Staffing Telephonic Hazard Assessment 052214 Working Draft

Information

Conducted on
Audit Title
Client Name
Client Website
Client Address
Personnel
Prepared by
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Industry Specialty Type(s)

Agriculture
Cotton
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Dairy
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Coffee
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Corn, Grain &/or Wheat
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Fruits & Vegetables
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Livestock
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Nuts & Beans
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Sugar
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Tobacco
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Wool
Job Title(s) Serviced
- Administrative Personnel
- Baler
- Stables Worker
- Bucker
- CDL Operator
- Cutter Operator
- Delivery/Transport Driver
- Facilities Maintenance Technician
- Farm Machinery & Equipment Operator
- Farrier
- Feeder
- General Labor
- Gin Operator
- Grain Elevator Operator
- Harvestor
- Health & Reproduction Technician
- Herdsman
- Blacksmith
- Landscaper
- Livery Hand
- Maintenance
- Mechanic
- Milker
- Packaging
- Pest Control
- Pest Control (Includes Crop Dusting)
- Picker
- Ranch Hand
- Shaker Operator (Includes Manual)
- Shearing Shed Hand
- Sheller Operator (Includes Manual)
- Sorter
- Stables Worker
- Trainer
Assembly Operation
Job Title(s)?
- Assembler
- Assistant
- CDL Driver
- Courier
- Crane Operator
- Custodian
- Delivery/Transport Driver
- Director of Operations
- Engineer
- Facilities Maintenance Personnel
- Facilities Operation Peronnel
- Feeder
- File Clerk
- Fleet Maintenance Mechanic
- Foreman
- Fork Lift Operator
- General Labor
- Groundskeeper
- Heavy Machine Operator
- Instructor
- Inventory Clerk
- Janitor/Custodian
- Journeyman
- Linesman
- Machine Operator
- Mail Room Clerk
- Maintenance Personnel
- Mechanic
- Nurse
- Operations Manager
- Ordnance Specialist
- Packaging
- Parking Attendent
- Pest Control
- Picker Operator
- Porter
- Processor
- Procurement Personnel
- Production Manager
- Quality Control Inspector
- Risk Management Personnel
- Runner
- Safety & Compliance
- Security
- Shipping/Receiving Personnel
- Sorter
- Storefront Clerk
- Supervisor
- Tool Room Attendant
- Truck Driver
- Tugger Operator
- Warehouse Personnel
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Type(s) of Assembly Warehouse Work Environment(s)?
- Automated
- Confined Space
- Climate Controlled
- Distribution Center
- Furnace
- Government
- Hazardous Materials
- Paint Booth
- Private
- Public
- Hazardous Atmospheres
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Aviation
Type(s) of Aviation Operations?
- Aircraft Maintenance
- Aircraft Manufacturing
- Airport Baggage/Materials Operations
- Airport Security Screening Operations
- Airport Traffic Operations
- Commercial
- Firefighting
- Government
- Law Enforcement
- Mail & Cargo
- Mass Transit
- Medical & Organ Transport
- Military
- Private
- Rescue & Recovery
Type(s) of Job Title(s)?
- Air Traffic Controller
- Aircraft Mechanic
- Assembler
- Aviation Designer
- Aviation Office Personnel
- Baggage Handler
- Cargo Specialist
- CNC Operator
- Crane Operator
- De-Icer
- Delivery & Transport Driver
- Electrician
- Emergency Medical Technician
- Engineer
- Facilities Maintenance Technician
- Fleet Maintenance Technician
- Flight Attendant
- Food Services
- Fork Lift Operator
- Landscaper
- Janitor/Custodian
- Lavatory Services
- Maintenance
- Mechanic
- Packaging
- Pilot
- Refueler
- Safety & Compliance
- Security
- Shipping & Receiving
- Test Pilot
- Ticket Agent
- TSA Agent
- Tugger Operator
- Welding
Type(s) of Environment(s)?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Clerical
Type(s) of Job Title(s)?
- Accountant
- Accounts Payable Personnel
- Accounts Receivable Personnel
- Administrative Assistant
- Attorney
- Auditor
- CEO
- Claims Adjuster
- Claims Administrator
- Claims Assistant
- Compliance Officer
- Comptroller
- COO
- Courier
- Credit/Collections Personnel
- Data Entry Operator
- Director of Operations
- Executive Assistant
- File Clerk
- HR Manager
- HR Personnel
- Inspection Personnel
- Inventory Clerk
- Legal Clerk
- Mail Room Clerk
- Marketing Clerk
- Marketing Manager/Director
- Office Assistant
- Office Manager
- Paralegal
- Payroll Clerk
- Payroll Manager
- President
- Procurement Personnel
- Public Relations Manager
- Receptionist
- Recruiter
- Regional Manager/Director
- Risk Management Personnel
- Safety Management Personnel
- Sales Manager
- Sales Person
- Secretary
- Shipping/Receiving Personnel
- Tax Officer
- Vice President
Construction Industry?
Commercial Construction
Type(s) of Construction Project?
- Airport
- Cemetary
- Demolition
- Farm Facilities
- Fracking
- Hotels/Motels
- Industrial & Manufacturing Buildings
- Medical Facility Buildings
- Multi-Family Residential
- Nuclear Reactor & Power Generation
- Oil & Gas Field
- Petro-Chemical & Refinery
- Pipeline
- Professional Office Building
- Railroad
- Remodeling/Renovation
- Restaurants
- Retail Shops
- Road & Civil
- Schools
- Ship Building
- Skyscrapers
- Stables
- Warehouse
- Zoo
Type(s) of Work Environment?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Type(s) of Job Title(s)?
- Active Pipeline Worker
- Administrative Office Personnel
- Apprentice
- Assembler
- Back Hoe Operator
- Brick Layer
- Carpenter
- Carpet Installer
- CDL Driver
- Concrete Worker
- Crane Operator
- Drill Operator
- Dry Wall/Sheet Rock Installer
- Electrician
- Excavator
