ࡱ> @ 8jbjb "wlhhhD Y b \},X x"h @Y C CCCX8 h }C|,}CCrTPhq$Uq c#C#qCREQUEST FOR CONSULTATION SERVICES ( HYPERLINK "http://www.oshainfo.gatech.edu" www.oshainfo.gatech.edu ) Type responses in gray-shaded square beside each response category 1. Company Name  FORMTEXT      Standard Industrial Classification (SIC) (if known)  FORMTEXT      2. Mailing Address P.O. Box/Drawer  FORMTEXT       City, State, Zip  FORMTEXT       County  FORMTEXT      Site Address (if different from Mailing) Street  FORMTEXT       City, State, Zip  FORMTEXT       3. Name, Title, of person making request  FORMTEXT       Phone Number:  FORMTEXT       Fax:  FORMTEXT       Email:  FORMTEXT      4. Contact person  FORMTEXT       Job Title  FORMTEXT       (if different from one making request) Phone Number:  FORMTEXT       Fax:  FORMTEXT       Email:  FORMTEXT       5. Who has overall responsibility for the safety and health management system at your facility? Name  FORMTEXT       Title  FORMTEXT       6. Has Georgia Tech provided Safety/Health Consultation services before? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If If yes, approximate date of previous services  FORMTEXT       7. Identify the requested types of assistance below (choose from A or B, and C) Hazard Identification Limited (Survey limited to specific operation, equipment, or loss source not entire facility or job site): Health  FORMCHECKBOX  Safety  FORMCHECKBOX  Both  FORMCHECKBOX  Describe what you want us to focus on:  FORMTEXT      Hazard Identification Full Service (complete hazard survey, technical program evaluation for the entire facility and job site): Health  FORMCHECKBOX  Safety  FORMCHECKBOX  Both  FORMCHECKBOX Safety & Health Program Management Assessment  FORMCHECKBOX  Comprehensive (58 items Evaluated)  FORMCHECKBOX  Limited (Limited to items associated with Hazard Survey)8. Briefly describe operations performed, flow processes, machinery or equipment used, and final products:  FORMTEXT       Check any of the following operations/processes that are performed at the site: FORMCHECKBOX  Compressed Gases  FORMCHECKBOX  Dip Tank Operations  FORMCHECKBOX  Grinding/Polishing  FORMCHECKBOX  Hazardous Chemicals  FORMCHECKBOX  Machining (cutting, shearing, forming) FORMCHECKBOX  Materials Handling (equip.)  FORMCHECKBOX  Sawing, Sanding, Planing  FORMCHECKBOX  Spray Finishing/Coating  FORMCHECKBOX  Welding/Burning (Gas/Electric)  FORMCHECKBOX  Working in Confined Spaces9. Identify which technical programs you currently have in place: FORMCHECKBOX  Bloodborne Pathogens  FORMCHECKBOX  Chemical Hygiene Program  FORMCHECKBOX  Confined Space Entry  FORMCHECKBOX  Emergency Action Plan  FORMCHECKBOX  Ergonomics  FORMCHECKBOX  Evacuation Plan  FORMCHECKBOX  Fire Protection  FORMCHECKBOX  Hazard Communication  FORMCHECKBOX  Hearing Conservation  FORMCHECKBOX  Lockout/Tagout  FORMCHECKBOX  Personal Protective Equipment  FORMCHECKBOX  Respiratory Protection10. Identify below the aspects you consider to be areas of concern: FORMCHECKBOX  Bloodborne