ACTSafe Awards

Please refer to the Nomination Form and Guide for full information on the Award Categories, Criteria for Judging and submission of entries and the Terms and Conditions for these Awards.

In order to submit this form, you must complete ALL mandatory fields, marked in red.

Entry Information:

Personal Information:

Entry Information

Person 1 Name and role of person submitting entry:
Phone:

Mobile Phone:

Facsimile:
Email Address:

Person 2 Name and role of second workplace contact person:
Phone:

Mobile Phone:

Facsimile:
Email Address:

Business Information:

Business Name:
Australian Business Number:

Business Address Address Line 1:
Address Line 2:
City/Town:
State:
Post Code:

Business Postal Address Address Line 1:
Address Line 2:
City/Town:
State:
Post Code:

Award Category Information:

Award Category Entered

Title of solution/initiative:

Business Details

Business Details Brief Description of Your Business and/or Operations:
Name Of Insurer:
Workers Compensation Policy Number:
Number of Employees:
ANZSIC Number: (if known)

Occupational Health & Safety Data

Under The OHS Act, my Organisation:

has has not been subject to a prosecution in the past 2 years. has has not had a work related fatality in the past 3 years.

Brief Overview

Provide an overview of your initiative: (Include comments against each judging criterion - see over page)
Additional material and comments should be included. All such inclusions should refer to the relevant criteria.

Criteria

Entry Criteria Brief Description of the problem, solution, and outcome:
Criterion 1:
Criterion 2:
Criterion 3:
Criterion 4:
Criterion 5:
Criterion 6:
Criterion 7:
Criterion 8:
Criterion 9:
Other Notes:

Upload Attachments File 1:
File 2:
File 3:
File 4:
File 5:
File 6:
File 7:
File 8:
File 9:
File 10:

Entry Checklist

Before submitting your entry, you must check the following:

Entry Checklist Provided all information requested Checked that all information on this form is accurate Checked that if used in print media, submitted content can appear as provided on this form Specifically addressed the judging criteria for the nominated award category Included the relevant documentation and photograph(s) to support my entry I have read and understood the conditions of entry

In submitting this form, you hereby agree to the conditions of entry.

ACT Occupational Health & Safety Awards 2008

Entry Form

Occupational Health and Safety Awards 2008