Form - CHWCA Safety Award Application - Client Documents Portal

CHWCA Safety Award Application

The CHWCA Risk Management Committee would like to hear about your safety ideas and solutions. The Cash for Safety Culture Program was established to promote a positive safety culture by recognizing and rewarding employees and agencies who take an active role in their agency’s safety program.

Submit your ideas and solutions by completing the form below and attaching the acknowledgement form (page 2 of the supervisor's instructions). We encourage you to submit your ideas and solutions as they arise. Use a separate application form for each submission.

Date*
MM slash DD slash YYYY
Agency Name associated with CHWCA*
If "Other" selected, please provide your agency name:
Department Name:
Name*
First Last
Phone*
Email*
Supervisor Name*
Supervisor Email*
Submission Type*
- Employee
- Agency
Describe the safety hazard or risk.*
Provide a description with details about your idea, program, and the solution(s).*
Provide a description of the change, outcomes, and results.*
Has this submission received approval from your supervisor?*
- Yes
- No
Other comments
Upload form*
Please attach signed acknowledgement form. You may attach supporting documents as well. The link is to the form is https://pooling.sedgwick.com/wp-content/uploads/2023/12/CHWCA_Safety-Award-Program_Supervisor-Instructions-2024.pdf

Supervisor Instructions
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

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