Loss Prevention Incentive Program Checklist
Purpose: This checklist is designed to make it easy for Safety and Wellness Committees to
track district progress towards earning the annual Loss Prevention Incentive offered by STSIG.
As items are checked off, initial in the appropriate box. When all activities have been completed
and the checklist has been signed by your district representative, please forward the form to
Kurt Walling at kwalling@stsig.org. If you have questions or seek clarification do not hesitate to
call us at 530-221-6444
DISTRICT:___________________________
REQUIRED ACTIVITIES:
1
Maintain an active safety committee that meets regularly though the year.
 Four committee meetings complete
 Illness and Injury Prevention Plan (IIPP) updated and approved by the district
board
 District Safety Champion identified (name)________________________
Activity 1 complete (initial)_______________
Participation in STSIG Loss Control Trainings throughout the year.
2
SIZE
Very Large Districts (Annual Payroll greater than $10 million)
Large Districts
(Payroll $5 million - less than $10 million)
Medium Districts
(Payroll $2 million – less than $5 million)
Small Districts
(Payroll less than $2 million)
Note: Classes must be completed by June 30.
MINIMUM ATTENDEES
50
25
10
3
Activity 2 complete (initial)_______________
3
4
Begin work on or review your existing Return To Work (RTW) program.
 Meet with Dennis Chandler, RTW Consultant (Contracted by STSIG)
Activity 3 complete (initial)_______________
Develop an active safety and wellness communication program.
 Signed memorandum forwarded to STSIG listing dates and types of
communication (examples onsite bulletin boards, employee newsletters, district
website, etc)
Activity 4 complete (initial)_______________
I certify that the four activities have been completed and my district qualifies for the loss
prevention incentive.
District Representative Signature__________________________