Psychological Safety Award

IMPORTANT: The form does not save your responses during input. Please have all your answers saved in a Word document then copy and paste your answers into the form.
Have you been an employer in Canada for the last five years or more?
Do you have more than 20 employees?
Are you willing to administer an employee perception survey provided by the Canada’s Safest Employers organizing committee to your workforce should you be shortlisted? (See FAQ section for details.)
Note: If you answered No to any of the questions above, you are not eligible to participate in the selection process for Canada’s Safest Employers Awards.
In the last five years, has your company been charged under occupational health and safety, workers' compensation and/or the Criminal Code legislation? (If yes, please give details)
In the last five years, has your company been convicted under the occupational health and safety, workers' compensation and/or the Criminal Code legislation? (If yes, please explain.)
In the last five years, have you incurred any workplace fatalities? (If yes, please explain)
Contact information
Employer name
Street address
Postal code
Contact person (Person responsible for this application)
E-mail address
Telephone number
Alternate contact
E-mail address
Telephone number
About the organization
Brief description of the organization / scope of operations.
Employee profile
Total number of employees
Please note that each question has a 7,000 character maximum.
Demonstrated management commitment (15 points)
Describe how your most senior leaders participate in leading the Psychological Health and Safety Management System (PHSMS) in your organization and how they show commitment to your PHSMS. How is PHSMS defined within your organization?
Risk identification (10)
Describe how psychological safety hazards and risks are identified, assessed and controlled. Please name any instruments used for this purpose.
Training and awareness (10)
Describe how you ensure managers are selected and adequately trained to identify and respond to psychological safety issues in the workplace.
Communication strategies (10)
Describe how you are communicating psychological safety messages to managers and employees. Please provide examples.
Reporting and investigations (10)
Describe your organization’s process for reporting and investigating work-related psychological health and safety incidents. How are psychological safety breaches addressed?
Return-to-work (10)
Does your organization have a developed return-to-work system for people on STD / LTD due to psychological health and safety issues? Please detail.
Employee Assistance Program (5)
Do you have an Employee Assistance Program / Employee and Family Assistance Program? If so list coverage details. Please list name of EAP supplier.
Innovative approaches (15)
Describe, if any, some of the innovative approaches and programs around your psychological health and safety management system (not previously mentioned) that you have implemented and the result of those programs.
Injury statistics in the last three years (5 points)
Lost time injury frequency rate


Statement of Truth
  1. I'm the person named in, and who subscribed in, this application form for Canada's Safest Employers. To the best of my knowledge and belief, the matters and facts in it are true. Where matters specifically stated in it are made upon information and belief, I believe them to be true. I make this declaration conscientiously believing it to be true and knowing that it is of the same force and effects as if made under oath.
  2. I understand if my company is a gold winner we need to participate in a phone interview with a journalist as well as an on-site video shoot. I understand I am not able to see the article or the video prior to publication as they are both pieces of journalism, not personalized marketing items.

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Deadline for submission: May 24
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