Before completing any grant application, be sure to review the pre-application steps.
Applying for a safety intervention grant
- Access the online Application for Safety Intervention Grant (SH-53)
- Complete the questions on the online application. Do not click submit..
- Save the online application. This will allow your Division of Safety & Hygiene (DSH) consultant to review Section I through Section V prior to submission. If you save the application, you may update it at any time prior to submission.
- Download and print Section VI (Budget) and Section VII (Statement of Agreement), which includes a DSH Consultant Review/Signature page.
- Complete the Budget and Statement of Agreement sections in hard-copy format, and then have your DSH consultant review your entire grant application, Section I through VII.
- The DSH consultant will then complete the DSH Consultant Review/Signature page. If you fail to complete this step, we'll return the Budget page, Statement of Agreement and application to you and will not consider your grant request.
- To schedule an appointment with a DSH consultant, call 1-800-644-6292.
- Once the DSH consultant has completed the review, submit your online application and print a copy for your files.
- You must mail the original signature documents, which includes both the Budget with price quotes and Statement of Agreement, along with the DSH Consultant Review/Signature page to the address below.
Ohio Bureau of Workers' Compensation
Safety Intervention Grants
13430 Yarmouth Drive
Pickerington, OH 43147-8310
Additional information on the Budget and Statement of Agreement, and other required forms
- Completing the Budget
Budget and Statement of Agreement signatures
- You must list all items and costs associated with your grant request in the Budget. You must provide equipment price quote(s) from your selected vendor. The price quote(s) must include the vendor's name, address and date of the quote,
and a contact name with phone number. Additionally, the quote(s) must include the employer's information with company location.
- The price quote should be obtained within 30 days prior to submitting the application. BWC highly recommends obtaining a price quote which is good for up to 120 days or longer.
- The Budget and quote detail must match one another. If a cost is not included, it will not be considered.
- If you do not include all price quotes, we'll consider your submission incomplete.
- You must include price quotes for all items requested in the Budget. Each item description and dollar amount must match the vendor price quotes.
- You must include freight and tax in both the budget and price quotes (even if estimated).
- All budget lines must multiply across correctly, and the sum in the Total column MUST be correct. In the calculations section, no rounding is allowed. Include all cents.
As a grant recipient, the state considers you a state supplier. This means you must obtain a supplier ID number and complete the two forms below.
Then send them to Ohio Shared Services.
NOTE: Your information provided on these forms must match the information provided under your BWC policy. If your BWC policy information is outdated, you must
update it to receive your grant funds.
- The Budget and Statement of Agreement sections require the signature of someone with fiduciary responsibility for the company, employer's legal name, and principal business location.
Note: We will return incomplete/incorrect and/or non-original signature forms which will delay the process.
- If you fail to include the DSH Consultant Review/Signature page, we will return the other documents to you and will not consider your grant request.
- We must receive the Budget with price quotes and Statement of Agreement with original signatures before we consider your grant request.
- Employers must sign the budget and statement of agreement, and initial the online application. This indicates they have primary fiduciary responsibilities under the employer's BWC policy number.
- The employer agrees the signer or any other person replacing them in the future will have the authority and responsibility to ensure the employer will fulfill its obligations to BWC for the one year after implementation of the intervention.
Request for Taxpayer Identification Number & Certification (W-9)
Complete all applicable sections of the document, including taxpayer type, a valid tax identification number and responsible party's signature. We do not accept
electronic signatures. The information you provide must match how you're registered with the IRS. You can find instructions for completing the form on the IRS website.
Should you require additional assistance, contact the IRS at 1-800-829-1040.
