Safe and Sound Week - Recognize Your Participation | Occupational Safety and Health Administration

OMB Control Number 1218-0269
Expiration date: 08/31/2027

Recognize Your Participation
Safe + Sound Week Event Feedback Form

To download a Safe + Sound Week certificate of recognition and challenge coin for your organization's participation, please fill out the required information below. We also hope that you will help us by answering a few optional questions about your participation and giving us feedback on our efforts. Please note that you are not required to request a Safe + Sound Week certificate of recognition or challenge coin and that if you choose to do so, OSHA will not use the information or feedback you provide for any purpose other than evaluating Safe + Sound Week and planning future outreach efforts. Also note that the certificate of recognition and web badge do not represent an assessment of compliance with OSHA standards at your worksite(s).

If you have issues with the certificate download, please email safeandsoundcampaign@dol.gov for assistance.

Congratulations and thank you for participating in Safe + Sound Week!

The fields indicated with an asterisk (*) are required to complete your submission.

Participant Information:

Email Address:

Name of Business or Organization:

Industry (select all that apply):

Other:

Did you participate in a U.S. State or Territory?:

Yes

Note: Select a State first before entering the City Name.

State/City/Country:*

Other:

Number of workers reached during your Safe + Sound Week event(s):

What was your primary motivation for participating in Safe + Sound Week?:

Celebrate meeting safety and health goal(s)

Engage workers in thinking about safety and health (e.g., get feedback, provide training, provide recognition, teambuilding)

Launch a new safety and health activity/initiative

Improve my organization's safety and health performance

Respond to a specific safety and health issue within my workplace

Show leadership in our industry on safety and health

Other

Other:

Participating in Safe + Sound Week had a positive impact on safety & health in my organization.:

Questions	Strongly Disagree	Disagree	Neither agree or disagree	Agree	Strongly Agree	NA
Participating in Safe + Sound Week had a positive impact on safety & health in my organization.	Strongly Disagree	Disagree	Neither agree or disagree	Agree	Strongly Agree	NA

Comments:

What did you like most about S+S Week?:

To help us better understand how participants used resources and what would be helpful in the future, Safe + Sound may wish to reach out to you for more information on your experience. Are you interested in sharing more about your experience?:

Yes

If yes, please provide contact information:

Contact Name:

Contact Phone Number:

Sign me up for the monthly Safe and Sound at Work email listserv. I want to receive communications on resources and upcoming events.:

PAPERWORK REDUCTION ACT

Public reporting burden for this voluntary collection of information is estimated to average 3 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. OSHA will use this information to evaluate participation in Safe + Sound Week. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, please send them to OSHAPRA@dol.gov or to US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.

Recognize Your Participation Safe + Sound Week Event Feedback Form

Participant Information:

Recognize Your Participation
Safe + Sound Week Event Feedback Form