Midwest Insulation Contractors Association

MIDWEST INSULATION CONTRACTORS ASSOCIATION

INSULATION FOR INDUSTRY 16712 ELM CIRCLE  OMAHA, NE 68130 402-342-3463  FAX: 402-330-9702 e-mail: [email protected]

2016 Midwest Insulation Contractors Association Best Practices in Safety Award

Application Instructions

1. All MICA members are encouraged to apply.

2. All applications must be received no later than April 15, 2016. Incomplete applications and completed applications received after this date will not be considered.

3. Applications should be typed for ease of readability.

4. PLEASE DO NOT ATTACH A COPY OF YOUR ENTIRE SAFETY PROGRAM. PLEASE ONLY ATTACH THOSE PORTIONS OF YOUR PROGRAM REQUESTED ON THE APPLICATION FORM. Answer all questions that do not request a copy of the program addressed by providing the grading committee the information requested in a narrative form. Please feel free to use additional paper if necessary.

5. Complete the application and return it to Gary Auman, Legal Counsel for MICA, at the address below, along with the application fee of $50 (made payable to MICA).

6. Applications may be submitted electronically to [email protected] or mailed to:

Dunlevey, Mahan & Furry Attn.: Brenda Lightner 110 North Main Street Suite 1000 Dayton, OH 45402-1738

7. Please send a notification e-mail to the MICA office at [email protected] that you are submitting an application. This is our internal check to make sure that all applications are properly processed.

Award level recognition will be based on the overall grade that your company achieves based on your safety program, means of communication and training, and your company’s safety policy. Participating companies will be recognized at MICA’s 59th Annual Spring Convention, June 20 – 23, 2016, at the Chateau on the Lake Resort & Spa in Branson, Missouri. Please register to attend the spring convention. MICA Best Practices in Safety Award

2016 Contractor Member Application Form Instructions:

Complete the application and return it to Gary Auman, MICA Legal Counsel, along with your Safety Policy Statement and the application fee, to be received no later than April 15, 2016. Please make checks payable to MICA. The application processing fee is $50.00. Only MICA members – contractors and associates are eligible.

Please complete all information. (Incomplete applications and those without payment will not be considered). DO NOT SEND A COPY OF YOUR ENTIRE SAFETY PROGRAM!

Section 1: General Information

Company name ______Address ______City ______State ______Zip code ______Contact for report verification ______Contact name ______Phone ______

Who in your company has the overall responsibility for safety? Name ______Phone ______E-mail ______

Confidentiality: The information in Section 1, and any reference in any part of this application to a specific company, will not be included with the application when the submissions are judged. This information will be kept in strict confidence. MICA reserves the right to publish any innovative safety ideas from the entries, for the good of the industry. However, any company-specific information regarding accident or injury statistics, or any other information identified by the applicant as proprietary, will be kept in confidence within MICA as applying to the specific company.

Section 2: Category

1) Please check one: 2) I confirm that my company is a contractor:

a) ___ Small Company (less than 100,000 man-hours) a) ___ Yes b) ___ Medium Company (100,001-500,000 man-hours) b) ___ No c) ___ Large Company (more than 500,001 man-hours)

2) I confirm that I am a MICA member in good standing. a) ___ Yes b) ___ No

3) Does your company have a formal written safety program? Yes ___ No ___

Section 3: Company Safety Program

1) Does your company have a distracted driving/working program? Yes ___ (Please attach a copy of this program) No ___

2) When and how do you train your new employees and indoctrinate them into your safety program and expectations? ______(Over) 3) How do you ensure safety knowledge and compliance on the job site on a daily basis? ______

4) Does your company have a Personal Protective Equipment (PPE) procedure for doing hazard assessments, doing training on PPE, and auditing employee use of PPE? Yes ____ No ____ If yes, please describe your procedures______

5) Does your company have a disciplinary action program? Yes ____ No ____ If yes, explain ______

6) Does your company have a fall protection program? Yes ____ No ____ If yes, please describe the program including each type of fall protection employed for employees working more than six feet above the ground. ______

7) Do you have a Substance Abuse Testing Program? Yes__ No__ If yes, check all that apply: a) __ Pre-employment Testing b) __ Post Accident Testing c) __ Testing for Cause please describe how your company handles positive test results______

8) Do you have a formal program to train and protect your employees from hazards of heat stress? Yes ____ No ____ If yes, please attach a copy of your heat stress program ______

Section 4: Safety Policy

If your company has a safety policy statement, please attach a copy to the application.

For those companies that would like feedback on the information submitted, please check here. Indicate whom you would like the feedback sent to and their e-mail address. Yes ____ Name ______E-mail ______All questions regarding the application process can be submitted to Gary Auman at [email protected]. All applications and appropriate fees must be received no later than April 15, 2016, to the e-mail address; [email protected], or mailed to:

Dunlevey, Mahan & Furry Attn. Brenda Lightner 110 North Main Street, Suite 1000 Dayton, OH 45402-1738 Note: An electronic copy of the application is available at www.micainsulation.org, or by contacting the MICA office directly.