The Official Website of the State of Arkansas

Safety Award Questionnaire

Safety Award Questionnaire

Questionnaire

If the company has been classified as a Rule 32 program employer, the company does not qualify for an award.

This field is hidden when viewing the form

Section Break

Company Name(Required)
Site Address:(Required)
Mailing Address:(Required)
Contact Person(Required)
Type of award company qualifies for:(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Does your company have a safety program established?(Required)
Does your company have a safety committee?(Required)
Does the committee represent both employees and management?:
Will there be any type of ceremony?:(Required)
If not, will it be acceptable for the award to be mailed?:
MM slash DD slash YYYY
Time
:

Contact Information