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Full name of your organization or company:

Full Name of the person filling out this form:

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Fax Number:

Number of employees:

Number of Company Vehicles:

Number of Forklifts:

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What is your industry?

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?

Do you have a 1st 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?

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

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 Responsible Safety Officer (RSO)?

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

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