Company Name (how would you like it to appear in your OSHA Safety Program?):

Your Name:

Email Address (where the final OSHA Safety Program will be sent):

Number of Employees:

Number of Supervisors/Managers:

Industry:

Description of your business, typical operations - what does your company do?:

Do you have a Hazard Communication Program?:

If you have an eyewash station, how many do you have?:

Do you have first aid kits?:
 Yes No

Where are they located?:

Where are your company's Material Safety Data Sheets (MDSD) kept?:

Do you have a safety committee?:
 Yes No

How many employees are on the committee?:

What job functions are represented on the safety committee?:

How often does the committee meet?:
 Weekly Monthly Quarterly Yearly

Who is responsible for performing safety inspections/walk-throughs?: [Names and Job Titles]

Does your company hold safety "tool-box talks," pre-shift safety meetings, or the like?[please describe]:

What is the physical address of your company? [This will be printed on the cover of your OSHA Safety Program]:

Any special considerations we should address in your OSHA Safety Program?: