Consultation Form 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 NameCompany Name* North American Industry Classification System Code (NAICS)* Search here: https://www.naics.com/search2. Mailing AddressMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country Site Address (if different from Mailing Address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country 3. Name, title & contact information of person making requestName* First Last Title* Phone*Email* FaxMailing 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 ContactName* First Last Title* Phone*Email* Fax5. 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 ServicesYear* 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 Informationa. 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 CitationsMax. 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 & ConditionsBy 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: 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. 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* Reset signature Signature locked. Reset to sign again 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 Δ