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KWEA Plant Safety Award Nomination

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Please complete all required fields!

To be eligible, the following questionnaire must be completed in its entirety and submitted by June 1. 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(*)

Please SelectCategory A: Less than 1.0 MGD Treatment FacilityCategory B: 1.0-5.0 MGD Treatment FacilityCategory C: Greater than 5.0 MGD Treatment FacilityCategory D: Industrial Treatment Facility

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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(*)

Please SelectAlabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho IllinoisIndiana Iowa KansasKentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri MontanaNebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsylvaniaRhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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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(*)

Please SelectAlabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho IllinoisIndiana Iowa KansasKentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri MontanaNebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsylvaniaRhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

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Zip(*)

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Facility NPDES Permit No.(*)

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Submitted By

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(*)

Facilities Lagoon

Aerated Lagoon

Influent Pump Station

Bar Screen

Comminutor

Grit Removal

Primary Clarifier

RBC

Trickling Filter

Activated Sludge

Extended Aeration

Pure Oxygen

Aerobic Sludge Digestion

Anaerobic Sludge Digestion

Sand Filtration

Chemical Treatment

Vacuum Filtration

Centrifuge

Belt Filter Press

Incineration

Disinfection - Chlorine

Disinfection - Ozone

Disinfection - UV

Disinfection - Other (Please describe)

Other (Please describe)

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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?(*)

Yes

No

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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?(*)

Please SelectYesNo

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How many accidents occured in last calendar year at your facility as a result of not using proper safety equipment?(*)

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How many accidents in the last calendar year resulted in lost time whatsoever?(*)

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How many man-hours of actual work were lost in the last calendar year 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?(*)

Please SelectYesNo

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Do you require pre-employment physical examinations of all personnel?(*)

Please SelectYesNo

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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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