WFIA Excellence in Safety Award

The WFIA EISA award application opens January 1 each year.

Step 1 of 9

Phone

This field is for validation purposes and should be left unchanged.

Please use the web form below to apply for the WFIA Excellence in Safety Award. If you prefer, you can download and mail in the form HERE.

You will receive a confirmation email once you complete this form.

Name(Required)

First Last

Email(Required)

Section 1 - Company Information

Enter your company name, address, contact information, CEO/Owner Name, business category, number of employees and total hours reported annually to Labor and Industries.

Company Name(Required)

L&I Account Number

Address

Street Address City State ZIP Code

Pick one industry that best describes your work

Number of Employees

Number of Locations

Contacts

President / CEO / Upper Management

Name

First Last

Phone

Location Manager

Name

First Last

Phone

Safety Contact

Name

First Last

Phone

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
CEO/Owner/top management actively participates in safety program (e.g., leads safety meeting, conducts site safety walk, recognizes employees for safety efforts, communications, etc.). Top management instills personal accountability for safety throughout company. (e.g., safety violation writeups). Top management integrates safety into all facets of company operations. (e.g., newsletters, communication, minutes, trainings, etc.). Top management understands the requirements of the WFIA retro program. (e.g., understanding of expectations, trainings, etc.).	Top management participates in safety program. Personal accountability for safety is expected, but accountability/enforcement is inconsistently applied. Top management provides the required safety resources for compliance. Top management is familiar but does not understand requirements of the WFIA retro program.	Top management supports safety but does not actively participate in program. Little personal accountability for safety just a "be safe" culture. Top management provides limited resources for safety. Top management has little or no understanding of the WFIA retro program.	Top management is not involved in safety process and demonstrates little interest. Safety left to office administrator or site supervisory personnel to handle "as needed". No accountability for safety. Little or no funding for safety activities. Top management is not aware of WFIA retro program.

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Safety orientation is communicated in a language that is understood for all newly hired employees. Safety orientation topics include but are not limited to: Safety expectations and employer commitment to safety. Safety responsibilities and accountabilities. PPE requirements and expectations. Site-specific safety hazards such as emergency procedures, reporting injuries, hazardous equipment, hazardous chemicals. New hire safety orientation is documented and made available on request with name, date, and employee performing the orientation.	Safety orientation is given to new employees, but the process has not been formalized. Safety orientation topics include at minimum: Explanation on employer safety commitment and expectations. Basic safety rules that pertain to the job. Record of safety orientation with employee signature is maintained.	Informal or on-the-job safety instruction is given. No uniform process or list of topics to cover. No documentation is maintained.	No orientation is given.

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Supervisors hold weekly safety meetings that are documented with names, date, and topics. Supervisors take proactive role in safety (e.g., address/discipline unsafe behaviors, frequently provides staff positive feedback/reinforcement, utilizes resources to fix hazards, follows-up with staff, safety protocol, review of serious injuries, near miss reporting). Supervisors play critical role in the incident report process. Supervisor conducts analysis of incident/injury and follows up with corrective actions to prevent future injuries.	Supervisors hold safety meetings monthly that are documented with names, date and topics. Supervisors encourage safety but are reactive in addressing issues. Serious injuries are generally reviewed. Supervisors have general knowledge of safety program. Supervisors complete incident report form for workplace injury, but do not include corrective actions to prevent future injuries.	Safety meetings are inconsistently held, without documentation. Passive approach to safety. Does not address unsafe hazards or behaviors. Only follows up when serious injury occurs. Supervisor has limited knowledge of safety program. Office administrator or other person may complete incident report form. Incident report is not properly completed.	Supervisors take hands off approach to safety.

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Employee and supervisor safety trainings are planned in advanced and tracked (e.g., annual training calendar). Company has set annual training requirements. Training is conducted by competent/qualified instructor. Safety training is offered to all and employees are encouraged to participate/deliver training. Employee training comprehension and understanding is verified and documented (e.g., skills assessment, tests). Training records are kept of all trainings - date, attendees, topic covered and trainer.	Safety training needs are determined, but a formal calendar / tracking system are not used. Training is conducted by competent/qualified instructor. Training documents are kept - date, attendees, topic covered and trainer.	Reactive training or on-the job safety training is arranged when required. There is no established training calendar or tracking system. Limited or no training documentation kept.	No formal safety training is provided.

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Employees are actively engaged in the safety process (e.g., safety inspections, hazard reporting, incident analysis, safety orientation, safety mentoring, safety committees, etc.). Employees regularly report incidents to supervisors immediately after incident occurs.	Safety participation is encouraged, and opportunities are available, but safety activities are not specifically documented. Employees infrequently report incidents to supervisors immediately after incident occurs.	Employees are encouraged to participate in the safety process, but no concerted efforts are made to engage them. Employees do not report incidents to supervisors immediately after incident occurs.	There are no opportunities for employees to participate in the safety process.

Performance Goal 6: Incident Investigation

Incidents are reviewed and corrective actions are identified and communicated to all employees.

Leading

Active

Maintaining

Passive

Incident report forms are completed for all workplace injuries/near misses.

Leading

Active

Maintaining

Passive

Current Score

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Employer reviews all incidents including near misses. Supervisors are trained in incident investigation. Incidents are investigated promptly by top management and safety/supervisors and preliminary report is communicated within 2-days. Incident report forms are completed for all incidents. Corrective actions are identified, tracked, and documented. Incident findings are shared openly with team and crews to improve overall safety performance.	Supervisors receive a basic level of incident investigation training. Reports are completed for all employee incidents, but not near misses. Employer only reviews incident reports not near misses. Corrective actions are identified but are not tracked or followed up on. Incidents are sometimes shared with crews but not regularly.	Supervisors receive little or no incident investigation training. Incident reports may or may not be completed by supervisor. Incident reports are not always completed. Little or no attempt to identify corrective actions. Lessons learned are not shared openly across the company.	Incidents are not investigated or reviewed.

Performance Goal 7: Return to Work

Employer has an established Return to Work program.

Leading

Active

Maintaining

Passive

Current Score

Leading (L)	Active (A)	Maintaining (M)	Passive (P)
Employer has internal contact that works with program administrator on claims. Employer has established procedures for returning employees back to work. Employer proactively identified light duty tasks for employees with restrictions. Employer contacts injured employees within 24-hrs of incident to ensure they are well. Employer utilizes the Washington State Stay-At-Work (SAW) program. Employer has attended workers compensation training in the last year.	Employer has internal contact that works with program administrator on claims. Employer has basic understanding of returnto-work procedures. Employer has light duty available for injured employees. Employer utilizes the Washington State Stay-At-Work (SAW program). Employer has attended workers compensation training in the last year.	Employer has internal contact that works with program administrator on claims. Employer has limited understanding of return-to-work procedures. Employer has light duty available on a case-by-case basis. Employer has not attended a workers compensation training in the past year.	Little to no understanding of workers compensation or return to work.

This field is hidden when viewing the form

Total Score

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

WFIA Excellence in Safety Award

Section 1 - Company Information

Contacts

President / CEO / Upper Management

Location Manager

Safety Contact

Section 2 - Safety Performance Data

Section 3 - WFIA On Safety Excellence Self-Assessment Worksheet

Performance Goal 1: Leadership Commitment

Performance Goal 2: New Hire Safety Orientation

Performance Goal 3: Supervisor Safety

Performance Goal 4: Employee Safety Training

Performance Goal 5: Employee Participation

Performance Goal 6: Incident Investigation

Performance Goal 7: Return to Work