What is the full name of your organization or company as you want it to print?

Please enter the name of the person who is filling out this information.

* First and Last Name

Business Phone:

Alternate phone number:

Email for the person that is filling out this information?

Fax Number

How many employees does your company have?

Number of Company Vehicles?

Number of Forklifts?

Number of Supervisors?

What is your industry?

Select One Agriculture Amusement Part Attorney Automotive Repair Auto Dealership Sales & Service Carpet & Flooring Sales and Installation Catering Cemetary Chiropractic Office Church Chrome & Metal Plating Shop City Municipality Construction Day Care Dental Office Engineer Contractor Electrical Contractor Food Service Fumigation Hair & Nail Salon Health Care Hospital Housing Janitorial Laboratory Landscaping Logging Manufacturing Metal Polishing Shop Mold Remediation Nursing/Retirement Housing Office Work Painting Automotive Painting - Residential/Commercial Petrochemical Petroleum Drilling Petroleum Production Pharmacy Photography Plumbing Plumbing - Heating - A/C Printing Property Management Retail Sales Restaurant Roofing Contractor Security School Shipping Tire Store Telecommunications Termite & Pest Control Textile Manufacturing Textile Warehousing & Distribution Trucking Upholstery Shop Towing Company Veterinarian Warehousing Winery/Vineyard X-Ray/Image Center

Other:

Please give a brief description of what your company or business does.

Does your company require a pre-employment physical or drug screen?

If you have an eyewash where is it located?

Where will all the safety notices be posted?

Examples: in the break room, on the bulletin board, next to the time clock, in the job site trailer, in the office.

Do you have a First Aid Kit?

Where is the First Aid Kit located?

Where will the "Material Safety Data Sheets" be kept?

How many employees are on the safety committee?

How often does the safety committee meet?

How much time between routine safety checks?

Select One Daily Weekly Every 2 Weeks Monthly Quarterly Other

Other:

How much time between safety meetings between all of the employees?

Select One Daily Weekly Every 2 Weeks Monthly Quarterly Other

Other:

If Tailgate Safety Meetings or Toolbox Talks are performed, how often are they done?

Where will the emergency phone numbers be kept?

What is the name of the RSO? (Responsible Safety Officer)

What is the title of the person who will be conducting the safety meetings?

Select One Safety Director Human Resource Director Foreman Jobsite Foreman Owner President Other

Other:

What is the physical address of your company?

This address will appear on the cover of your Safety Manual.

Are there any special considerations or concerns you have that need to be addressed in your safety manual?

Please tell us how did you find out about our Website?

Select One Altavista AOL Ask Jeeves Dogpile Excite Go Google Goto iWon Looksmart Lycos NBCi Netscape MSN Yahoo Friend Other

Please list other