- Facilities Operator
- Flagger
- Foreman
- Fork Lift Operator
- Framer
- General Labor
- Groundskeeper
- Heavy Machine Operator
- HVAC Installer
- Insulation Installer
- Iron Worker
- Journeyman
- Landscaper
- Painter
- Pipe Fitter
- Plumber
- Porter
- Project Manager
- Railroad Worker
- Rescue Team Personnel
- Rig Operator
- Roofer
- Runner
- Scaffold Builder
- Signal Man
- Superintendent
- Supervisor
- Utility Transmission Line Linesman
- Welder
- Window/Door Installer
- Oil Field Worker
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Residential Construction
Type(s) of Construction Project?
- Demolition
- Horticulture
- Landscaping
- Multi-Family
- Remodel/Renovation
- Single Family
- Tree Trim
Type(s) of Work Environment?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Type(s) of Job Title(s)?
- Apprentice
- Arborist
- Assembler
- Back Hoe Operator
- Brick Layer
- Carpenter
- Carpet Installer
- CDL Driver
- Concrete Worker
- Crane Operator
- Dry Wall/Sheet Rock Installer
- Electrician
- Excavator
- Facilities Operator
- Flagger
- Foreman
- Fork Lift Operator
- Framer
- General Labor
- Groundskeeper
- Heavy Machine Operator
- Horticulturist
- HVAC Installer
- Insulation Installer
- Journeyman
- Landscaper
- Office Personnel
- Painter
- Pipefitter
- Plumber
- Porter
- Project Manager
- Rescue Team Personnel
- Roofer
- Runner
- Scaffold Builder
- Superintendent
- Welder
- Window& Door Installer
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Crane Operation
Type of Crane(s)?
- Backhoe Crane
- Carry Deck Crane
- Clamshell
- Dragline
- Gantry Crane
- Hook
- Hydraulic Truck Crane
- Overhead Rail Crane
- Piledriver
- Shovel
- Tower Crane
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Education
Education Level
- Daycare
- Elementary (Grades K-4)
- Intermediate (Grades 5-6)
- Middle School (Grades 7-8)
- Pre-Kindergarten
- High School
- Technical, Undergraduate, College, University, etc.
Type(s) of Job Title(s)?
- Administrative Office Staff
- Assistants
- Aides
- Cafeteria Personnel
- Counselor
- Custodian
- Fleet maintenance Technician
- General Labor
- Landscaper
- Librarian
- Maintenance Personnel
- Mechanic
- Nurse
- Parking Attendent
- Physical Education Personnel
- Porter
- Principle
- School Store Personnel
- Security (Armed & Unarmed)
- Superintendent
- Teacher
- Tool Room Attendent
Emergency Services
Type(s) of Emergency Service?
- 911 Call Center
- Ambulance (Municiple)
- Ambulance (Private)
- Ambulance (Volunteer)
- Fire Department (Municiple)
- Fire Department (Volunteer)
- Police
- Third Party Alarm Call Center
Type(s) of Job Title(s)?
- Administrative Office Staff
- Assistants
- Aides
- Cafeteria Personnel
- Counselor
- Custodian
- Fleet maintenance Technician
- General Labor
- Landscaper
- Librarian
- Maintenance Personnel
- Mechanic
- Nurse
- Parking Attendent
- Physical Education Personnel
- Porter
- Principle
- School Store Personnel
- Security (Armed & Unarmed)
- Superintendent
- Teacher
- Tool Room Attendent
Type(s) of Environment(s)?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Environmental Clean Up & Response
Job Title(s)?
- Coordinator
- Demolition Personnel
- Disaster Site Recovery Specialist
- Engineer
- Fleet Maintenance Personnel
- Forklift Operator
- General Labor
- Heavy Machine Operator
- Inspector
- Lift Operator
- Materials Handling Personnel
- Occupational Safety & Health Personnel
- Office Personnel
- Response Manager
- Scaffold Builder
- Scaffold Worker
- Shift Manager
- Site Hazard Engineer
- Site Supervisor
- Truck Driver
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc. (include Disaster Site Recovery Certification Procedures)
Firearm, Ammunition & Explosives Manufacturing
Type(s) of Job Title(s)?
- Assembly
- Bore Dill Operator
- CDL Driver
- CNC Lathe Machining Operator
- CNC Machine Operator
- Finishing Technician
- Fleet Maintenance Mechanic
- Fork Lift Operator
- General Labor
- Gunsmith
- Hammer Forging Operator
- Janitor Custodian
- Maintenance
- Manual lathe Machining Operator
- Office Personnel
- Operations Manager
- Ordnance Specialist
- Packaging
- Procurement Specialist
- Production Manager
- Quality Control Inspector
- Sales
- Security (Armed & Unarmed)
- Shipping
- Tester
- Warehouse Personnel
Type(s) of Environment(s)?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Fire/Flood Clean Up & Response
Job Title(s)?
- Coordinator
- Demolition Personnel
- Disaster Site Recovery Specialist
- Engineer
- Fleet Maintenance Personnel
- Forklift Operator
- General Labor
- Heavy Machine Operator
- Inspector
- Lift Operator
- Materials Handling Personnel
- Occupational Safety & Health Personnel
- Office Personnel
- Response Manager
- Scaffold Builder
- Scaffold Worker
- Shift Manager
- Site Hazard Engineer
- Site Supervisor
- Truck Driver
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc. (include Disaster Site Recovery Certification Procedures)
Forestry & Logging Industry?
Job Titles?
- CDL Driver
- Fire Jumper
- Firefighter
- Fleet Maintenance Mechanic
- Foreman
- Harvestor
- Janitor/Custodian
- Logger
- Logging Machine Operator
- Lumbar Yard Personnel
- Office Personnel
- Picker Operator
- Porter
- Processor
- Saw Mill Worker
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Foundry Operation
Work Environment(s)?
- Degassing
- Degating
- Finishing
- Furnace
- Hammer Press
- Heat Treating
- Melting
- Mold Making
- Pouring
- Punch Press
- Shake Out
- Stamping Press
- Surface Cleaning
Type(s) of Metal(s)?
- Aluminum
- Brass
- Bronze
- Cast Iron
- Magnesium
- Steel
- Zinc
Job Title(s)?
- Crane Operator
- Degassing Personnel
- Degating Personnel
- Electrician
- Engineer
