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100 Years of Safety Pledge Form

An estimated 6 million lives have been saved over the past century due to the efforts of the safety movement. On the Journey to Safety Excellence, we continuously work to progress and improve. In the coming year, we will be gathering your safety pledges and will share the collective results at the 2013 NSC Congress & Expo Leading Safety into the Future. Together we can make an even greater impact in the century to come starting with your pledge.
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First Name*
Last Name*
Company Size*  
[If you are an individual, please add your name under company name and list company size as 1]
Zip/Postal Code*    
Phone* - -
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On your Journey to Safety Excellence, impact the future of safety by making a pledge in the following area(s). (Fill out all that apply)
I pledge to make a difference in workplace safety by: (limit 50 words)
Sample pledges
  • Identifying and correcting hazards that could harm my co-workers
  • Making my workstation ergonomically correct
  • Starting each meeting with a 5 Minute Safety Talk
I pledge to make a difference in preventing cell phone distracted driving by: (limit 50 words)
Sample pledges
  • Refraining from using my cell phone while driving
  • Explaining the dangers of using a cell phone while driving to my friends and family
  • Ending phone calls with others if I know they are talking while behind the wheel
I pledge to make a difference in teen safe driving by: (limit 50 words)
Sample pledges
  • Knowing the teen driving laws in my state, but following the best practice principles of Graduated Drivers Licensing
  • Encouraging teen drivers not to drive after dark, with teen passengers or while using a cell phone
  • As a parent, continuing to practice driving with my teen driver at least 30 minutes a week before and after they earn their license
I pledge to make a difference in safety in my home and community by: (limit 50 words)
Sample pledges
  • Removing tripping hazards, such as clutter and cords, from each room in my home
  • Creating a family fire escape plan and practicing it
  • Looking into getting my community designated as a Safe Community through the Safe Communities America program
I pledge to make a difference in preventing prescription drug overdose by: (limit 50 words)
Sample pledges
  • Never sharing my prescription drugs with anyone
  • Properly disposing of unused prescription medicine
  • Keeping my medication up and away and out of sight of children
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