Application for the 2021 Safe Worker Award

Fields marked with an * are required.

Name of nominee: *
Nominee's job title:
(This award is not open to management, front line supervisors, or those in dedicated safety positions.)
Name of workplace: *
Type of industry:
Employer WCB firm number (if known):
Workplace address: *
City: *
Province: *
Postal Code: *
Phone number: *
Email address:
Average number of workers: *
Name of nominee as it sould appear on the award: *
Do you wish to let this application stand for two years?
Employee OHC Co-Chair or OH&S Representative:
Employer OHC Co-Chair:
How did you find out about the Safe Worker Award?

To submit your nomination
Complete this form and answer each of the applicable questions. Supplemental materials such as newspaper articles, photographs and publications are welcome.

All nominations must be received at the Saskatchewan Workers’ Compensation Board by October 31, 2020.

You may submit more than one application for your workplace. Please use a separate form for each application. This award is not open to management, front line supervisors or those in dedicated safety positions.

Award Selection
A review committee composed of representatives from each of the partners will evaluate the applications using a standardized evaluation process and criteria to determine the winner.

Email your application:
Complete the online form at or send it to

Questions? Contact Catherine Fuchs at 306.787.4342.

1. Description
Describe the nominee’s involvement with health and safety. *

Does the nominee sit on their Occupational Health & Safety Committee?

2. Tell us about an innovative safety idea or project the nominee championed in the workplace.
Describe how the idea resulted in changes to a job or task. *

Was the idea presented before an incident had occurred?

How was it implemented? *

Why was it implemented? *

3. Were there any barriers to overcome? *
If yes, how did the worker overcome the barriers to implement their idea? (e.g. cost, time, culture)

4. Health and Safety Benefits
What workplace safety and health benefits resulted from the nominee's effort(s) or idea? *

5. Other Measurable Results
Describe any measurable results that can be used to quantify the success of the effort for which you seek recognition. *

6. Cultural Benefits
Describe any cultural benefits that were gained as a result of the nominee’s initiative. *

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