OSHA Consultation Request Form

West Virginia Division of Labor

West Virginia Division of Labor Safety Section

Home > Safety Section> OSHA Consultation

Company Name

Type of Business
SIC/NAICS Code (If known)

Mailing Address

Site Address

Name & Title of Person Making Request

Phone #

Fax #

Email

Who has overall responsibility for the safety and health Programs at your facility?

Name

Title

Check all of the following operations/processes that are performed at the site:

Welding/Burring (Gas/Electric)	Dip Tank Operations
Work in Confined Spaces	Spray Finishing/Coating
Machining (cutting, shearing, forming)	Materials Handling (equip.)
Hazardous Chemicals	Compressed Gases
Grinding/Polishing	Sawing, Sanding, Planing

Identify which technical programs you currently have in place:

Hearing Conservation	Emergency Action Plan
Chemical Hygiene Program	Confined Space Entry
Respiratory Protection	Evacuation Plan
Bloodborne Pathogens	Personal Protective Equipment
Fire Protection	Ergonomics
First Aid	Lockout/Tagout
Hazard Comm

Identity below the aspects you consider to be your areas of concern:

Number of Employees at this Location

I have read and understand West Virginia Division of Labor's free on-site consultation service conditions

Name

Title

Have you had an OSHA inspection in the last 12 months?

If YES:
Are there any items cited by OSHA now being contested?
Yes No