Safety Excellence Award Form - Indiana WEA

2026 Safety Excellence Award Application

Award Applications must be submitted no later than March 1st for consideration of awards. Applications received after the deadline may potentially not be considered for either safety award. Once your application has been received, the committee will forward the self-audit form for review so you will know what to expect during the audit process.

George W. Burke Jr. Award applicants will complete additional sections on this form to gather more information prior to the audit process.

Facilities applying for either award must be accessible for the auditor within a reasonable time frame and be able to accommodate the schedule of the volunteer.

Award Consideration

Safety Excellence Award

George W Burke, Jr. Award *(See Notes Above)

If awarded this year, do you need a new plaque from IWEA?

Yes, we are first time applicants

Yes, our current plaque has no remaining metal plate spots

No, our current plaque has spots remaining

If you are a previous recipient and have a plaque from IWEA, how many date tag spots do you still have remaining?

Facility Name: (As it Should Appear on the Award)(Required)

Facility Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Facility Mailing Address

If same as above, please leave blank.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person(Required)

First Last

Fax

Phone

Please read below:

Due to the number of facilities requesting inspection, it is important for the safety committee to recruit new volunteers for the Safety Committee and auditing of facilities. Please check below if you are willing to help conduct safety audits for the safety committee. It will be noted if your facility is applying for the Burke Award, you will not be assigned to conduct any Burke Award audits.

I would like to volunteer (or appoint another representative) to help conduct Safety Excellence Audits

Plant Classification

Municipal I

Municipal II

Municipal III

Municipal IV

Industrial A

Industrial B

Industrial C

Industrial D

George W. Burke, Jr. Award Application

In order to be consider for the WEF Member Association Award, the George W. Burke, Jr. Facility Safety Award, all applicants must complete the fields below and attach the supporting documentation, where indicated.

Facility Flow

MGD

List of Treatment Processes

Number & Types of Personnel

Status of Safety Program: Please describe the status of the safety program at your facility.

Including, but not limited to: how long the program has been in effect, the method used to develop the program, who is tasked with developing/maintaining the program, if formal and/or written policies and procedures exist, and whether all policies/procedures have been implemented. For elements of the program that are not fully established, explain the progress to date and schedule for future completion.

Is there a formal Safety program?

Yes

Is there a written Safety program?

Yes

Please upload a copy of your written Safety program.

Max. file size: 50 MB.

Personal Safety Awareness Program: How does your facility teach awareness of and encourage personal safety?

Is there a formal Personal Safety Awareness program?

Yes

Is there a written Personal Safety Awareness program?

Yes

Please upload a copy of your written Personal Safety Awareness program.

Max. file size: 50 MB.

Established Safety Goals: What are the goals of the safety program at your facility?

Are there formalized Established Safety goals?

Yes

Are there written Established Safety goals?

Yes

Please upload a copy of your written Established Safety goals.

Max. file size: 50 MB.

Safety Orientation Program: What type of safety-related orientation and/or initial training are provided to new employees or those transferred from other departments?

This may include one-on-one, hands-on, formal classroom, or other orientation/training efforts.

Is there a formal Safety Orientation program?

Yes

Is there a written Safety Orientation program?

Yes

Please upload a copy of your written Safety Orientation program.

Max. file size: 50 MB.

On-going Safety Training Program: What type of on-going safety training is provided to employees?

Provide information about the content, type, duration, and frequency of training, as well as whether it is provided by facility staff, by outside professionals, or a combination. If no formal program exists, show evidence that training is on-going (i.e., list courses attended or required, etc.)

Is there a formal On-going Safety Training program?

Yes

Is there a written On-going Safety Training program?

Yes

Please upload a copy of your written On-going Safety Training program.

Max. file size: 50 MB.

Inventory of Safety Equipment: Please list the safety equipment/supplies currently available for use at your facility.

To ensure that the Committee understands the purpose and value of each piece of equipment, please list the equipment by category (i.e., confined space entry, HAZMAT, first aid, disease prevention, electrical safety, etc.). Feel free to make up your own category headings and use as many categories as you feel are necessary to provide clarity.

Please list any safety equipment that has been formally requested, but that has not yet been purchased or budgeted.

Provide evidence of the formal equipment request.

Max. file size: 50 MB.

Injury Occurrence Statistics: Please provide a summary of the injury occurrence statistics for your facility over the last five (5) years.

Attach copies of OSHA logs or other recognized reporting forms.

Max. file size: 50 MB.

Attach the Workman's Compensation Rating Factor from your insurance company.

Max. file size: 50 MB.

Is there an injury reporting program?

Yes

Is there a written injury reporting program?

Yes

Please upload a copy of your written injury reporting program.

Max. file size: 50 MB.

Safety Committee: What type of Safety Committee has been established to oversee safety at your facility?

Who are the participants on the Committee and how often are meetings held?

Are formal Minutes kept?

Yes

Please upload a copies of the Minutes for the previous year.

Max. file size: 50 MB.

Evidence of Worker Participation in the Safety Program: How is worker participation evaluated?

Is there a formal program for Work Participation?

Yes

Is there a written program for Worker Participation?

Yes

Please upload a copy of your written program for Worker Participation.

Max. file size: 50 MB.

What measures are taken to ensure that employees follow established policies and procedures?

Is there a process for evaluating the qualifications of personnel to perform specific tasks or operate pieces of equipment? Is a written record of these personnel qualifications readily available to supervisors?

Is there a formal program for evaluating qualifications for tasks or pieces of equipment?

Yes

Is there a written program for evaluating qualifications for tasks or pieces of equipment?

Yes

Please upload a copy of your written program for evaluating qualifications for tasks or pieces of equipment.

Max. file size: 50 MB.

Safety Program that Extends Beyond the Treatment Facility: Do policies, procedures, and training efforts encompass and/or encourage safety awareness and behavior outside of the workplace and after hours (i.e., when not at work)? Please elaborate. Does your facility conduct any “outreach” training or have other programs that benefit/encourage safety in the community, contractors, and mutual response operations? Please explain.

Is there a formal Safety Program that Extends Beyond the Treatment Facility?

Yes

Is there a written Safety Program that Extends Beyond the Treatment Facility?

Yes

Please upload a copy of your written Safety Program that Extends Beyond the Treatment Facility.

Max. file size: 50 MB.

Safety-related Articles/Publications/Presentations Done by the Facility or Its Staff Members: Please list any articles/publications/presentations/etc. on safety-related topics prepared by staff at the facility as a facility or individual effort.

Please upload any copies of articles listed above.

Max. file size: 50 MB.

Highlights of the Current Safety Program: Please comment on parts of your program that were successful, improvements made to the program, safety initiatives and suggestions implemented, ways that illness or injury were prevented as a result of the program, and any other highlights of your program during the previous year.

Outstanding Safety-related Feature: Please take this space to describe any safety-related feature that you believe sets your facility apart from other facilities of similar size, design, and staffing.

Is there a formal program that fits the above?

Yes

Is there a written program that fits the above?

Yes

Please upload a copy of the written program listed above.

Max. file size: 50 MB.

Please describe your facility's affiliation with WEF/IWEA.

Total Number of Employees

Number of WEF/IWEA Members

Please upload any verification of WEF/IWEA membership for facility personnel.

Max. file size: 50 MB.

2026 Safety Excellence Award Application

George W. Burke, Jr. Award Application

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