Safety Summit Award Nomination Form
AWARD PROGRAM INFORMATION
The Zero Fatalities Award Program recognizes individuals and organizations who have made contributions to transportation safety in the State of Utah. The program recognizes accomplishments in the public and private sector by individuals, state and local governments, federal agencies and businesses and organizations that promote traffic safety. This program is sponsored by the Utah Department of Transportation (UDOT), the Utah Department of Public Safety (UDPS), and many other traffic safety partners that are dedicated to reducing death and injury on Utah's roadways. Nominations should include:

1. Description of the program(s) and/or activities that the nominee has conducted, why they occurred and what made them unique.

2. Supporting information or data on what problems existed and what the desired accomplishments were.

3. Description of outstanding elements or accomplishments of the nominee or programs (e.g. number of people trained, number of people impacted, etc.).


ELIGIBILITY
Any individual, organization, business or government agency is eligible. The nominee must have made an outstanding effort to change the attitudes and behaviors of motorists leading to the reduction of crashes, injuries and fatalities associated with transportation in Utah.


CRITERIA FOR SELECTION
There are eight award categories for which nominations will be accepted. Award selection will be made by the Zero Fatalities Safety Summit Planning Committee. Entries will be judged on impact on the community, program effectiveness, creativity, innovation and overall dedication to the field of transportation safety. An additional award category, Outstanding Traffic Safety Program Award, recognizes one UDPS and one UDOT project or subgrantee, and is selected by department leadership.


NOTIFICATION & PRESENTATION OF AWARD
Winners will be notified by March 21, 2018 and will be honored at the Zero Fatalities Safety Summit Awards Ceremony on Wednesday, April 11, 2018 at the Utah Valley Convention Center in Provo, Utah. Award recipients will be able to attend the summit at no charge and will be provided with lodging and other travel expenses, if necessary. In addition, recipients will be able to bring up to four additional guests to the awards luncheon.


SUBMIT
Completing this form online will submit your nomination. If you have any questions or concerns please contact Robyn Lalumia, Utah Highway Safety Office, at 801.386.1888.


NOTE
Activities and programs must have taken place during calendar years 2016-2018. This requirement applies to all award categories except the Zero Fatalities Leadership Award, which honors an individual for sustained outstanding leadership. For nominations in this category, please include all relevant information that demonstrates a long-term effort to make Utah's roadways safer.

Select Award Category
To review award categories, visit ut.zerofatalities.com/summit/awards-program/
Name
Of person (first and last) or organization being nominated for award
Your answer
Title and Employer (if applicable)
Of person or organization being nominated
Your answer
Street / Mailing Address
Of person or organization being nominated
Your answer
City, State
Of person or organization being nominated
Your answer
Zip Code
Of person or organization being nominated
Your answer
Nominee's Phone number
Please provide the best phone number for contacting your nominee
Your answer
Person Submitting Award Nomination
Please provide first and last name
Your answer
Title and Employer
Of the person submitting award nomination
Your answer
Street / Mailing Address
Of the person submitting award nomination
Your answer
City, State
Of the person submitting award nomination
Your answer
Phone
Of the person submitting award nomination
Your answer
Email Address
Of the person submitting award nomination
Your answer
Explain why you are nominating this individual or group for a Zero Fatalities Award. Review the award categories [link to safety summit nomination webpage] and provide information that is relevant to the award for which you are nominating this person, team or organization.
Your answer
Include a description of the programs and/or activities that the nominee has conducted. Why did it occur and what made it unique? Include any relevant information and data on what problems existed and what the desired accomplishments were.
Your answer
Describe any outstanding elements or accomplishments of the nominee or program (e.g. number of people trained, number of people impacted, reduction in fatalities etc.)
Your answer
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