WFIA Excellence in Safety Award

The WFIA EISA award application opens January 1 each year.

Step 1 of 18

Please use the 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

Type of Business

Number of Employees

Contacts

President / CEO

Name

First Last

Phone

Site Manager

Name

First Last

Phone

Safety Champion

Name

First Last

Phone

Section 2 - Safety Performance Data

Review each performance question and check the box that best represents your company. Type answers for each short question.

Have you been involved with the WFIA Waiver Program over the last 2 years?

Yes

Is your current experience modification factor (EMR) below the base rate of 1.0?

Yes

How many DOSH/OSHA citations has your company received in the last three (3) years?

If cited, please list citation:

Section 3 - WFIA On Safety Excellence Self-Assessment Worksheet

The WFIA Excellence in Safety self-assessment performance goals are listed below. Use the self-assessment worksheet to identify the performance level which best represents your company’s climate. Examples of performance goals are found on the following pages to guide you in your evaluation. You do not have to have all items completed in the guide below to meet a status level, however, you must be able to demonstrate why you selected the score based on the criteria provided.

A) Leadership Commitment

A - Leadership Commitment

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
CEO/store manager is engaged in the safety program. Leadership is held accountable for safety in their departments. Safety goals and objectives are tracked annually. Safety is integrated into performance reviews. Leadership is visible and plays an active role in safety program. Leadership follows and enforces safety rules. Leadership is aware of the WFIA retro program.	Members of company management participate in safety program. Personal accountability for safety expected, but little or no recourse. Safety program has goals/objectives, but does not track progress. Periodically request feedback on safety performance. Safety is expected but not included in job performance or annual reviews. Leadership is aware of the expectations of the WFIA retro program.	Employer wants and supports safety, but does not actively engage. Little personal accountability for safety – just “be safe”. Leadership does not address and correct unsafe acts that are observed. No annual safety goals or objectives are established. Leadership has some understanding of the WFIA retro program.	Employer not involved in safety program and demonstrates little interest in it. Safety left to site supervisory personnel to handle “as needed” No accountability for safety No annual safety goals or objectives are established. Leadership does not engage or understand the expectations of the WFIA retro program.

B) Responsibilities

B - Responsibilities

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Responsibilities for safety are defined for all employees (ex. PPE utilization, incident reporting). A policy to hold everyone accountable for safety is in place and is universally applied.	Responsibility for safety defined for all employees in company. Accountability for safety is not always universally applied to all employees.	Responsibility for safety rests solely with designated safety coordinator or safety committee. Little or no accountability for safety.	Responsibility for safety has not been defined within company. Little or no accountability for safety within company.

C) Strategic Planning

C - Strategic Planning

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Safety is part of the annual strategic plan and goals and objectives are established and reviewed annually. Action plans are developed, documented and communicated to assure goals are tracked and accomplished.	Safety planning is established, but is not formalized into an annual strategic plan meeting. Goals and objectives are not reviewed. Action plan has been discussed, but has not been documented.	Informal or infrequent safety program goals are established. No or little documentation/communication of goals.	No process of safety program goal setting.

D) Leading/Lagging Indicators

D - Leading/Lagging Indicators

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Employer has internal means to track leading indicators (ex. near-misses, safety trainings, unsafe behaviors, safety inspections). Employer uses leading indicators as part of communication with leadership and team members (ex. post metrics, newsletters, integrated into operation meetings). Leadership team and safety committee are aware of lagging indicators and trends such as # of injuries in a injury types, costs, etc.	Leadership team is familiar with key safety metrics such as frequency and severity rates. Leadership team periodically communicates leading/lagging indicators during operations/managers meetings.	Lagging safety metrics such as frequency and severity rates are measured internally, but leadership team is not familiar or communicated numbers. Lagging indicators are the only safety measures that are tracked and are seldom reviewed by leadership team.	Company does not measure safety performance internally. Rely only on external communication for safety matrix on claims/frequency issues.

E) Resource Allocation

E - Resource Allocation

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Reasonable resources (funds, time, personnel, equipment, supplies, etc.) are regularly budgeted or invested in safety and return on investment is tracked to evaluate effectiveness of resource allocation.	Reasonable resources are budgeted or invested in safety, however return on investment is not tracked.	Minimal investments are made in safety.	Money is taken from general fund to react to safety issues (ex. DOSH citations/fines).

F) Operations/Leadership Meetings

F - Operations/Leadership Meetings

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Safety is part of agenda during each operation meeting. Discussion includes performance trends, incidents, training etc.	Safety is discussed at operation meetings periodically, but it is reactive not proactive.	Safety discussion only occurs after an event.	Safety is never on the agenda or discuss.

G) Employee Participation

G - Employee Participation

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Conditions are established that allow employee participation in safety program. (ex. safety newsletter, etc.)	Team members are encouraged to participate but no concerted efforts are made to engage them.	General team member safety participation outlet: “If you have questions or concerns, speak with your supervisor”.	No opportunities for employee engagement or participation.

H) Employee Safety Training

H - Employee Safety Training

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Safety training is planned and developed annually and documented. Employees participate in training.	Safety training is planned according to the current needs at time and records are documented.	Informal or on-the-job safety training arranged as needed. Limited or no training documentation kept.	No formal safety training provided to employees.

