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Safety Awards Entry Form

Company:*
Contact Person:*
E-mail:*
Phone:*
-
Construction Type*
Section (G) Number of Fatalities*
Section (H) Number of Cases with Days Away from Work*
Section (I) Number of Cases with Job Transfer or Restriction*
Section (J) Number of other Recordable Cases*
Total company work hours:*

Cases only for heavy, highway, railroad and utility work performed within the 33 counties of Western Pennsylvania.

Section (H) *
Work hours*