Print & Submit Evaluation Form

Download and print PDF, fill out contact information, and score each section.

Once completed please send to Mike Flowers by email ( or mailing a printed copy to:
NUCA STAR Program 
ATTN: Mike Flowers - Safety Director
3925 Chain Bridge Road, Suite 300
Fairfax, VA 22020

Review each key section carefully and evaluate your company's standard practices and/or policies currently in place.

How to score points: 
Start your review with the first point subsection (12 points). If your company meets all guidelines/practices, you can score 12 points in the text box under SCORE SECTION. If you cannot agree that your company meets all guidelines under the 12-point section move on to subsection 8 – 0. Score yourself accordingly in the SCORE SECTION text box.  

IMPORTANT NOTE: If you do not evaluate your company 8 points and above this is a key indicator that those areas need additional attention moving forward.  

The NUCA Safety STAR Review Board will review and may request additional documentation (i.e., supporting safety policies, mission statement, training records, etc.).as part of the overall review process prior to awarding your STAR level membership.