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Safety Award Nomination

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To be eligible, the following questionnaire must be completed in its entirety. You may have an unannounced visit by one or more of the members of the KWEA Safety Committee.

Fields marked with an (*) are required.

Section A: General Information

Category(*)
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Name of Community or Industry(*)
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Mailing Address(*)
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City(*)
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State(*)
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Zip(*)
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Name of Treatment Facility(*)
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Approximate Location of Facility(*)
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Facility Address(*)
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City(*)
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State(*)
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Zip(*)
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Facility NPDES Permit No.(*)
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Full Name(*)
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Phone(*)
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Email(*)
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Section B: Process Information

Design Capacity of Facility (MGD)(*)
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Check all applicable unit processes included in facility operation(*)

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Disinfection - Other (Please describe)
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Other Unit Process(es)
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Number of full-time operations personnel assigned to your facility(*)
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What percent of certified personnel is assigned to your facility?(*)
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Section C: Safety Information

Does your organization have an active safety program?(*)
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Please provide a general description of your program.
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Does your wastewater department have a person assigned as a safety coordinator?(*)
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How many accidents occured in 2016 at your facility as a result of not using proper safety equipment?(*)
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How many accidents in 2016 resulted in lost time whatsoever?(*)
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How many man-hours of actual work were lost in 2016 due to accidents at your facility?(*)
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Do you have monthly meetings for the purpose of discussing safety issues at your facility?(*)
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Do you require pre-employment physical examinations of all personnel?(*)
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What percent of employees at your facility have received first-aid training within the last three years?(*)
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