HAZARD ELIMINATION LEARNING PROGRAM APPLICATION EMPLOYER SERVICES DIVISION SFN 54493 (11/2005) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-3800 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com Please type or print clearly. All employers must complete Sections 1-6 and the attached W-9. Thank you for your interest in providing a safe workplace for your employees. The WSI HELP Review Team will use your application to approve or deny the project. Therefore, the information you provide on this application must describe the significance of the problem and the effectiveness of the safety intervention. Incomplete application forms will be returned. Please attach any and all supporting materials with this application. SECTION 1 – EMPLOYER INFORMATION Name of Employer Employer Contact Name Employer Address Title City State Zip Phone Number Email Address WSI Employer Account Number Applicant Signature Fax Number Date To ensure WSI has the necessary information to issue grant funds, please complete the attached W-9 form. The W-9 will be used by the state accounting system and will allow WSI to process reimbursement of funds to successful applicants. SECTION 2 – EMPLOYEE IMPACT INFORMATION Baseline Data – Please complete the requested information below. Reporting period – Provide the dates that begin and end the two-year reporting period for the baseline data. The reporting period must be two years prior to date of this application. The end date should be in the recent past, within one month prior to submitting the application. (Example: today is January 1, 2006, the reporting period could be December 15, 2003-December 15, 2005). All information requested in this application should reflect the two-year reporting period provided. Beginning Date Ending Date Number of employees affected – Provide the number of employees that will be directly affected by the proposed safety intervention. (For reporting purposes, these employees will be considered to be the POPULATION.) Please note that the population may or may not include all employees at your facility. For example, a nursing home facility that employs 65 people is awarded a grant to purchase four hoyer lifts as a safety intervention. The hoyer lifts only affect the 14 nursing and CNA staff. The population, in this example, only refers to the nursing and CNA staff that work with this safety intervention. The other 51 employees comprised of administration, housekeeping, dieticians, etc. would not be included in the reporting number for the population because they don’t specifically work with the hoyer lifts. Number of employees affected: Population hours worked – Provide the total number of hours worked during the reporting period by the population. Include the hours worked only by those in the population, and include all the hours worked by the population, regardless of what tasks the population was performing. Include overtime hours, but exclude vacation, sick time and other leave. Population hours worked: American LegalNet, Inc. www.FormsWorkflow.com HAZARD ELIMINATION LEARNING PROGRAM APPLICATION (cont’d) WSI Employer Account Number PAGE 2 Employer SECTION 2 – EMPLOYEE IMPACT INFORMATION (cont’d) Exposure level – List the dates of all the claims, near hits, near misses, and/or incident reports that were filed during the reporting period by those employees in the population. Please list only those claims/near misses/near hits/incident reports that occurred to employees who are in the population; do not list those that were filed by employees who will not be affected by the safety intervention. Please provide a copy of any supporting near misses/near hits, incident reports, and incident investigations along with this application. Please submit the following information on a separate document with this application. SECTION 3 – DESCRIPTION OF THE PROBLEM Loss Experience – Quantify the loss experience for the area affected by your proposal. Supporting information should include: • Injury/illness claim frequency rate for the population for the two-year reporting period. (Formula = # claims x $1 million/gross payroll). • Types of injuries/illnesses for the population. • Body parts affected for the population. • Estimated: Monetary impact of direct costs such as claims costs including medical costs and cost of lost wages, productivity interruption or stoppage, property damage, etc. Monetary impact of indirect costs. The following examples can be used to calculate indirect costs, but not limited to: time involved to complete the task by injured worker compared to time to complete the same task by new or retrained employee, cost of wages of supervisors, management and clerical workers associated with the paperwork and investigations due to incidents and accidents, time associated with employees in the population that stopped work to assist with the incident, rehiring and retraining costs, overtime necessitated by incident, etc. • Employee turnover rate of the population (turnover rate formula= total # employees separated from employment/total # of employees). Exposure – Quantify the exposure and the potential risk factors for the tasks which will be affected by your proposal (ex., excessive force, repetitive motion, awkward postures, exposure to pinch points, electrical hazards, chemical hazards, fall hazards, etc.) Supporting information should include: • Videos, photographs, or drawings of the affected operation. • Description of risk factors associated with affected tasks. • Exposure levels of chemical hazards (if available). • Pertinent job hazard analyses and standard operating procedures for the affected tasks. • Productivity – What is the cost, in quantitative terms (ex., parts per hour, time per task, etc.), to complete the task with the current method used. • Quality – describe how quality is measured for the operation, ex. defective parts, employee satisfaction of product quality issues, customer satisfactions, etc. • Cost – given your productivity measurement, what is your cost to produce/make/complete this task? This will be used in the future to calculate return on investment. SECTION 4 – PROPOSED INTERVENTION Description – Provide a description of the safety intervention. A thorough description should include: • A description of how the safety intervention will be incorporated into the process/task of operation and how the safety intervention works. Supporting materials could include diagrams, photographs, videos, brochures and links to vendor web sites; • The anticipated impact, including how the safety intervention will eliminate or dramatically reduce the risk of injury; and • Training requirements, if any. Will the safety intervention cause any other foreseeable hazards? If so, please explain. American LegalNet, Inc. www.FormsWorkflow.com HAZARD ELIMINATION LEARNING PROGRAM APPLICATION (cont’d) WSI Employer Account Number PAGE 3 Employer SECTION 5 – IMPLEMENTATION Implementation plan – Describe your plan to implement the safety intervention, identify who will be responsible for implementation, and define the expected time to implement the intervention. If the period exceeds 30 days to implement the safety intervention, please explain why. • Please complete the itemized expense information for your project. Attach additional sheets if necessary. Attach original vendor price quotes for all proposed items. SECTION 6 – BUDGET Item Quantity Cost/Unit Total Grand Total Funding lifetime maximums are determined according to the premiums shown. These premium levels are based upon standard premium (manual premium as modified by the experience rate surcharge or discount) for the most recent completed premium year. PREMIUM SIZE LIFETIME MAXIMUM Minimum - $2,000 $10,000 $2,001-$5,000 $25,000 $5,001 and greater $50,000 To determine the grant amount you are requesting please complete the worksheet below. The HELP award is based upon a 5-to-1 cash match; with WSI contributing the large portion of the ratio. WSI may contribute upon submission of a successful application, up to the lifetime maximum for the duration of this program. Standard premium: Total Amount of project (A) (A/6 = B) Total Amount supplied by applicant Total Amount supplied by WSI (WSI total not to exceed lifetime maximum as shown above) (B) (A-B) Please submit the Hazard Elimination Learning Program application and all supporting documentation to: HELP Program Coordinator Workforce Safety & Insurance 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck, ND 58506-5585 American LegalNet, Inc. www.FormsWorkflow.com