Fax number
Alternate contact name and title
E-mail address
Telephone Number
Fax number
About the Organization
Brief description of the organization / scope of operations (please include year founded)
Employee Profile
Total Number of Employees
 
Full-time
Part-time
Contract
OHS Management System (10 points)
Describe your company’s occupational health and safety management system.
Demonstrated management commitment (10)
Describe how your most senior leaders participate in leading the OHS Management System in your organization and how they show commitment to OHS.
Joint Health and Safety Committee (5)
Explain how participation in the JHSC works at your organization, as well as how often it meets, how meetings are documented and any training participants receive.
Hazard/Risk assessment (5)
Describe any hazard/risk assessments that have been done for specific role/jobs in the organization, or within the overall work environment.
Training (10)
Describe how you ensure that employees are adequately trained to perform their work effectively and safely.
Workplace inspections (10)
Describe how often inspections are conducted, the inspection process, and follow-up processes.
Emergency response/ organizational continuity plan (5)
Describe your organization’s emergency response/continuity plans and procedures, including the types of emergencies/threats it covers, the steps employees should take in response, and training.
Employee engagement (10)
What initiatives and activities do you do to keep your workers engaged in safety?
Communication strategies(5)
Describe how you are communicating safety messages
Health and wellness (10)
Describe your health and wellness program.
Innovative approach (10)
Describe, if any, some of the innovative approaches and programs around health and safety (not previously mentioned) that you have implemented and the result of those programs.
Injury Statistics in the last three years (5)
(Please provide data as indicated in your WCB statement of cost or account rate profile)
WCB reportable injuries/illnesses
Total Number of Lost-time injuries (optional)
2011 2012 2013
Total Number of No Lost-time injurires (optional)
2011 2012 2013
Injury frequency for period (optional)
Lost Time Injury Frequency
2011 2012 2013
Industry Frequency Rate (as indicated in statement of cost) (optional)
2011 2012 2013
Total Injury Rate ([Lost-time injury]+[no lost-time injury]/[full time equivalents]) (mandatory)

2011 2012 2013



If you wish, you can use the space below to provide more information or elaborate on your injury statistics.
Injury/incident investigation (5)
Please describe the steps taken when an injury or “near miss” incidents occur. How do you ensure that recommended corrective actions are implemented?
Statement of Truth
I'm the person named in, and who subscribed in, this application form for Canada's Safest Employers. To the best of my knowledge and belief, the matters and facts in it are true. Where matters specifically stated in it are made upon information and belief, I believe them to be true. I make this declaration conscientiously believing it to be true and knowing that it is of the same force and effects as if made under oath.
Name Title Date

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Deadline for submission: June 24
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