Consultation Form - Safety, Health, Environmental Services

Onsite and Virtual Consultation Request Form

Any fields indicated with an * is a required field. You will not be able to submit the form unless all fields are answered.

1. Company Name
Company Name*
North American Industry Classification System Code (NAICS)*

Search here: https://www.naics.com/search
2. Mailing Address
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Site Address (if different from Mailing Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
3. Name, title & contact information of person making request
Name*
First Last
Title*
Phone*
Email*
Fax
Mailing List
- Yes
Yes, I agree to receive information about Georgia Tech’s Safety, Health and Environmental Services news, updates and upcoming training opportunities.
4. 2nd Person of Contact
Name*
First Last
Title*
Phone*
Email*
Fax
5. Who has overall responsibility for the safety and health management system at your facility?
Name*
First Last
Title*
6. Has Georgia Tech provided Safety/Health Consultation Services before?
Select One*
- Yes
- No
Month*

Approximate the Date of Previous Services
Year*
7. Identify the requested types of assistance below (choose ONE from A, B, or C)
A. SELECT ONE - Full Service*
Hazard Identification FULL SERVICE (includes a complete hazard survey, technical program evaluation for the entire facility or job site):
- Health
- Safety
- Both
- Reset Options
B. SELECT ONE - Limited Survey*
Hazard Identification LIMITED (Survey limited to specific operation, equipment, or loss source NOT ENTIRE facility or job site):
- Health
- Safety
- Both
- Reset Options
Describe what you want us to focus on:*
C. SELECT ONE - Safety and Health Program Management Assessment*
Safety & Health Program Managment Assessment
- Comprehensive (58 items evaluated)
- Limited (Limited to items associated with Hazard Survery)
- Reset Options
8. Briefly describe operations performed, flow processes, machinery or equipment used, and FINAL PRODUCTS:
Description*
9. Check any of the following operations/processes that are performed at the site:
Check any that apply
- Compressed Gases
- Dip Tank Operations
- Grinding/Polishing
- Hazardous Chemicals
- Machining (cutting, shearing, forming)
- Materials Handling (equip.)
- Power Presses/Brakes
- Sawing, Sanding, Planing
- Spray Finishing/Coating
- Welding/Burning (Gas/Electric)
- Working in Confined Space
- Other
10. Identify which technical programs you currently have in place:
Check any that apply
- Bloodborne Pathogens
- Chemical Hygiene Program
- Confined Space Entry
- Emergency Action Plan
- Ergonomics
- Evacuation Plan
- Fire Protection
- Hazard Communication
- Hearing Conservation
- Lockout/Tagout
- Personal Protective Equipment
- Respiratory Protection
11. Identify below the aspects you consider to be areas of concern:
Check any that apply
- Bloodborne Pathogens
- Chemical Exposure
- Combustible Dust
- Concrete and Masonry Work
- Cranes, Hoists, and Rigging
- Electrical Safety
- Ergonomics
- Fall Protection
- Fire Protection
- Flammables Liquid Storage
- Indoor Air Quality
- Machine Guarding
- Materials Handling
- Mechanical Power Press Operations
- Noise Exposure
- Powered Industrial Trucks
- Power Tools
- Process Safety Manangement
- Scaffolding
- Trenching/Excavation
- Other
12. Employee Information
a. Number of Employees Employed at the Location:*
b. Number of Employees Covered by Consultation:*
c. Total Number of Employees in your U.S. Corporation*
d. Number of Shifts*
e. Number of Employees on Largest Shift:*
13. Do you have regular access to Corporate Safety and Health Resources?
Select One
- Yes
- No
14. When was the last Corporate Safety or Loss Prevention Visit conducted at your facility or job site?
Month
Year
15. Have you had an OSHA Inspection?
Select One*
- Yes
- No
a. Date of last Inspection ( If within 1 year, please send a copy of the citations with this request form)
Month*
Year*
Upload Citations
Max. file size: 256 MB.
b. Are any items cited by OSHA now being contested?
Select One*
- Yes
- No
c. Have all items cited by OSHA been corrected?
Select One*
- Yes
- No
d. If not, when are the corrections due?
Month*
Year*
16. Was this request the result of a settlement agreement with OSHA?
Select One
- Yes
- No
17. How did employer learn of Georgia Tech's program?
Select One*
- Georgia Tech
- OSHA
18. Are you involved in an active OSHA partnership or alliance?
Select One*
- Yes
- No
State the Name of the Partnership or Alliance*
General Contractor (if applicable)
19. Terms & Conditions
By accepting Georgia Tech’s free on-site consultation service, as a representative of Company Listed wtih Signature Below, I understand and agree to the following conditions:
1. To correct all hazards identified during the survey. I further understand that a time limit for correcting hazards OSHA would classify as SERIOUS will be established at the time of the survey based primarily upon the judgment of the Georgia Tech consultant who will take into account such factors as probability of serious injury and feasibility of correction.
2. To notify Georgia Tech, in writing, of the corrections of the SERIOUS hazards that are identified in this consultation including the date that the correction was made and specifically what was done to correct the hazard. I also understand:
- Because this program is operated separately from any governmental enforcement activity, Federal compliance officers are not bound by advice given by the Georgia Tech consultant or by the failure of the consultant to point out a specific hazard. The employer may, but is not required to, furnish a copy of the consultant’s survey report to inspecting compliance officers.
- That the company has the right to stop the consultation at any point during the assistance, but is responsible for correcting all hazards identified up to that point.
- That Georgia Tech can stop the consultation at any point if there are indications that the company is not committed to fulfilling their obligations for the scope of assistance requested.
- An extension of the time frame(s) set for the correction of serious hazard(s) may be requested in writing if the company has made a good faith effort to correct the hazard(s), shows or demonstrates that the delay was beyond its control, and have given assurance that interim safeguards are in use to protect employees from the hazard(s).
Signature*

Use your mouse to sign your name in the space above.
Company Name*
Name*
First Last
Title*
Date*
MM slash DD slash YYYY
By Checking this box I am agreeing to the Terms & Conditions Listed Above*
- Agree
CAPTCHA

Onsite and Virtual Consultation Request Form

1. Company Name

2. Mailing Address

3. Name, title & contact information of person making request

4. 2nd Person of Contact

5. Who has overall responsibility for the safety and health management system at your facility?

6. Has Georgia Tech provided Safety/Health Consultation Services before?

7. Identify the requested types of assistance below (choose ONE from A, B, or C)

8. Briefly describe operations performed, flow processes, machinery or equipment used, and FINAL PRODUCTS:

9. Check any of the following operations/processes that are performed at the site:

10. Identify which technical programs you currently have in place:

11. Identify below the aspects you consider to be areas of concern:

12. Employee Information

13. Do you have regular access to Corporate Safety and Health Resources?

14. When was the last Corporate Safety or Loss Prevention Visit conducted at your facility or job site?

15. Have you had an OSHA Inspection?

16. Was this request the result of a settlement agreement with OSHA?

17. How did employer learn of Georgia Tech's program?

18. Are you involved in an active OSHA partnership or alliance?

19. Terms & Conditions