Safety Award Application
Safety Award Application
Safety Award Application
APPLICATION FORM
NATIONAL SAFETY COUNCIL OF INDIA (NSCI)
AWARDS-2018
FOR SAFETY OFFICERS IN FACTORIES
AFFIX
PASSPORT SIZE
PHOTO
I. Candidate Information:
1 Full Name
4 Contact No
5 Contact E mail ID
7 Educational Qualification
(General & Safety Related)
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II. Information of Factory
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III. Safety performance of factory :
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IV. Performance of safety officer in Safety management:
2 Total number of in house safety training programmes organized/conducted by you. Please provide
following details
3 Total No. of safety training programmes organized/conducted with the help of outside agencies.
Please provide following details
5 Give your contribution in developing Safe Operating procedures (SOPs) including details thereof.
years No. of safety studies / No. of points identified No. of points corrected
surveys / audits
2017
2016
2015
2017
2016
2015
9 Number of Occupational Health and Safety survey conducted/arranged (on Noise, heat,
ventilation, illumination etc.). Explain your role in details
10 Explain your contribution in Hazard identification & risk assessment using technique like HAZOP,
JSA, QRA etc.
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11 Safety committee meetings held during assessment period
1. New initiatives and systems developed and established by you in the last three years.
2. Innovative methods implemented towards Occupational Health & Safety and benefit of it to
organization.
5. Give any other details which make you to feel that you are one of the best safety officer
3. Provide information regarding your role in operation of MARG in your area if any
Bank Name_______________________________________________________________
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VIII. Certificate
Part A
I hereby declare that the particulars given in this application including the documents are true and correct
to my knowledge.
Place: Name:
Designation:
Part B
I hereby certify that the applicant Mr______________________________ is working in our organization for
the past_____________________ years and the particulars provided by him in this application including
Place: Name:
Designation:
Factory Seal:
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IX. Affidavit
I, Mr / Mrs / Ms -----------------------------------------------------------------------------
S/o / D/o ----------------------------------------------------- Residing at --------------------
-------------------------------------------------------------------------------------------------------
--------------------------------------------------- hereby declare that the information
provided in application form and attachments are true & correct. I have
taken initiatives to improve Safety / Health / Environment in the work
place located at -----------------------------------------------------------.
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