- Finishing Personnel
- Forklift Operator
- Furnace Personnel
- General Labor
- Grinder
- Hammer Press Personnel
- Heat Treating Personnel
- Helper
- Machinist
- Maintenance Personnel
- Melting Personnel
- Millwright
- Mold Making Personnel
- Molder
- Office Personnel
- Operations Manager
- Pattern Maker
- Pipe Fitter
- Pouring Personnel
- Punch Press Personal
- Shake Out Personnel
- Shipping & Receiving Personnel
- Stamping Press Personnel
- Surface Cleaning Personnel
- Truck Driver
- Welder
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Hospitality Industry
Job Title(s)?
- Bar Hop
- Bartender
- Bell Boy(girl)
- Bus Boy(girl)
- Cafeteria Line Personnel
- Cashier
- Concierge
- Cook
- Dishwasher
- District Manager
- Doorman
- Front End Manager
- Host(ess)
- Janitor
- Laundry Attendant
- Maid
- Maintenance Personnel
- Parking Attendant
- Security Officer
- Shift Manager
- Shuttle Driver
- Store Manager
- Waitress(ress)
Healthcare
Job Titles?
- Air Flight Personnel
- Anesthesiologist
- Assistants
- Cafeteria Personnel
- Certified Nurse Assistant
- Counselor
- Custodian
- Doctor
- Emergency Medical Technician
- Emergency Vehicle Driver
- Fleet Maintenance Technician
- General Labor
- Gift Shop Personnel
- Greeter
- Housekeeper
- Lab Technician
- Landscaper
- Laundry Room Attendant
- License Nurse Practictioner
- Maintenance Personnel
- Mechanic
- Medical Assistant
- Medical Records Clerk
- Morgue Personnel
- Nurse
- Office Staff
- Parking Attendant
- Phlebotomist
- Radiologist
- Receptionist
- Receptionist
- Sanitizing Personnel
- Security
- Surgeon
- Surgical Equipment Attendant
- Tool Room Attendant
- Triage Attendant
- X-Ray Technician
Iron/Steel Erection
Job Title(s)?
- Apprentice
- Crane Operator
- Electrician
- Estimator
- Fabricator
- Fitter
- Fleet Maintenance Personnel
- Forklift Operator
- General Labor
- Heavy Machine Operator
- Journeyman
- Lift Operator
- Maintenance
- OCS/Catenary Engineer
- Occupational Safety & Health Personnel
- Office Personnel
- Ornamental Iron Worker
- Porter
- Project Manager
- Reinforcing Iron Worker
- Rigger
- Scaffold Builder
- Scaffold Worker
- Signal Man
- Site Supervisor
- Structural Iron Worker
- Structure Inspector
- Truck Driver
- Welders
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Law Enforcement
Job Title?
- 911 Call Center Operator/Dispatch
- Accident Scene Investigator
- Aircraft Pilot
- Arson Investigator
- Assistant
- Bomb Detection Team Personnel
- Constable
- Coroner
- Correctional Officer
- Counselor
- Crime Scene Investigator
- Deputy
- District Attorney
- Drug Investigator
- EMS Technician
- Fire Chief
- Firefighter
- Fire Marshall
- Fleet Maintenance Personnel
- First Response Team
- Fleet Maintenance Personnel
- Forensic Analyst
- Fraud Investigator
- General Labor
- Jailer
- Janitor/Custodian
- Judge
- K-9 Handler
- Lab Technicians
- Life Flight/Air Evac Personnel
- Marshall
- Mechanic
- Medical Examiner
- Nurse
- Office Personnel
- Police Chief
- Police Officer
- Recovery Specialist
- Rescue Epecialist
- Robbery Investigator
- Sheriff
- Storefront Personnel
- SWAT Personnel
- Undercover Personnel
- Warden
- White Collar Crimes Investigator
- Wire Fraud Investigator
Machine Press Manufacturing?
Type of Press Mechanism(s)?
- Hydraulic
- Mechanical
- Pnuematic
Type(s) of Machine(s)?
- Brake Press
- Punch Press
- Brake Press
- Hammer Press
- Rotary Tablet Press
- Forging Press
- Print Press
Type of Molding Environment(s)?
- Automated
- Confined Space
- Climate Controlled
- Distribution Center
- Furnace
- Government
- Hazardous Materials
- Paint Booth
- Private
- Public
- Hazardous Atmospheres
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Maritime
Job Title?
- Cafeteria Personnel
- Captain
- Crane Operator
- Deck Hand
- Dock Manager
- Dock Warehouse Personnel
- Dock Worker
- Engine Room Personnel
- Fleet Maintenance Personnel
- Forklift Operator
- General Labor
- Heavy Machine Operator
- Housekeeping Personnel
- Janitor
- Loading/Unloading Personnel
- Marina Manager
- Navigator
- Office Personnel
- Porter
- Rescue Team Personnel
- Scuba Diver
- Shipbreaker
- Ship Maintenance Personnel
- Signal Man
- Sling Rigger
- Truck Driver
- Tugger Operator
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Mass Transit
Job Title?
- Aeronautical Personnel
- Aerospace Engineer
- Air Traffic Control Personnel
- Aviation Safety Inspector
- Bus Operator
- Cab Driver
- Captain
- Civil Engineer
- Electrical Engineer
- Engineering Personnel
- Environmental Protection Personnel
- Facilities Maintenance Personnel
- Ferry Operator
- Fleet Maintenance Personnel
- Inspector
- Legal Personnel
- Limo Driver
- Marine Survey Tech
- Materials Handler
- Motor Carrier Safety Specialist
- Naval Architect
- Office Personnel
- Pilot
- Program Manager
- Rail Vehicle Operator
- Railroad Engineer
- Safety Personnel
- Shuttle Vehicle Operator
- Survey Tech
- Transportation Specialist
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Mining
Type of Mining?
- Excavation
- Landfill Mining
- Open Pit
- Quarrying
- Strip Mining
- Sub-Surface (underground)
- Surface Mining
Type of Minerals Mined?
- Aluminum
- Antimony
- Barium
- Bauxite
- Beryllium
- Chromite
- Clays
- Cobalt
- Copper
- Feldspar
- Flourite
- Gallium
- Gold
- Gypsum
- Halite (sodium chloride-salt)
- Indium
- Iron Ore
- Lead
- Lithium
- Mangnese
- Mica
- Molybdenum
- Nickel
- Perlite
- Platinum Group Metals
- Phosphate Rock
- Potash
- Pyrite
- Quartz (silica)
- Silica
- Silver
- Sodium Carbonate (soda ash or trona)
- Sulfur
- Tantalum
- Titanium
- Tungsten
- Uranium
- Vanadium
- Zeolites
- Zinc
Job Titles
- Boiler Maker
- CAM Operator
- Chemical Engineer
- CHO Engineer
- Civil Engineer
- Drill Engineer
- Electrical/Instrument Engineer
- Engineer
- Environmental Engineer
- Equipment Operator
- Field Assistant
- Field Hydrologist
- Fitting & Machining
- Front Line Manager
- Geotechnical Engineer
- Heavy Machine Operator
- HR Personnel
- IT Personnel
- Jug Hustler
- Laboratory Personnel
- Legal Personnel
- Machine Setter
- Manufacturing Manager
- Mechanical Engineer
- Mine Assistant
- Mine Shift Manager
- Mineral Process Engineer
- Mineral Processing Operator
- Mining Engineer
- Mud Logger
- Occupational Safety & Health Personnel
- Office Personnel
- Operational Manager
- Petroleum Engineer
- Petroleum Technician
- Plant & Fleet Mechanic
- Process Plant Operator
- Project Manager
- QA Officer
- Rig Manager
- Roughneck
- Sampler
- Senior Operator
- Sheet Metal Worker
- Shotfirer
- Surveyor
- Technical Officer
- Trades Assistant
- Truck Driver
- Welder
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Molding Manufacturing?
Type of Press Mechanism(s)?
- Hydraulic
- Mechanical
- Electrical
Type(s) of Machine(s)?
- Injection Molding
- Plaster Molding
- Blow Molding
- Plastics Extrusion Molding
Type of Molding Environment(s)?
- Automated
- Confined Space
- Climate Controlled
- Distribution Center
- Furnace
- Government
- Hazardous Materials
- Paint Booth
- Private
- Public
- Hazardous Atmospheres
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Oil/Gas/Off Shore Operations
Type of Operation
- Gas
- Off Shore
- Oil
- Oil Field
- Pipeline
- Refinery
Job Title
- Acidizer
- Acid Treater
- Acid Truck Driver
- Ballast Control Operator
- Blender Machine Operator
- Carbon Dioxide Truck Operator
- Cementer
- Cementing Equipment Operator
- Cement Truck Operator
- Chemical Services Operator
- Chemical Truck Operator
- Coiled Tuning Operator
- Control Room Operator
- Crane Operator
- Derrick Hand
- Derrick Worker
- Dynamic Positioning Operator
- Firefighter
- First Response Personnel
- Formation Fracturing Operator
- Frac Driver
- General Labor
- Heavy Machine Operator
- Maintenance Personnel
- Motorperson
- Nitrogen Operator
- Nitrogen Truck Operator
- Office Personnel
- Oil Well Acidizer
- Power-Tong Operator
- Production Tubing Operator
- Pumper Operator
- Reeled Tubing Operator
- Snubbing Unit Operator
- Well Treatment Blender
- Well Treatment Pump Operator
- Heavy Machine Operator
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Restaurant Industry
Job Title(s)?
- Bartender
- Busboy(girl)
- Cafeteria Line Personnel
- Cashier
- Cook
- Dishwasher
- District Manager
- Front End Manager
- Host(ess)
- Janitor
- Maintenance Personnel
- Shift Manager
- Store Manager
- Waiter(ess)
Skilled Labor
Job Title(s)?
- Carpenter
- CNC Operator
- Crane Operator
- Dry Wall/Sheet Rock Installer
- Electrician
- Engineer
- Fork Lift Operator
- Heavy Machine Operator
- HVAC Installer/Technician
- Insulation Installer
- Linesman
- Locomotive Engineer
- Machinist
- Mason
- Painter
- Pipe Fitter
- Plumber
- Press Operator
- Print Operator
- Roofer
- Siding/Trim Installer
- Solderer
- Tool & Die Maker
- Torch Cutter
- Truck Driver
- Welder
- Window/Door Installer
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Utilities?
Type(s) of Utility(s)?
- Cable
- Cell Phone
- Electricity
- Gas
- GPS
- Internet
- Maps
- Nuclear
- Oil
- Satellite
- Sewer
- Telephone (LAN)
- Water
Type(s) of Work Environment?
- Active Blasting Area
- Active Bridge/Roadway
- Active Construction Site
- Airport
- Arial Crane/Lift
- Assembly
- Building Constructed Before 1980
- Cemetary
- Confined Space (Permit Required & Non Permit Required)
- Crawler Crane
- Demolition
- Depths Below 4 Feet
- Hazardous Atmosphere
- Hazardous Energy
- Heights Above 4 Feet
- Hot Work
- In-Flight
- Landfills
- Live Loads
- Military Installations
- Mines
- Navigable Water Ways/Docks
- Office
- Offshore Platform
- Oil &/or Gas Fields
- Port
- Power &Telecommunication Post & Line Transmission
- Quarry
- Refinery
- Suspended
- Telecommunication Antenna & Bridge Tower
- Tower Crane
- Tunnel
- Underground Public Works
- Utility Pole
- Warehouse
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Warehouse Operation
Type(s) of Warehouse Work Environment(s)?
- Automated
- Confined Space
- Climate Controlled
- Distribution Center
- Furnace
- Government
- Hazardous Materials
- Paint Booth
- Private
- Public
- Hazardous Atmospheres
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Job Title(s)?
- Assembler
- Assistant
- CDL Driver
- Courier
- Crane Operator
- Custodian
- Delivery/Transport Driver
- Director of Operations
- Engineer
- Facilities Maintenance Personnel
- Facilities Operation Peronnel
- Feeder
- File Clerk
- Fleet Maintenance Mechanic
- Foreman
- Fork Lift Operator
- General Labor
- Groundskeeper
- Heavy Machine Operator
- Instructor
- Inventory Clerk
- Janitor/Custodian
- Journeyman
- Linesman
- Machine Operator
- Mail Room Clerk
- Maintenance Personnel
- Mechanic
- Nurse
- Operations Manager
- Ordnance Specialist
- Packaging
- Parking Attendent
- Pest Control
- Picker Operator
- Porter
- Processor
- Procurement Personnel
- Production Manager
- Quality Control Inspector
- Risk Management Personnel
- Runner
- Safety & Compliance
- Security
- Shipping/Receiving Personnel
- Sorter
- Storefront Clerk
- Supervisor
- Tool Room Attendant
- Truck Driver
- Tugger Operator
- Warehouse Personnel
Provide Specific Details on Job Duties, PPE, Environment, Min & Max Work depth/height work requirements, types of explosives, HAZ Atmospheres, HAZ Environment, etc.
Waste, Recycle &/or Refuse Operation
Type(s) of Waste, Recycle & Refuse Operation?
- Yes
- No
- N/A
Job Title
- Yes
- No
- N/A

Branch Locations

Multiple Branch Locations
Total Number of Branch Locations
Branch Office #1 Name
Branch Office #1 Manager Name
Branch Office #1 Address
Branch Office #2?
Branch Office #2 Name
Branch Office #2 Manager Name
Branch Office #2 Address
Branch Office #3?
Branch Office #3 Name
Branch Office #3 Manager Name
Branch Office #3 Address
Branch Office #4?
Branch Office #4 Name
Branch Office #4 Manager Name
Branch Office #4 Address
Branch Office #5
Branch Office #5 Name
Branch Office #5 Manager Name
Branch Office #5 Address
Branch Office #6?
Branch Office #6 Name
Branch Office #6 Manager Name
Branch Office #6 Address
Branch Office #7?
Branch Office #7 Name
Branch Office #7 Manager Name
Branch Office #7 Address
Branch Office #8?
Branch Office #8 Name
Branch Office #8 Manager Name
Branch Office #8 Address
Branch Office #9?
Branch Office #9 Name
Branch Office #9 Manager Name
Branch Office #9 Address
Branch Office #10?
Branch Office #10 Name
Branch Office #10 Manager Name
Branch Office #10 Address
Branch Office #11?
Branch Office #11 Name
Branch Office #11 Manager Name
Branch Office #11 Address
Branch Office #12?
Branch Office #12 Name
Branch Office #12 Manager Name
Branch Office #12 Address
Branch Office #13?
Branch Office #13 Name
Branch Office #13 Manager Name
Branch Office #13 Address
Branch Office #14?
Branch Office #15?
Branch Office #15 Name
Branch Office #15 Manager Name
Branch Office #15 Address
Branch Office #14 Name
Branch Office #14 Manager Name
Branch Office #14 Address

Company Safety

Dedicated Safety Professional
Name & Title of Safety Professional
Telephone Number
Email Address
Years of Experience
Safety Designations
Document & Maintain Loss Documentation for Analysis?
How Often Are All Incidents, Accidents, Near Miss &/or Med Refusal Occurrences Data Analyzed?
- Weekly
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annual
- Annual
Does Client Have an Injury & Illness Prevention Program?
Injury & Illness Prevention Program in Place
Injury & Illness Prevention Program Reviewed?
How Often?
- Annually
- Monthly
- New Hazards Introduced
- Policy/Procedures Change
- Quarterly
- Semi-Annual
- Work Environment Changes
Does Client Perform Safety Meetings?
How Often With Branch Staff?
- Weekly
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annual
- Annual
How Often with EE's?
- Weekly
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annual
- Annual
Safety Meetings Documented Verbally?
Safety Meeting Documented in Writing and Maintained in EE's file? (Signed Acknowledgement form by EE)
In House Safety Committee Established?
How Often Does Safety Committee Meet?
- After Every Incident/Accident/Near Miss
- Annually
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annually
- Weekly
Member of Host Employers Safety Committee?
How Often Does Safety Committee Meet?
- After Every Incident/Accident/Near Miss
- Annually
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annually
- Weekly
Safety Meeting Documentation Compliance Audit Performed?
How Often?
- Weekly
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annual
- Annual

Drug Free Work Place Program

Do You Have a "Written" Drug Free Work Place Program?
Is Your Drug Free Work Place Program in Force?
Pre-Employment Drug Screen Program?
Post Accident Drug Screen Program?
Random Drug Screen Program?
Reasonable Suspicion Drug Screen Program?
Return to Work Drug Screen Program (After One Week Absence)

New Client Screening

Assessment of Job Duties?
Client Injury & Illness Prevention Program Review?
Client OSHA Logs Review?
Confirmation of Dedicated Safety Professional?
Confirmation of a Safety Committee?
D & B (Dun & Bradstreet) Check?
E-Mod Check?
Face to Face Visit with Client?
FMCSA SMS Database Check (DOT & Vehicle Maintenance Compliance)?
OSHA Establishment Check?
Site Visit to Determine Exposures & Hazards?

New Employee Screening

Application?
Behavioral Assessment?
Criminal Background Screen?
Current CDL License?
Current DOT Medical Credentials?
Health Screening (TB, HEP Series, etc.)?
I-9 Verification?
In Person Interview?
Pre-Employment Drug Screen?
MVR Check?
Personal Reference Screen?
Reliable Transportation?
Technical Skills Assessment?
Valid Skilled Labor Licensing?
W/C Claim History Screen?
Work Experience Verification?

New Employee Safety Training

Does Client Perform New Hire Safety Orientation Training?
Do All Employees Execute an Acknowledgement Form Acknowledging & Understanding Training Received?
Ariel Lifts Training?
Minimum & Maximum Work Height? Outline Specific Job Title, Duties, Environment and Types of Fall Protection Required. Host Employer Name and Address. (OSHA Fall Protection Trigger 10 Feet for Scaffolding Under Construction Industry; State OSHA triggers may be more stringent)
Does Client Verify if Host Employer has a Fall Prevention Program In place (Site by Site Specific)?
CDL Operation Training?
Outline Specific Job Title, Duties and Types of Vehicles, Type of Freight, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing (Including Medical), DOT Compliance, Documentation, Maintenance of Documentation and Follow Up Procedures
Define Client's Specific Screening & Training Obligations
Define Host Employer's Screening & Training Obligations
Client Specific Safety Orientation Training Video?
Confined Space (Including Permit Required) Training?
Outline Specific Job Title, Duties and Types of Confined Space Work, Job Sites, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical & PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client have a Confined Space (including Permit Required) Program in Place?
Does Host Employer Have a Written Confined Space (including Permit Required) Program in Place?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Crane Operation?
Outline Specific Job Title, Duties and Types of Cranes, Job Sites, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Defensive Driving Training?
Outline Specific Job Title, Duties and Types of Vehicles, Type of Freight, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing, DOT Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Execution of General Safety Rule Acknowledgement Form?
Fall Protection Training?
Type of Fall Protection Required?
Minimum & Maximum Work Height? Outline Specific Job Title, Duties, Environment and Types of Fall Protection Required. Host Employer Name and Address. (OSHA Fall Protection Trigger for General Industry 4 feet and 6 Feet for Construction Industry; State OSHA triggers may be more stringent)
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Forklift Training?
Outline Specific Job Title, Duties and Types of Powered Industrial Vehicles, Type of Material Handled, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures.
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
General Safety Orientation Video?
General Bloodborne Pathogen Training?
Outline Specific Job Title, Duties and Potential Type of Exposures. Define Work Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client Have a Written Bloodborne Pathogen Program In Place?
Does Host Employer Have a Written Bloodborne Pathogen Program in Place?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Bloodborne Pathogen Program in Place?
GHS HAZCOM Training?
Does Client Have a Written GHS HAZCOM Program in Place?
Does Host Employer Have a Written GHS HAZCOM Program in Place?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Hand Tools Training?
Outline Specific Job Title, Duties, Types of Tools required to operate & Host Employer Name and Address.
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
HAZMAT Training?
Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Types of Vehicles, Type of Freight, All Types of Hazardous Material, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client Have a Written HAZMAT Program in Place?
Does Host Employer have a Written HAZMAT Program in Place?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
HAZWOPER Training?
Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Types of Vehicles, Type of Freight, All Types of Hazardous Waste(s), Environments & Host Employer Name and Address.
Does Client Have a Written HAZWOPER Program in Place?
Does Host Employer have a Written HAZWOPER Program in Place?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Hearing Conservation Training?
Outline Specific Job Title, Duties, Required Types of PPE, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical), Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client Have Written Hearing Conservation Program in Place?
Does Client Arrange To Have Annual Audiograms Performed, At No Cost To Their Affected Employees?
Does Host Employer include Client's Affected Employee's In Its Testing Program?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Lock Out/Tag Out Training?
Outline Specific Job Title, Duties, Required Types of PPE, Equipment, Environments & Host Employer Name and Address.
Does Client Have a Written Lock Out/Tag Out Program in Place?
Does Host Employer Have a Written Lock Out/Tag Out Program in Place?
Define Client's Specific Training Obligations
Define Host Employer's Specific Training Obligations
Machine Guarding Training?
Needle Stick/SHARPS Training?
Outline Specific Job Title, Duties and Potential Type of Exposures. Define Work Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical and PPE Fitting), Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client Have a Written Needle Stick/SHARPS Program?
Does Host Employer Have a Written Needle Stick/SHARPS Program?
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
Policy and Procedures Check List Acknowledgement Form?
Motorized Equipment Operation Training?
Outline Specific Job Title, Duties and Types of Motorized Equipment, Type of Material Handled, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing, OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures.
Define Client's Specific Screening & Training Obligations
Define Host Employer's Specific Screening & Training Obligations
PPE Compliance Training?
Respiratory Protection Training?
Outline Specific Job Title, Duties and Types of Respirator Equipment, Type of Material Handled, Environments & Host Employer Name and Address.
Outline Specific Initial Screening & Testing(Including Medical & PPE Fitting), OSHA Certification, Documentation, Maintenance of Documentation and Follow Up Procedures
Does Client Have a Written Respiratory Protection Program In Place?
Does Host Employer Have a Written Respiratory Protection Program In Place?
Define Client's Specific Screening & Training Obligations
Define Host Employers Specific Screening & Training Obligations
Review Of Job Duties?
Review of Job Duties Verbal
Review of Job Duties in Writing (EE Executes Acknowledgment of Review)
Scaffolding Training?
Does Client Verify if Host Employer has a Fall Prevention Program In place (Site by Site Specific)?
Does Client Verify Host Employer has a Qualified Person Inspect Scaffold at the Start of each Shift?

