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OhioBWC - Employer - Form: (Safety Grant Application) - Introduction

Application for Safety Intervention Grant (SH-53)

Introduction
BWC awards safety grants to employers for the purchase of ergonomic, safety and/or industrial equipment. Employers can use this equipment to help reduce or eliminate injuries and illnesses. With the safety intervention grant, private and public employers are eligible for a 3-to-1 matching grant, up to a maximum of $40,000 for each eligibility cycle. This means BWC gives $3 for every $1 the employer contributes. In return, the employer will submit to BWC quarterly data reports and a case study one year after the date of the intervention. BWC will use this information to determine the effectiveness of the intervention and share successes with other employers.

IMPORTANT: Prior to completing the online application, you must meet with a BWC consultant. If you have not done so, we'll not consider the application.



Additional information
While there are seven sections in the application, you can only complete the first five online. You must download and print Section VI (Budget) and Section VII (Statement of agreement), complete both in hard-copy format, and mail them to the address below. The sections require signatures, employer's legal name and principal business location. Incomplete forms will be returned.
Download sections VI (Budget) and VII (Statement of agreement)
Ohio Bureau of Workers' Compensation
Safety Intervention Grants
13430 Yarmouth Drive
Pickerington, OH 43147-8310



Required information

NOTE: If you plan to copy and paste any of your answers from other documents, please use Internet Explorer, more specificially versions 7, 8, 9 or 10. You cannot copy and paste from Internet Explorer 11 or any other Web browser. We apologize for the inconvenience.
  • BWC policy number
  • Employer contact name, title, address, phone number and email for the Safety Intervention Grant Program
  • Number of full- and part-time employees
  • Number of hours worked for full- and part-time employees
  • Description of what organization does
  • Job tasks and area of operation in which intervention will be used
  • Current situation and conditions
  • Risk factors associated with area of operation
  • Description and severity of injuries/illnesses that have occurred in the area over that last two years
  • Estimated costs of the injuries/illnesses
  • Estimated employee turnover due to the injuries/illnesses
  • Affected body parts of the injuries/illnesses
  • Description of equipment to be purchased and how it works
  • How employees will be trained on new equipment
  • Does the intervention create an additional risk/hazard? Yes or No.
  • How the intervention will reduce or eliminate exposure and how it will reduce or eliminate injury
  • How the intervention will impact productivity and quality
  • Name and title of person responsible for implementation
  • Time it will take to order and install equipment
  • Name and title of person responsible for training employees on the new equipment
  • Name and title of person responsible for completing BWC follow-up reports

IMPORTANT: Be sure you have all required information and additional documentation before you begin. Once you start completing the grant application, the system will automatically time out after 20 minutes of inactivity. If this occurs, you will have to start over.


If you have all the required information on hand, simply click the start button to begin.

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