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

"*" indicates required fields

Date*

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

Other comments

File

Max. file size: 50 MB.

If you are unable to upload a file, please e-mail a copy of the acknowledgment form (page 2 of Supervisor Instructions) and any supporting documents to [email protected]

The link is to the form is https://www.chwca.org/wp-content/uploads/2024/12/2025-CHWCA_Safety-Award-Program_Supervisor-Instructions.pdf