Pathogens  FORMCHECKBOX  Chemical Exposure  FORMCHECKBOX  Concrete and Masonry Work  FORMCHECKBOX  Cranes, Hoists, and Rigging  FORMCHECKBOX  Electrical Safety  FORMCHECKBOX  Ergonomics  FORMCHECKBOX  Fall Protection FORMCHECKBOX  Fire Protection  FORMCHECKBOX  Flammables Liquid Storage  FORMCHECKBOX  Indoor Air Quality  FORMCHECKBOX  Machine Guarding  FORMCHECKBOX  Materials Handling  FORMCHECKBOX  Noise Exposure  FORMCHECKBOX  Powered Industrial Trucks FORMCHECKBOX  Power Tools  FORMCHECKBOX  Process Safety Management  FORMCHECKBOX  Scaffolding  FORMCHECKBOX  Trenching/Excavation  FORMCHECKBOX  Mechanical Power Press Operations  FORMCHECKBOX  Other: Specify  FORMTEXT        11. Employee Information Number of Employees Employed at this Location:  FORMTEXT       Number of Employees Covered by Consultation:  FORMTEXT       Total Number of Employees in Your U.S. Corporation:  FORMTEXT       Number of Shifts:  FORMTEXT       Number of Employees on largest shift:  FORMTEXT       12. Do you have regular access to Corporate Safety and Health Resources? Yes  FORMCHECKBOX  No  FORMCHECKBOX  13. When was the last Corporate Safety or Loss Prevention Visit conducted at your facility or job site? Month  FORMTEXT       Year  FORMTEXT      14. Have you had an OSHA Inspection? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If your answer is yes, fill in the following: a. Date of last inspection (If within 1 year, please send a copy of the citations with this request form) Month  FORMTEXT       Year  FORMTEXT       b. Are any items cited by OSHA now being contested? Yes  FORMCHECKBOX  No  FORMCHECKBOX  c. Have all items cited been corrected? Yes  FORMCHECKBOX  No  FORMCHECKBOX  d. If not, when are the corrections due? Month  FORMTEXT       Year  FORMTEXT      15. Was this request the result of a settlement agreement with OSHA? Yes  FORMCHECKBOX  No  FORMCHECKBOX 16. How did employer learn of Georgia Tech s program? Georgia Tech  FORMCHECKBOX  OSHA  FORMCHECKBOX  Other  FORMTEXT       By accepting Georgia Tech s free on-site consultation service, as a representative of _________________________________________, 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 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 consultants 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 to correct the hazard(s), show that the delay was beyond its control, and have given assurance that interim safeguards are in use to protect employees from the hazard(s). Date  FORMTEXT      Signature __________________________________________ Name  FORMTEXT       Title  FORMTEXT       Please return form to: Attention: Anika Harris Vines Georgia Institute of Technology GTRI/HESL/OSHD Safety & Health Consultation Program 430 10th St., N.W. North Building Atlanta, GA 30332-0837 E-mail: anika.harris@gtri.gatech.edu FAX: (404) 407-8275 PHONE: 404-407-7431Revised 6/2006 FOR INTERNAL USE ONLY Date Received: __________________________ 7D. High Hazard: ___ Yes ___No 11. Special Program ________________________________________ 