Step 1 of 4 25% Company Name*Contact Person* First Last Title*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone Number*Email* Year Established*Primary North American Industry Classification Code (NAICS)* PLEASE use 6 digit NAICS code; 4 digit is acceptable. (do not submit SIC code). For assistance in determining your NAICS code, visit: https://www.census.gov/naics/Reporting as:*Entire Wisconsin OrganizationNEW! ONE Separate Division/Operations UnitNEW THIS YEAR! If reporting separate division/operating unit, you may only apply with 1 division (not multiple divisions/units). 1. Were there any fatalities within your organization in 2024?*YesNoWisconsin organizations with any work-related fatality to any employees or temporary/contract employees in 2024 are excluded from the 2024 WI Workplace Safety Awards. Temporary/Contract EmployeesAverage Number of temporary/contract employees in 2024*Please enter a value greater than or equal to 0.Number of temporary/ contract employee hours worked*Please enter a value greater than or equal to 0.Number of temporary/contract employee recordable cases*Full Time Employees (whole numbers only) 2022 2023 2024 Average number of employees on Payroll in 2022*Please enter a value greater than or equal to 0.Average number of employees on Payroll in 2023*Please enter a value greater than or equal to 0.Average number of employees on Payroll in 2024*Please enter a value greater than or equal to 0.Total number of hours worked in 2022*Please enter a value greater than or equal to 0.Total number of hours worked in 2023*Please enter a value greater than or equal to 0.Total number of hours worked in 2024*Please enter a value greater than or equal to 0.[Work Hours (WH) are the number of paid work hours for the calendar year (including office hours). PLEASE NOTE: WH are the actual payroll hours worked, excluding vacation and holidays. You must include all full-time, part-time, seasonal and temporary/contract employees that work under your organization’s supervision.]Total number of recordable cases (from OSHA form 300): 2022 2023 2024 Column H (days away from work) 2022*Column H (days away from work) 2023*Column H (days away from work) 2024*Column I (job transfer or restriction) 2022*Please enter a value greater than or equal to 0.Column I (job transfer or restriction) 2023*Please enter a value greater than or equal to 0.Column I (job transfer or restriction) 2024*Please enter a value greater than or equal to 0.Column J (other recordable cases) 2022*Column J (other recordable cases) 2023*Column J (other recordable cases) 2024*Total Column (H, I and J) 2022*Total Column (H, I and J) 2023*Total Column (H, I and J) 2024*If your answer above to Column H (Days away from work) is zero, how far back does this record go?Date Hours WorkedPlease enter a value greater than or equal to 0.Incidence Rate (Recordable):Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2022)*Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2023)*Total Column (H, I, J) (above) x 200,000/Total Number of Hours Worked = Rate (2024)*Incidence Rate (Lost Workday Case):Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2022)*Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2023)*Column H (days away from work) x 200,000/Total Number of Hours Worked = Rate (2024)*Brief description of job tasks performed at your location.*Why do you feel you should move on to Phase II?*Application Must be Received By Monday, Feb. 3, 2025 at 11:55AM. I hereby certify that the information included in this application form is factual and accurate.* Agree Completed by*CommentsThis field is for validation purposes and should be left unchanged.