NYS Agricultural Society

Farm Name*

Farm Owner(s)*

Address of Farm*

Please include street or PO Box, city, state, zip

Phone # of contact at Farm*

Email

Farm type*

Number of Employees*

Does your farm have (select all that apply):*

Safety committee

Incentive/motivation program

Employee wellness program

Formal training/mentoring program

Safety inspection program

Hazard correction program

What is your farm's policy/philosophy regarding safety?*

Please provide an example of your management's commitment to safety (please also provide key elements of your safety and health program).*

Please provide 2 examples of ways your employees are encouraged to participate in the safety process.*

Please provide a photo of your team

Other important file (photos of the farm, awards, etc.)

Name, title and email of person nominating*

New York Farm Safety Award Application