Authorization Agreement for Direct Deposit of EFT Payments (OBM-4310-Rev.11/1/2011)
The preferred method of payment for the State of Ohio is EFT. Complete this form and include a current voided check or bank letter. The agreement contains instructions. Send the completed forms to:
Ohio Shared Services
P.O. Box 182880
Columbus, OH 43218-2880
Employers may only use safety intervention grant funds to purchase ergonomic, safety and/or industrial hygiene equipment to substantially reduce or eliminate workplace injuries or illnesses. Employers may test equipment
before applying for a safety grant. BWC grant funds will not be used to cover the cost of testing. Therefore, the agreement for the testing period is between the employer and the vendor. If the employer decides to test equipment
and applies for grant funds to purchase the equipment, the baseline data must be the two-year period prior to the test period. Include prior rentals or testing of requested equipment in your application. Also, include the
frequency of your rental.
Concurrent program participation
Employers may participate in both the current Safety Intervention Grant Program and FEEEG Program.
Prior grant applications
Employers must be current on receipt documentation and quarterly reporting, including their case study and cost benefit analysis, for all "in program" grants at the time they submit a new grant application. BWC will not review new applications
until the delinquent documentation is received and accepted by the grant department.
Moratorium items and unapproved purchases
Equipment is placed on the moratorium list once enough information and data has been gathered to demonstrate the effectiveness of the safety intervention. This list is dynamic and will be updated throughout the life of the Safety Intervention Grant Program.
Additionally, we have included a list of unapproved items which are outside the scope of the Safety Intervention Grant Program.
Note: The unapproved list is NOT all inclusive.
- Anti-fatigue mats
- Automated external defibrillators (AED)
- Automated beverage dispensers
- Bathing systems
- Bleachers/powered bleacher systems
- Boom lifts - articulated and/or extensible
- Bulk material transferring / dispensing equipment
- Cable pulling equipment
- Chairs (i.e. office chairs, industrial stools, etc.)
- Clothes pressing machines
- Conduit bending equipment
- Crash attenuators
- Deep fryers
- Digital x-ray equipment
- Dough mixers
- Dry cleaning and Laundering machines. Exception: Turnout Gear machines
- Earth moving equipment: (i.e. skid steers, front-end loaders, bobcats, etc.)
- Electric beds
- Floor cleaning equipment
- Flooring/floor treatments
- Food slicers
- Forklifts, Ride-on pallet trucks
- Fry hoppers; Oil filtration systems and related equipment
- Hydro excavation systems
- Orchard storage bins
- Order picking equipment
- Portable Traffic Systems/Signals
- Powered hand tools. Exception: Pipe saws
- Remote meter readers
- Road repair systems
- Saws with flesh detection technology
- Shrink wrap equipment
- Sit/stand workstations
- Snow removal equipment
- Standard guardrailing systems
- Tables (i.e. cafeteria tables, etc.)
- Tire changers/wheel balancers/alignment machines
- Truck/trailer restraints, Dock leveling systems
- Valve maintenance exercising equipment
- Vehicle lifts
- Vehicles: all driven vehicles including, utility vehicles, tractors, etc.
- Veterinary adjustable tables (i.e. stretchers, carts, etc., for transport, lifting, or care of animals)
- Veterinary bathing systems
- Walk behind loaders
- Wire/cable stripping equipment
- Wrist splints
- Back belts
- Basic machine guarding devices and equipment
- Building and/or property improvements
- Consumable goods
- Equipment for new buildings
- Equipment intended to meet minimum OSHA compliance
- Equipment related to capital improvement projects
- Exercise equipment
- Interventions used solely for rehabilitative purposes
- Office interventions
- Personal protective equipment
- Passive devices (i.e. cameras, security equipment, monitoring equipment, warning devices, etc.)
- Rented or leased equipment
- Routine equipment replacement
- Training simulators
- Vehicles: All driven vehicles including cars, gators, trucks
Guidance for Powered Cots and Cot Loading Equipment
Employers may apply for cot loading systems or cots with an integrated loading system. They may apply for a powered cot that raises and lowers the patient only if
they are replacing a manual cot AND if they're also purchasing or applying for a powered load system that will safely assist in loading the cot and patient onto the