IMWCA Safety Study Grant Application - Iowa Municipalities Workers' Compensation Association

Organization

Contact Name

First Last

Contact Email

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Total Number of Employees

Total Number of Employees To Be Trained

Hazards to be Addressed in Application (please check all that apply)

Other Hazard To Be Addressed

Total Amount Requested

Tell Us About Your Project

Briefly describe the nature of the project including a description of the training and services provided. Be sure to state how you plan to implement your project and the long term goal.

What Are Your Safety Study Goals

Identify and describe the injury history of the targeted occupation(s) (if any), or preventative safety issues you intend to address in this proposal. Connect the safety study with the work the employee performs.

Budget Narrative

Please provide a detailed written description of the proposed study plan, explaining how each item in the budget summary will be utilized. The aim is to evaluate the cost-effectiveness of the program, identify the safety study objectives, outline the cost of each item, specify the budget line item, and describe how the program will be funded in the future.

IMWCA Safety Grant Application