First Name:  
Last Name:  
Company Name:  
Phone Number:  
Street Address:  
City, State and Zip:  
Email Address:  
 

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How did you hear about our services?
What kind of industry are you in?  
Does your organization incorporate a single or muliple facilities? Single Multiple
What is the square footage of the building(s) (approximate)?
How many employees do you have (approximate)?  
What are some of your safety issues (i.e. forklifts, machine guarding, blood borne pathogens etc)?
 
Have you been audited by OSHA in the last three years? Yes No
How soon would you like to get started?  

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Please choose True or False for each question
(If you do not know the answer to a question, please choose "False")

True False We have a comprehensive corporate "Health & Safety Policy" manual plan in place
True False We are familiar with local, State & Federal regulations and we abide by them
True False We display the Federal "It's the Law" poster (or state equivalent) in a conspicuous place
True False We have developed a comprehensive written safety inspection process
True False We conduct written safety inspections on a regular basis (monthly or more frequently?)
True False We keep all OSHA records for a minimum of five years
True False We keep records of employee injuries and illnesses using OSHA Forms 300, 300A and 301
True False During February through April we display the OSHA Form 300A in a conspicuous place
True False Annually we review our records, training, inspections and safety policies to make improvements
True False We keep medical exposure records for 30 years + the duration of employment of the exposed employee
True False We have current MSDS for all chemicals onsite
True False We keep a chemical inventory list of all MSDS for 30 years
True False We have completed a written job hazard analysis for all tasks in our organization
True False We conduct comprehensive training based on the employees exposure to workplace hazards
True False We have developed a corporate policy for workplace violence and threats
True False We have conducted an emergency evacuation drill within the last six months
True False We have developed a floor plan that identifies emergency related features
True False We have trained specific employees as floor captains (evacuation aids)

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Rank the Following Compliance Issues:
(1 represents a "great challenge", 5 represents "not a challenge for my organization")

1 2 3 4 5 Lack of management support
1 2 3 4 5 Lack of employee support
1 2 3 4 5 Lack of direction (I don't know what I'm supposed to do)
1 2 3 4 5 I don't understand local, State and Federal government requirements
1 2 3 4 5 I have no idea of what a Health & Safety Policy manual should look like
1 2 3 4 5 Insufficient budget
1 2 3 4 5 Not enough time (To many other responsibilities)

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Would you like us to prepare a no-obligation proposal for OSHA training services? Yes Please! No, Thanks