16. Consultant Assigned: ________________________________________ 18. Optional Information: ________________________________________ 27. Strategic Plan Activity: ________________________________________ FH`bfh(*,68<@B`ؿͲؤͲؚ،Ͳ؇~jOJQJUOJQJjCJOJQJU5>*CJOJQJj%CJOJQJUjCJOJQJUmHjCJOJQJUjCJOJQJU CJOJQJ5CJOJQJ 5OJQJ60JjU jU,`b:<d `  X Z @ dh$IfG$$Ifl0Ll-T44 la dh$If$a$`b:<d `  X Z \  j |~HR H(V   MNOv /0Szabc,Ik           X   8 : N P R \ ^ `   0 2 F H J T V \ ` b ӺȭӣӕȭӇȭrbrj5CJOJQJUj5CJOJQJU5CJOJQJjiCJOJQJUjCJOJQJU5>*CJOJQJjCJOJQJUmHjCJOJQJUjCJOJQJU CJOJQJOJQJjOJQJUmHjOJQJUj OJQJU$Z \  j |4_YOO $If 0*$If6$$IflL0**4$ 4 ladh$If oC dh$If 0*I$$Ifl0Ll-T44 la    " $ d f z | ~   2 4 6 @ B      j ҷݩҷݛҷݓݓ䓃sk6CJOJQJj'5CJOJQJUj5CJOJQJU5CJOJQJj;CJOJQJUjCJOJQJUjCJOJQJUmHjQCJOJQJUjCJOJQJU CJOJQJj5CJOJQJUj5CJOJQJUmH*j TVjlnxz~HPRThjlvx 024>@sju5CJOJQJUj5CJOJQJUmHj5CJOJQJUj5CJOJQJU5CJOJQJjCJOJQJUjCJOJQJUjCJOJQJUmHjCJOJQJUjCJOJQJU CJOJQJ-|~HoI$$IflV0L(T3|) 44 la dh$If$If6$$IflL0**4$ 4 la  ">@BNPlnpQho FGHRj1 CJOJQJUj CJOJQJUjI CJOJQJUjCJOJQJUmHj CJOJQJUj_ CJOJQJUjCJOJQJUjCJOJQJU5CJOJQJ CJOJQJ1R h_x_4$$IflL0**4$ 4 la dh$If^ & Fdh$If dh$IfG$$Ifl0L0*\ 4$ 4 la RS  <T>@\^`tv$%&LM[\] ҼҮҠҒ҄zlj_CJOJQJU5>*CJOJQJj CJOJQJUjw CJOJQJUj CJOJQJUj CJOJQJUj CJOJQJU5CJOJQJ CJOJQJjCJOJQJUmHjCJOJQJUj CJOJQJU*H( }Dsssss h$If^h6$$Ifl8L0**4$ 4 la dh$If4$$IflL0**4$ 4 la dh$If^  HJfhj '()789VWefg}ojCJOJQJUjCJOJQJU CJOJQJjCJOJQJUj1CJOJQJUjCJOJQJUjICJOJQJUjCJOJQJU5CJOJQJj5CJOJQJU CJOJQJjCJOJQJU+(V   MN h$If^h dh$If^$$Ifl4&FL\ X 0*` 4$     4 la$If   LOP^_`vw uj-CJOJQJUjCJOJQJUjECJOJQJUjCJOJQJUj]CJOJQJU5CJOJQJjCJOJQJUjuCJOJQJUjCJOJQJU CJOJQJjCJOJQJU.NOv /0Sz8$If$If h$If^hK$$Ifl40LX 0* !  4$ 4 la01?@ASTbcdz{ !`cdrstߵ߬ߍwwijCJOJQJU5CJOJQJjYCJOJQJUjCJOJQJUjqOJQJUOJQJjOJQJUjCJOJQJUjCJOJQJUjCJOJQJU CJOJQJjCJOJQJUjCJOJQJU)abcOp EEE h$If^hI$$Ifl40LX 0* !  4$ 4 la dh$If^$$Ifl4JFL\ X 0*  4$     4 lat ,-;<=IJXYZklz{|~pjCJOJQJUjmCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUjCJOJQJUj)CJOJQJUjCJOJQJUjACJOJQJUjCJOJQJU CJOJQJ,,Ik&Gs $If h$If^hk&Gs !2!!:""##v$%%j&&*(()**f+h++,,,,,,..i/Y01s2.34445p5r5555556 6'6G6V6{66666777788                         K&'567GHVWXst  8 }j CJOJQJUj CJOJQJUjCJOJQJUj%CJOJQJUjCJOJQJUj=CJOJQJUjCJOJQJUjUCJOJQJU CJOJQJjCJOJQJU,8 : < !!0!!!!!!!!""("*","6"8""""""""""#####߮߮ߠߒ߄vj#CJOJQJUj'#CJOJQJUj"CJOJQJUjS"CJOJQJU5CJOJQJjCJOJQJUmHj!CJOJQJUji!CJOJQJU CJOJQJjCJOJQJUj CJOJQJU. !2!!:""##v$% & Fdh$If dh$IfZ$$IflFL\ 0*\ x4$     4 la #b#d#x#z#|####$&$($D$F$H$R$T$p$r$t$v$z$$F%V%X%l%n%p%z%|%%%%%%%%%%%&&&8&:&<&F&H&d&j=&CJOJQJUj%CJOJQJUjQ%CJOJQJUj$CJOJQJUje$CJOJQJU5CJOJQJjCJOJQJUmHj#CJOJQJUjCJOJQJU CJOJQJ1%%j&&*(()**f+h++,,| X hdh$If^h dh$If4$$IflL0**4$ 4 la d&f&h&'''''''(((((&(((((((((((((^)`)|)~)))))))**0*2*4*>*@*Z*߶ߨߚߌ~pj)CJOJQJUjw)CJOJQJUj)CJOJQJUj(CJOJQJUj(CJOJQJUj'CJOJQJUjCJOJQJUmHj)'CJOJQJU CJOJQJjCJOJQJUj&CJOJQJU,Z*\*p*r*t*~*****+++4+6+8+B+D+`+b+d+h+n+p++,, ,",$,4,6,R,T,V,h,j,~,,,,,,,,44wj5CJOJQJUj,CJOJQJUj;,CJOJQJUj+CJOJQJUjO+CJOJQJUj*CJOJQJU5CJOJQJjCJOJQJUmHjc*CJOJQJU CJOJQJjCJOJQJU.,,,,,..i/Y01s2upkkaaWW & F$If & F$If h$If^h4$$IflL0**4$ 4 la hdh$If^hG$$Ifl0L0*\ 4$ 4 la s2.34445p5r55555 $If^4$$IflL|)0*4 4 la h$If^h & F$If 44444455|5~55555555555555566777(7)7T7W7777788H8K888888OJQJCJ5CJOJQJ CJOJQJ5CJH*OJQJ CJOJQJj.5CJOJQJUj-5CJOJQJUj5CJOJQJUmHj'-5CJOJQJUj5CJOJQJU5CJOJQJ-556 6'6G6V6{6666677H h$If^hG$$Ifl0L(4 4 la 777(7)7S7T77777788H8e88 -DM -DM $dha$G$$Ifl0L0*\ 4$ 4 la888888$dha$ -DM -DM  1h/ =!"