Montana University System
Self-Funded Workers’ Compensation Program
$afety $mart Program
APPLICATION
Instructions
Please type or print clearly.
The MUS Self-Funded Workers’ Compensation Committee will use the $afety $mart application
to approve or deny the proposed safety/loss control initiative. The information provided on this
application must describe the significance of the problem and the effectiveness of the proposed
solution. Incomplete application forms will be returned. When signed by authorize
representative, attach supporting materials to the application and submit to:
MUS Self-Funded Workers’ Compensation Program
$afety $mart Proposal Review
ltietz@montana.edu
Section I: Employer information
Montana University System location:
Unit/Department/Program:
Unit/Department/Program Supervisor:
Application contact name:
Telephone number:
Accounting Contact Name:
Title:
E-mail:
Phone:
Email:
Section II: Employee Information
Provide the number of employees and approximate frequency and duration of tasks that will
be addressed by the proposed safety/loss control project. Provide a brief description on
how you arrived at these numbers.
Section III: Description of the problem
Provide a brief description of the safety concern and how you are proposing to address it.
Supporting information should include:
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Indicate if seeking funds for a “Targeted Project” or for a “Safety Initiative” (see
$afety $mart Policy for description)
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A description of the applying unit/department/program;
A description and/or pictures of task(s) being performed;
Description of hazards associated with the tasks;
Related workers’ Comp claim history to include number, types, and costs of claims,
and time loss incurred over the past 5 years, (this may be requested from your
campus work comp claim coordinator);
Documented equipment or material damage or loss, if available;
Near-hit reports, if available (incidents where no one was injured);
FY14 $afety $mart Application
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Other pertinent information such as why or how the situation presents a work place
hazard, risk or loss potential not otherwise reflected in the data.
Section IV: Proposed Safety/Loss Control Initiative
Provide a thorough description of the proposed safety/loss control project, to include:
 Description of the proposed safety/loss control project and why this is the best
solution - supporting materials could include assessment of alternative approaches,
diagrams, photographs, videos, brochures, cost benefit analysis, statistics, and links
to Web sites;
 The safety goal of the proposal;
 Specific items or training to be acquired with $afety $mart funds;
 Initial and ongoing training requirements;
 Any hazards that may be introduced through implementation of the proposal and
how they will be addressed;
 The anticipated useful life of this specific safety investment;
 Potential applicability to other units/departments/programs or situations.
Section V: Budget
Please provide the proposed budget for the project. $afety $mart funds may be used only
for purposes stated in the Policy and as described in this application. $afety $mart funds
may not be used to reimburse for expenditures made prior to receipt of awarded funds.
$afety $mart funds may not be used to pay for any costs associated with preparing the
application.
Itemize all expenses associated with the project anticipated within the award year. Add as
many lines as necessary.
Item
Quantity Cost
Total
To ensure that $afety $mart funds are awarded to projects that are well planned for longterm success, complete the budget information below if proposed safety project will entail
ongoing expenses, training or operations and maintenance, and how these expenses will be
paid. Identify additional expenses and funding sources if applicable.
Total amount of ongoing costs / timeline
Training
Operations and Maintenance
Other…..
Quantity Cost
Total
Source
FY14 $afety $mart Application
Section VI: Implementation, measurement and reporting
1. Implementation plan – Describe your plan to implement the proposed safety/loss control
initiative. Please include:
 The person or team members responsible for the implementation;
 Anticipated timetable for $afety $mart fund expenditure and project completion.
2. Required Report – All $afety $mart fund recipients are required to submit an electronic
report describing the effectiveness of the $afety $mart investment within 90 days of the end
of the fiscal year in which $afety $mart funds were awarded. Information in the report is
expected to include, but is not limited to the following:
1. A description and/or pictures of task(s) being performed before $afety $mart funding;
2. A description and/or pictures of task(s) being performed after $afety $mart funding;
3. Whether the funded goal was met and any supporting data or material; if the goal was not met,
what lessons were learned;
4. Accounting of $afety $mart fund expenditures;
5. Number of employees and departments impacted;
6. The anticipated useful life of this specific Campus $afety $mart investment;
Thank you for your commitment to providing a safe and healthful workplace with well
trained and well equipped employees.
By my signature, I agree to fully comply with the terms and conditions of the $afety $mart
program and to use all funds solely for the purposes intended. I further understand I may be
subject to civil, criminal and/or administrative penalties as the result of any false, fictitious
and/or, misleading or fraudulent statements made and/or if funds are not used, or are misused,
misapplied, or misappropriated in any way and/or are used for purchases and/or services not
associated with the approved budget and/or itemized proposal submitted.
_________________________________
Authorized representative (printed name)
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Signature authorized representative
_________________________________
Title
________________________________
Date
FY14 $afety $mart Application