I) Safety Rules

I - Safety Rules

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Rules are in writing and posted. Explained to employees at time of new hire orientation. Enforced equally among all employees.	Rules are in writing and posted. Explained to employees at time of new hire orientation. Usually enforced equally among all employees.	Rules that do exist are boilerplate and are not site specific to company’s operations. Not regularly enforced.	No safety rules at facility.

J) Inspections

J - Inspections

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Weekly departmental safety inspections are conducted and documented.	Monthly departmental safety inspections are conducted and documented.	Informal departmental safety inspections are conducted some are documented.	No departmental safety inspections conducted.

K) Job Hazard Analysis

K - Job Hazard Analysis

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Job hazard analysis (JHA) has been completed for all major positions with input from employees. JHA are used to identify and mitigate risk and are used as a training tool for new hires and are updated annually to ensure hazards are identified.	Job hazard analysis have been created for most positions within the establishment without employee involvement. JHA are reviewed periodically by managers, but no scheduled process has been formalized.	Job hazard analysis have not been established or created for most positions within establishment.	No hazard analysis has been created for job positions.

L) Safety Committee

L - Safety Committee

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Safety committee is employee driven with leadership support. Safety committee chair is elected and sets agenda. Committee members are housed for each department and have established duties and meet monthly. Minutes are posted and documented. Safety committee supports strategic plans goals and objectives. (ex. Creates tools to support strategic plan goals).	Safety committees meet monthly and minutes are documented and posted. Committee members have established duties and meet monthly. Minutes are posted and documented. Committee has representation from most departments. Hazards and injuries are reviewed by committee and corrective actions are delegated and tracked.	Safety committee meets periodically. Minutes are documented and posted. Hazards and injuries are reviewed and discussed.	Safety committee meets infrequently or no established committee meetings held. No safety committee documentation.

M) New Hire Orientation

M - New Hire Orientation

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Site-specific safety orientation in place for all new hires. Orientation addresses most common injuries identified by strategic plan. Supervisors provide department specific orientation. Safety committee, employees have role in onboarding process.	Documented new member orientation is given to new employees. Departmental supervisor may provide department review of safety hazards, but not always documented.	Informal or on-the-job safety instructions given to new hires. Supervisors are not part of onboarding process. No documentation kept.	No safety instruction or orientation is given.

N) Incident Analysis

N - Incident Analysis

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Leadership is trained in incident analysis techniques. Incident reports are completed for both employee injuries and near miss incidents. Incidents forms are completed by supervisors and submitted to program administrator within 2-days of incident. Team member incidents are reviewed to proactively identify risk and to mitigate future occurrences. Corrective actions are identified and tracked.	Incident reports are completed by supervisors and documented. Incident report forms are completed and submitted to program administrator within 2-days of incident. Employer reviews all serious employee injuries and takes action to prevent future injuries.	Incident reports not always completed by supervisors. Incident report form are periodically submitted to program administrator within 2-days and some incidents are just reported via phone without incident report form.	Incident report not completed for employee injuries. Incident report not submitted to program administrator or lag days are over 7 days per incident.

O) Return-To-Work

O - Return-To-Work

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
Employer has identified an internal champion/contact to work with program administrator on claims management. Employer has established procedures for returning employee back to work under light duty. Employer has identified and works with local occupational medical clinic. Employer has identified internal light duty tasks for employees with restrictions. Employer contacts injured employee within 24hrs of incident to ensure they are going well. Employer uses Kept on Salary (KOS) and light duty to prevent time loss. Employer utilizes the Stay At Work (SAW) Program.	Employer has identified an internal champion/contact to work with program administrator on claims management. Employer has light duty identified and available for injured employees. Employer submits light duty and activity prescription form to program administrator claims manager and are on file. Employer has job offer letter that is used most of the time to bring back employee to light duty. Supervisors understand the basic impact of timeloss and light duty. Employer uses Kept on Salary (KOS) as a tool to bridge work restrictions and light duty to prevent time loss.	Employer has not identified an internal champion/contact but does communicate and work with program administrator claims manager. Employer has some light duty jobs but has not identified specific tasks (creates something when an injury occurs). Supervisors are not aware of impact of timeloss or light duty.	Employer does not have internal champion/contact identified and communication with program administrator claims manager is sporadic. Employer does not have light duty or KOS available.

P) Performance Review

P - Performance Review

Leading

Active

Maintaining

Passive

Hidden

Selected value

Current Score

Leading	Active	Maintaining	Passive
CEO/store manager reviews safety performance quarterly. Emphasis of review is on whether program is producing expected results. Defined criteria exist where performance is measured (ex. EMR, frequency rate, safety trainings inspections, etc.) Results become part of safety evaluation process and are reviewed and discussed with staff.	Owner/CEO is involved in an annual review of safety program to determine if it is producing expected results. Some criteria exist against which performance is measured. Results are discussed with staff and supervisors.	Limited owner/CEO involvement. Mainly left to someone else (safety manager, insurance company). Some criteria exist against which performance is measured. Results may or may not be reviewed with staff and supervisors.	No review of safety program performance.

Hidden

Total Score

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