Safety Champion Recognition Nomination Form

A nomination form for recognizing employees who consistently prioritize workplace safety, follow protocols, and make proactive contributions that reduce risk and improve safety culture.

Nominee Information

• Nominee full name
• Nominee department
• Nominee job title

Safety Contribution Details

• Why are you nominating this employee?
  Summarize the nominee's safety contribution in 2-5 sentences.
• Which safety actions best describe their contribution?
• Provide a specific example of their safety impact
  Include what happened, what the employee did, and the result. Avoid confidential incident details unless necessary.
• What was the outcome of their action?

Recognition and Impact

• How significant was the safety impact?
• Recognition category
• Additional notes for the review team
  Use this field for any context that may help with review or verification.

Submitter Information

• Submit anonymously
  Select this if you do not want your name shared with the nominee.
• Your name
• Your email address
• Your phone number