#h$h%DyK yK @http://www.oshainfo.gatech.edu/tD2Text1tD Text2tD2Text3tD2Text4tD2Text5tDKText6tDKText7tDFText8tDText9vDText10vD-Text11vD(Text12vD(Text13vDText14vDText15vD-Text16vDText17vDText18tDeCheck1tDeCheck2vDText19tDeCheck3tDeCheck4tDeCheck5vD<Text20tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7vD<Text21tDeCheck8tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9tDeCheck9vDText22jD jD jD jD jD vDeCheck10vDeCheck11vD Text25vDText26vDeCheck10vDeCheck11vD Text25vDText26vDeCheck10vDeCheck11vDeCheck10vDeCheck11vD Text25vDText26vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDKText24vDText27vDText28vDText29 i4@4 NormalCJ_HmH sH tH @@@ Heading 1$$@&a$5>*OJQJ<A@< Default Paragraph Font0>@0 Title$a$ 5OJQJ6'@6 Comment ReferenceCJ0@0  Comment TextCJ0+"0  Endnote TextCJ6*@16 Endnote ReferenceH*.U@A. Hyperlink >*B*ph  !z!zGH  j R t8 #d&Z*48"%'(*,.02478:<=@Z |(N %,s25788#&)+-/1359;>?ABCk8$6#Qi DPVo{$*[gm x*6< GSY'7iyX d j  . > T d  A Q   - = U e r   ' 7 W g #?Om}.CSfv%5K[r-9?nz"(x"3?ErFRXfrx$*:r~fv#/5@LR XFFFFFFFFFFFFFFFFFFG G FG G G FG G G G G FG G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G G FFFFFFG G FFG G FFG G G G FFG G G G FFFF8%(@D'(  TB  c $D)N  3 )  B S  ?l  j)t0h-ht+Text1Text2Text3Text4Text5Text6Text7Text8Text9Text10Text11Text12Text13Text14Text15Text16Text17Text18Check1Check2Text19Check3Check4Check5Text20Check6Check7Text21Check8 OLE_LINK1 OLE_LINK2Check9Text22Check10Check11Text25Text26Check12Check13Text24Text27Text28Text29 Ep\y+HjY y4g$A   !"#$%&'()*W+n! = Zzk #Fw6S  & y~w jl;DeoO[|  #1Yd%)w~w ::::::::::::::::::::::: Mark Hodges6Mark's Machine:Users:markhodg:Desktop:consult-form.dotfk!hw EX_2zVPc(^`OJPJQJo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(^`o(.^`OJPJQJo(pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.hh^h`o()^`B*OJQJo(ph88^8`o()^`o(()^`o(()pp^p`o(()  ^ `o(.@ @ ^@ `o(.  ^ `o(.^`o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.k!VPcw E-.>?ABC[\9:n o n o p GHUVfgh ">">@ X1~+TTe e eeeeeeeeee PPP PPP$@PP,@PP4@P P"P$P&P(P*P,P\@P4Pl@GTimes New Roman5Symbol3 ArialA Arial Narrow? Arial Black? Courier New;Wingdings"qh7jF &D 7, 2h>0d2qH!REQUEST FOR CONSULTATION SERVICESaharris Mark Hodges Oh+'0 0< X d p |'"REQUEST FOR CONSULTATION SERVICEScrEQUaharrisharharconsult-form.dotLTA Mark Hodges23kMicrosoft Word 10.0@ @>3@R@4=F ՜.+,D՜.+,X hp  ' Georgia Tech.o7 $ "REQUEST FOR CONSULTATION SERVICES Title 8@ _PID_HLINKS'AxqV http://www.oshainfo.gatech.edu/@  !"#$%&'()*+,-./0123456789:;<=>?@ABCDFGHIJKLMNOPQRSTUVWXYZ[\^_`abcdefghijklmnpqrstuvxyz{|}~Root Entry FFData E.1Table]#WordDocument"SummaryInformation(oDocumentSummaryInformation8wCompObjX FMicrosoft Word DocumentNB6WWord.Document.8