OSHA Logs & Safety Compliance

Are OSHA 300 Logs Kept and Maintained?
Are OSHA 300a Summary Forms Posted at Each Branch Locations from 02/01 - 04/30?
Are OSHA 301 Forms Kept and Maintained?
Does Client Have a Progressive Disciplinary Program in Place?
New Equipment or Process Training (Documented)?
Retrain &/or Re-Certification Program in Place for all reported adverse events (including unsafe operation, near miss, &/or Med Refusal Occurrences)?
Safety & Compliance Checks (Documented)?
How Often?
- 2-3 times a week
- Annually
- Bi-Weekly
- Monthly
- Quarterly
- Semi-Annually
- Weekly
Safety Incentive Program?

OSHA Establishment Inspection Inquiry

OSHA Visit History-Current Year?
Total OSHA Visit(s)-Current Year
Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?
Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)
Total Number of Visit(s) as a Result of a Complaint(s)?
Provide Details and Results of Inspection(s) Prompted by Complaint(s)
Total Number of Visits as a Result of a Follow-Up Inspection(s)?
Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)
Total Number of Visits Due to Imminent Danger(s)
Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit
Total Number of Visits as a Result of Programmed Inspection(s)?
Provide Details and Results of Programmed Inspection(s)
Total Number of Visits as a Result of a Referral(s)?
Provide Details and Results of Inspection(s) Prompted by Referral(s)
Total Number of Violation(s)?
Total Number of Repeat Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Repeat Violation(s)?
Total Number of Serious Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Serious Violation(s)?
Total Number of Willful Violation(s)?
Total Dollar Amount of Willful Violation(s)
Provide Details on Standard(s) Cited and Abetements
OSHA Visit History-2013?
Total OSHA Visit(s)-2013
Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?
Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)
Total Number of Visit(s) as a Result of a Complaint(s)?
Provide Details and Results of Inspection(s) Prompted by Complaint(s)
Total Number of Visits as a Result of a Follow-Up Inspection(s)?
Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)
Total Number of Visits Due to Imminent Danger(s)
Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit
Total Number of Visits as a Result of Programmed Inspection(s)?
Provide Details and Results of Programmed Inspection(s)
Total Number of Visits as a Result of a Referral(s)?
Provide Details and Results of Inspection(s) Prompted by Referral(s)
Total Number of Violation(s)?
Total Number of Repeat Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Repeat Violation(s)?
Total Number of Serious Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Serious Violation(s)?
Total Number of Willful Violation(s)?
Total Dollar Amount of Willful Violation(s)
Provide Details on Standard(s) Cited and Abetements
OSHA Visit History-2012?
Total OSHA Visit(s)-2012
Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?
Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)
Total Number of Visit(s) as a Result of a Complaint(s)?
Provide Details and Results of Inspection(s) Prompted by Complaint(s)
Total Number of Visits as a Result of a Follow-Up Inspection(s)?
Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)
Total Number of Visits Due to Imminent Danger(s)
Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit
Total Number of Visits as a Result of Programmed Inspection(s)?
Provide Details and Results of Programmed Inspection(s)
Total Number of Visits as a Result of a Referral(s)?
Provide Details and Results of Inspection(s) Prompted by Referral(s)
Total Number of Violation(s)?
Total Number of Repeat Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Repeat Violation(s)?
Total Number of Serious Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Serious Violation(s)?
Total Number of Willful Violation(s)?
Total Dollar Amount of Willful Violation(s)
Provide Details on Standard(s) Cited and Abetements
OSHA Visit History-2011?
Total OSHA Visit(s)-2011
Total Number of Visits Due to A Catastrophe(s) &/or Fatality(s)?
Provide Details of Catastrophe(s) &/or Fatality(s) that Prompted Inspection(s)
Total Number of Visit(s) as a Result of a Complaint(s)?
Provide Details and Results of Inspection(s) Prompted by Complaint(s)
Total Number of Visits as a Result of a Follow-Up Inspection(s)?
Provide Details and Results of Inspection(s) Prompted by Follow-Up Inspection(s), Including Details To Initial Inspection Visit(s)
Total Number of Visits Due to Imminent Danger(s)
Provide Details of Imminent Danger(s) that Prompted Imminent Danger Visit
Total Number of Visits as a Result of Programmed Inspection(s)?
Provide Details and Results of Programmed Inspection(s)
Total Number of Visits as a Result of a Referral(s)?
Provide Details and Results of Inspection(s) Prompted by Referral(s)
Total Number of Violation(s)?
Total Number of Repeat Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Repeat Violation(s)?
Total Number of Serious Violations?
Provide Details on Standard(s) Cited and Abatements
Total Dollar Amount of Serious Violation(s)?
Total Number of Willful Violation(s)?
Total Dollar Amount of Willful Violation(s)
Provide Details on Standard(s) Cited and Abetements

