Million Hour Safety Award Application

Safety Awards Program
N.C. Department of Labor
1101 Mail Service Center
Raleigh, NC 27699-1101
919-707-7855
Email: safety.awards@labor.nc.gov

MILLION HOUR SAFETY AWARD APPLICATION

Million Hour Safety Awards are presented by the N.C. Department of Labor in recognition of working one million employee hours, or multiples thereof, with no cases of injury or illness involving days away from work (CDAW).

Name of Company, exactly as it is to appear on award: *

North American Industry Classification System
(NAICS) Code: *

Number of employee hours with no cases
involving days away from work: *

Date hours began (start with day following last lost-time injury): * +

Date hours achieved (do not include day of lost-time injury): * +

is this record continuing? *

During this period, were there any restricted work activity cases? *

How many days were restricted work activity cases? *

Attach all OSHA 300 Logs and OSHA 300A Forms as one attachment for the time period you are applying for this award. *

Presentation Arrangements (please mark your choice): *

Present at local annual safety awards banquet (held in the spring)

Mail

County:

OPTIONAL - please provide any additional instructions or requests that you may have.

CONTACT INFORMATION

First Name *

Last Name *

Title *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Official's signature certifying that the information contained on this form is correct. *

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Date submitted: * +