George W. Burke, Jr. Safety Award

SECTION 1
PLEASE INDICATE WHICH AWARD YOU ARE NOMINATING FOR *	Walter J. Courmon Award George W. Burke Award
Nominator Information Please complete the following information for the person completing this nomination.
Nominator Full Name *
Nominator Organization *
Nominator Professional Title
Nominator Address (Include City, State, and Zip) *
Nominator Phone *
Nominator Email Address *
SECTION 2
Organization General Information Complete the following fields related to the organization being nominated for the award.
Facility Name:
Utility Name:
Facility Type:	Water Treatment Water Distribution Wastewater Collection Wastewater Treatment
Facility Address (include city, state and zip code):
Facility Contact Person and Professional Title:
Contact Person Phone Number
Contact Person Email:
SECTION 3
Utility Memberships Please indicate which (if any) the organization has a membership with.
Memberships (select all that apply)	AWWA WEF
SECTION 4
Organization Details Each organization applying for this award is required to submit the OSHA Form 300A: "Summary of Work-Related Injuries and Illness" with this application. Please do so in the space provided below. For the organization details, fill in numbers in the space provided next to each question.
Please provide the OSHA Form 300A “Summary of Work-Related Injuries & Illness' *
Facility Information

Number of Utility Department Employees *
Number of Treatment Plants Operated *
Number of Treatment Plant Employees *
SECTION 5
Organization Safety Programs Check an answer next to each program to describe the status of each program at the utility.
Key: Program In place = 4 pts, Program being developed = 2 pts, Not Applicable = 0 pts

Accident Prevention/Investigation Program	Program in Place Program Being Developed Program Not Applicable
Blood borne Pathogen Exposure Control Plan and Training	Program in Place Program Being Developed Program Not Applicable
Cranes/Hoists Training and Inspection Programs	Program in Place Program Being Developed Program Not Applicable
Electrical Safety	Program in Place Program Being Developed Program Not Applicable
Emergency Action Plan	Program in Place Program Being Developed Program Not Applicable
Fire Prevention Plan	Program in Place Program Being Developed Program Not Applicable
First Aid/CPR Training	Program in Place Program Being Developed Program Not Applicable
Forklift Training and Inspection Program	Program in Place Program Being Developed Program Not Applicable
Hazard Communication Program	Program in Place Program Being Developed Program Not Applicable
Hazardous Waste Operations and Emergency Response	Program in Place Program Being Developed Program Not Applicable
Hearing Protection and Training Program	Program in Place Program Being Developed Program Not Applicable
Lockout/Tagout Program	Program in Place Program Being Developed Program Not Applicable
Permit Required Confined Space Program	Program in Place Program Being Developed Program Not Applicable
Personal Protective Equipment Program	Program in Place Program Being Developed Program Not Applicable
Policy on Storage of Flammable/Combustible Liquids	Program in Place Program Being Developed Program Not Applicable
Policy on Storage and Handling of LP Gas	Program in Place Program Being Developed Program Not Applicable
Portable Fire Extinguisher Training	Program in Place Program Being Developed Program Not Applicable
Process Safety Management	Program in Place Program Being Developed Program Not Applicable
Respiratory Protection Program	Program in Place Program Being Developed Program Not Applicable
Welding, Cutting and Brazing	Program in Place Program Being Developed Program Not Applicable
Fall Protection Program	Program in Place Program Being Developed Program Not Applicable
Risk Management Program	Program in Place Program Being Developed Program Not Applicable
Job Hazard Analysis for each position/task	Program in Place Program Being Developed Program Not Applicable
Machine Guarding	Program in Place Program Being Developed Program Not Applicable
SECTION 6
Additional Information Select “Yes” or “No” to the following questions, and provide further details when prompted to do so. If additional space is needed, please attach a separate document at the end of this form. You may also use this tool to add any other supporting documents.
Are all of personnel required to have & use approved safety glasses, hard hats, and safety footwear?
Are all personnel aware of the organization’s Safety & Health Manual?
Does each division of the organization have job specific Safety Policies and/or Procedures in place?
Does every employee attend regularly scheduled safety meetings?
Does the organization have a Safety Committee?
If yes, please describe the Safety Committee philosophy:
Do employees understand management’s commitment to Safety and Health?
Please Explain:
Does each new employee receive training from someone other than his or her immediate supervisor?
Was anyone disciplined during the year for a violation(s) of a safety rule(s)?
Please Provide Explanation:
Are employee driving records checked periodically?
Is there a Competent Person assigned to operate each backhoe assigned to a crew?
Does organization have a trenching and shoring program?
Does organization posses and train on the use of portable fire extinguishers?
Is there a Highway Work Zone Safety Program?
Are employees offered the Hepatitis B vaccines?
Are employees offered Tetanus vaccines? (If recommended by doctor)
Do all supervisors have first-aid/CPR training?
Are MSDS’s current, in order and located in each work area?
Is a baseline survey of the worksite conducted to identify hazards?
Please Describe:
Are accidents and near misses promptly investigated in order to discover the root cause?
Describe what actions are taken to investigate and prevent the accident from happening again.
Additional items about the Safety Program that should be considered in the selection of the Award:
SECTION 7
Uploading Supporting Documents If you would like to upload responses to open-ended questions, or additional materials, please convert them to PDF format and merge all documents into a clearly labeled file.
Upload any supporting documents here