OSHA requested items / information checklist

• CLIENT:

• CONTACT AND PHONE #

• Location
  Address

• Requested on:

  Date

• Prepared by:

  Sign

OSHA Complaints

• Written complaint or visit

  Select written site visit phone follow up

  • written
  • site visit
  • phone follow up

• COMPLAINT IS:

  Select INCIDENT ACCIDENT DANGEROUS CONDITION UNSAFE CONDITION other request for info only near miss

  • INCIDENT
  • ACCIDENT
  • DANGEROUS CONDITION
  • UNSAFE CONDITION
  • other
  • request for info only
  • near miss
complaints

• LIST COMPLAINTS

OSHA requested information or items checklist

• OSHA compliance officer assigned: [name and info]

• Date of visit

  Date

• Check if visit is for complaint.

• DATE / TIME OF INCIDENT / ACCIDENT

  Date

• Notes on request

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Add media

  Media

• Copy of site specific health and safety program

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Add media

  Media

• Copy of Toolbox talks / Safety Meetings

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Add media

  Media

• Number of employees on this site and all sites

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• answer to above:

• legal name of company & owners or corporate officers

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Answer to above

• Federal Tax ID #

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Answer to above:

• NAICS code #

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Answer to above:

• Complete mailing address and phone # for corporate office & regional office [if applicable]

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Answer to above:

• Official name and address of project [if applicable]

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• Answer to above:

• Check if other information requested [list below]
item or information

• List Other Information or items

• status

  Select supplied pending waiting from client waiting from subcontractor sent to office sent to OSHA on file

  • supplied
  • pending
  • waiting from client
  • waiting from subcontractor
  • sent to office
  • sent to OSHA
  • on file

• does hazzard still exist

  YES

  NO

  NA

• Union ?

  YES

  NO

• Union, local, shop steward or business agent information

• injured overnight stay or other required report

• OSHA notified by

  Select rufolo client complaint police EMS other other employee

  • rufolo
  • client
  • complaint
  • police
  • EMS
  • other
  • other employee

• Date and time OSHA notified

  Date

• Notes on injury;

• injured is employee of?

  client direct employee

  subcontractors employee

  2nd tier subcontractor employee

  visitor to site

• Subcontractor info:

• Injured info:

• Witnesses:

• Witness Information