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2012 STEP Application Form

Please Note: Diamond applicants must apply manually.
Also, please make sure you email all supporting documents, including your OSHA 300 and 300A forms to stepapps@abc.org

Section 1: Company Information

Company Name

Address

City

state

zip

Chapter

This application and data:

Represents entire company
Represents specific location, dept, or div.

Is this IDENTICAL STEP application being submitted to other ABC chapters? Yes No

If yes, select the additional ABC chapters to apply:

Primary NAICS Code as entered on your OSHA #300A

Work Type:

Residential	%		Commercial	%
Industrial	%		Public works/Military	%

Percentage of work perfomed:

<100 miles of HQ
Within 101-250 miles
>250 miles

Percentage of your contract work

Self-performed
Sub-Contracted

View Section 2: Safety Performace Data

Refer to your 2011 OSHA FORM 300A for items (a) through (h)

a. Total number of DEATHS (line G on the OSHA 300A)
b. Total number of CASES with days away from work (line H on the OSHA 300A)
c. Total number of CASES with job transfer/restriction (line I on the OSHA 300A)
d. Total number of OTHER RECORDABLE CASES (line J on the OSHA 300A)
e. Total number of DAYS away from work (line K on the OSHA 300A)
f. Total number of DAYS of job transfer or restriciton (line L on the OSHA 300A)
g. Annual average number of employees (as entered in your OSHA 300A)
h. Total hours worked by all employees (as entered in your OSHA 300A)
Incidence rate = [(a+b+c+d) X 200,000] / h
Experience Modification Rate (EMR or "mod factor")
Number of federal/state OSHA inpsections in 2011
Number of federal/state OSHA citations issued (after settlements) in 2011

For calendar years 2009, 2010 and 2011 have you had any employee fatalities corporate-wide that resulted in an OSHA citation?

Yes
No

Length of safety orientation (in minutes)

Toolbox safety talks frequency

Daily
Weekly
Bi-Weekly
Monthly
Other

Do you have a substance abuse program that includes a drug/alcohol screening process?

Yes
No

View Section 3: 20 Key Components Safety Self-Assesment

Click on a KC to pop-up the scoring block/definition. You must not have pop-up blockers enabled.
A. Employer Involvement
B. Policy Statement on Safety
C. Responsiblity for Safety
D. Trailing Indicators
E. Resources for Safety
F. Safety Program Goal Setting
G. Employer Supervisory Meetings
H. Pre-Planning for Jobsite Safety
I. Employee Participation
J. New Employee Orientation
K. Safety Rules
L. Employee Safety Training
M. Toolbox Safety Meetings
N. Inspection
O. Supervisory Training Topics
P. Incident Investigation
Q. Use of Personal Protective Equipment
R. Safety Program Performance Review
S. Substance Abuse Policy
T. Recordkeeping & Documents
Total:
Are you part of ABC's AQC Program?
If applying for Platinum, initial here that you meet all qualification criteria*

View Section 4: Company and ABC Chapter Certification

Name*
Title
Signature (Please provide your initials)*

View Section 5: Insurance Carrier Contact Info

Representatives Name
Title Company
Address
City / State / Zip
Phone Number or Email Address

View Congratulations, you may qualify for STEP's Platinum Level.

In order to apply for Platinum, please provide your payment information below.

First Name
Last Name
Platinum Amount:
Card Type:
Name on Card:
Card Number:	Exp. (mm/yyyy): / *Expiration must be in MM/YYYY format

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Associated Builders and Contractors (ABC) is a national association with 74 chapters representing 22,000 merit shop construction and construction-related firms with nearly two million employees. Visit us at www.abc.org.
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