George W. Burke, Jr. Facility Safety Award Nomination Form - NEWEA - New England Water Environment Association

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George W. Burke, Jr. Facility Safety Award

The Water Environment Federation (WEF) George W. Burke, Jr. Facility Safety Award is presented through the New England Water Environment Association to a selected municipal or industrial wastewater facility in recognition of an on-going safety initiative documented by the development, implementation, and/or improvement of a comprehensive safety program. The award is presented to the selected facility at the NEWEA Annual Conference.

Application
1. Applicant Information
Facility Name*
Address*
Street Address Address Line 2 City State ZIP Code
Contact Person for Application*
First Last
Contact Email*
Contact Phone*
Flow (in mgd)*
List of Treatment Processes*
Number and Types of Personnel*
2. Status of Safety Program*
Please describe the status of the safety program at your facility, including, but not limited to: how long the program has been in effect, the method used to develop the program, who is tasked with developing/maintaining the program, if formal and/or written policies and procedures exist, and whether all policies/procedures have been implemented. For elements of the program that are not fully established, explain the progress to date and schedule for future completion.
Is there a formal safety program?*
- Yes
- No
Is there a written safety program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
3. Personal Safety Awareness Program*
How does your facility teach awareness of and encourage personal safety?
Is there a formal personal safety awareness program?*
- Yes
- No
Is there a written personal safety awareness program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
4. Established Safety Goals*
What are the goals of the safety program at your facility?
Does the facility have formalized goals?*
- Yes
- No
Does the facility have written goals?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
5. Safety Orientation Program*
What type of safety-related orientation and/or initial training are provided to new employees or those transferred from other departments? This may include one-on-one, hands-on, formal classroom, or other orientation/training efforts.
Is there a formal safety orientation program?*
- Yes
- No
Is there a written safety orientation program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
6. On-Going Safety Training Program*
What type of on-going safety training is provided to employees? Provide information about the content, type, duration, and frequency of training, as well as whether it is provided by the facility staff, outside professionals, or a combination. If no formal program exists, show evidence that training is on-going (i.e. list courses attended or required, etc.).
Is there a formal on-going safety training program?*
- Yes
- No
Is there a written on-going safety training program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
7. Inventory of Safety Equipment*
Please list the safety equipment/supplies currently available for use at your facility. To ensure that the Committee understands the purpose and value of each piece of equipment, please list the equipment by category (i.e., confined space entry, HAZMAT, first aid, disease prevention, electrical safety, etc.). Feel free to create your own category headings and use as many categories as you feel are necessary to provide clarity.
Safety Equipment Requests
Please list any safety equipment that has been formally requested, but that has not yet been purchased or budgeted. Provide evidence of the formal equipment request.
Please upload evidence of formal equipment requests, if available. Otherwise, send a copy to the NEWEA office.
Drop files here or

Max. file size: 64 MB.
8. Injury Occurence Statistics*
Please provide a summary of the injury occurrence statistics for your facility over the past 5 years. Attach copies of OSHA logs or other recognized reporting forms. Also, provide the Workman's Compensation Rating Factor from your insurance company.
Is there an injury reporting program?*
- Yes
- No
Is there a written injury reporting program?*
If so, please attach a digital copy in the field below, or otherwise mail a copy to the NEWEA office.
- Yes
- No
Injury Occurence Statistics Forms
Attach all documents related to injury occurrence statistics, injury reporting logs, injury reporting programs, and/or Workman's Compensation documents here.
Drop files here or

Max. file size: 64 MB.
9. Safety Committee*
What type of Safety Committee has been established to oversee safety at your facility?
Who are the Safety Committee participants, and how often are meetings held?*
Are formal Safety Committee minutes kept?*
- Yes
- No
Please upload copies of the minutes for the previous year, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
10. Evidence of Worker Participation in the Safety Program*
How is worker participation evaluated?
What measures are taken to ensure that employees follow established policies and procedures?*
Is there a formal program?*
- Yes
- No
Is there a written program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
11. Evaluation of Qualifications*
Is there a process for evaluating the qualifications of personnel to perform specific tasks or operate pieces of equipment? Is a written record of these personnel qualifications readily available to supervisors?
Is there a formal evaluation program?*
- Yes
- No
Is there a written evaluation program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
12. Safety Program that Extends Beyond the Wastewater Treatment Facility*
Do policies, procedures, and training efforts encompass and/or encourage safety awareness and behavior outside of the workplace and after hours (i.e., when not at work)? Please elaborate.
Outreach Training*
Does your facility conduct any outreach training or have other programs that benefit/encourage safety in the community, contractors, and mutual response operations? Please explain.
Is there a formal "safety outside the facility" program?*
- Yes
- No
Is there a written "safety outside the facility" program?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
13. Safety-related Articles/Publications/Presentations Done by the Facility or its Staff Members*
Please list and provide copies of any articles/publications/presentations/etc. on safety-related topics prepared by staff at the facility as a facility or individual effort.
Please upload any articles/publications/presentations/etc.
If digital copies are not available, send copies to the NEWEA office.
Drop files here or

Max. file size: 64 MB.
14. Highlights of the Current Safety Program*
Please comment on parts of your program that were successful, improvements made to the program, safety initiatives and suggestions implemented, ways that illness and/or injury were prevented as a result of the program, and any other highlights of your program during the previous year.
15. Outstanding Safety-related Feature*
Please take this space to describe any safety-related feature that you believe sets your facility apart from other facilities of similar size, design, and staffing.
Is there a formal program related to your outstanding feature?*
- Yes
- No
Is there a written program related to your outstanding feature?*
- Yes
- No
Please upload a digital copy, if available, or otherwise send a copy to the NEWEA office.
Max. file size: 64 MB.
16. Member Affiliation with WEF/NEWEA*
Please provide verification of membership for facility personnel.
Total number of employees*
Number of WEF/NEWEA members*
Acknowledgement
I do solemnly swear that all of the information presented in this application in true in substance and effect.
Signature*
By completing this field, you consent to the acknowledgement above.
First Last
Date
MM slash DD slash YYYY
Please submit all additional documentation digitally if possible. For all documents that do not exist digitally, either scan and upload in the corresponding field, or mail to:

New England Water Environment Association

10 Tower Office Park, Suite 601

Woburn, MA 01801

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George W. Burke, Jr. Facility Safety Award

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Acknowledgement

Please submit all additional documentation digitally if possible. For all documents that do not exist digitally, either scan and upload in the corresponding field, or mail to:

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