Accident Investigation & Reporting

All Reported Incidents Reported to Carrier or TPA within 24 hours (Including Med-Refusals)
Are Employees Required to Notify Both Client & Host Employer immediately of all work related events, regardless of severity?
Provide Details on Who and When Employees are Required to Report Work Related Events?
Client Completes an Accident/Incident Investigation Form(Possibly Coordinated with Host Employer)?
Client Conducts Onsite Accident/Incident Investigation Immediately?
Provide Details on Who Conducts Onsite Accident/Incident Investigation and When?
Currently Has a Preferred Medical Provider Vendor Pool?
Is an ER the Preferred Health Care Provider for all Injuries and Drug Screens?
Is a Non Urgent (Occupational) Care Facility the Preferred Health Care Provider for all Non-Life-Threatening or Non Immediate Emergency Injuries and Drug Screens?
Urgent Care Facility the Preferred Health Care Provider for all Non-Life-Threatening or Non Immediate Emergency Injuries and Drug Screens?
Medical Provider Protocols Established with Each Provider?
Medical Care Provider forwards Medical & Post Accident Drug Screen Documentation to Client immediately after each visit?
Currently Pay Any Injury, Accident or Post Accident/Incident Drug Screen Expenses In House?
Detail What Expenses are Currently Paid in House
Currently Pay/Handle Any Reported Incidents/Accidents/Injuries In House?
Detail What Incidents/Accidents/Injuries are Currently Handled in House
Employee Required to Complete and Execute a Statement of Refusal of Medical Treatment, if Medical Treatment is Declined at the Time of Report?
Employee Required to Complete an Employee Statement of Injury/Incident/Near Miss?
Employee Required to Forward All Medical Documentation Immediately After Each Doctors Visit?
Employee Required to Contact Branch Office Once a Week To Update Current Medical and Work Status?
For Non-Immediate Emergency Injuries; Client Transports Injured Worker to Health Care Provider
For Non-Immediate Emergency Injuries; Employee Required to Transport Themselves to Health Care Provider
For Non-Immediate Emergency Injuries; Host Employer Transports Injured Worker to Health Care Provider
Post Accident/Incident Drug Screen Required (including Med Refusal, Near Miss and Unsafe Operation Occurrences)
Provide Light Duty Accommodations to Injured Workers?
Light Duty Accommodations?
- Host Employer
- In House
- Outside Vendor
Official Bona Fide Offer of Employment Letter Provided to Employee for Acceptance & Execution, by Verifiable Means? (Copy of Work Status Report Must also be attached and sent Certified Mail, if being mailed)
Employee Paid Same Wages and Similar Hours?

Claim History

Loss Runs Provided for Review?
2013 Loss Runs Provided
Total Number of Claims for Policy Year 2013
Total Incurred for Policy Year 2013
Explain Frequency and Total Incurred for Policy Year 2013
Details of Circumstances regarding Highest Total Incurred Claims
2012 Loss Runs Provided
Total Number of Claims for Policy Year 2013
Total Incurred for Policy Year 2013
Explain Frequency and Total Incurred for Policy Year 2013
Details of Circumstances regarding Highest Total Incurred Claims
2011 Loss Runs Provided
Total Number of Claims for Policy Year 2013
Total Incurred for Policy Year 2013
Explain Frequency and Total Incurred for Policy Year 2013
Details of Circumstances regarding Highest Total Incurred Claims
2010 Loss Runs Provided
Total Number of Claims for Policy Year 2013
Total Incurred for Policy Year 2013
Explain Frequency and Total Incurred for Policy Year 2013
Details of Circumstances regarding Highest Total Incurred Claims
2013 Loss Runs Provided
Total Number of Claims for Policy Year 2013
Total Incurred for Policy Year 2013
Explain Frequency and Total Incurred for Policy Year 2013

Non CDL/DOT Motor Vehicle Operation

Employees Required to Operator Motor Vehicles As a Condition of Employment
Job Title(s)?
- Assembler
- Assistant
- CDL Driver
- Courier
- Crane Operator
- Custodian
- Delivery/Transport Driver
- Director of Operations
- Engineer
- Facilities Maintenance Personnel
- Facilities Operation Peronnel
- Feeder
- File Clerk
- Fleet Maintenance Mechanic
- Foreman
- Fork Lift Operator
- General Labor
- Groundskeeper
- Heavy Machine Operator
- Instructor
- Inventory Clerk
- Janitor/Custodian
- Journeyman
- Linesman
- Machine Operator
- Mail Room Clerk
- Maintenance Personnel
- Mechanic
- Nurse
- Operations Manager
- Ordnance Specialist
- Packaging
- Parking Attendent
- Pest Control
- Picker Operator
- Porter
- Processor
- Procurement Personnel
- Production Manager
- Quality Control Inspector
- Risk Management Personnel
- Runner
- Safety & Compliance
- Security
- Shipping/Receiving Personnel
- Sorter
- Storefront Clerk
- Supervisor
- Tool Room Attendant
- Truck Driver
- Tugger Operator
- Warehouse Personnel
Driver(s) Screened?
Initial MVR Check?
Follow Up MVR Checks?
- Monthly
- Quarterly
- Semi-Annual
- Annual
Defensive Driving Certification Course?
Vehicle Ownership?
- Client Owned
- Host Employer Owned
- Owner Operator
Vehicle Maintained By?
- Client Maintained
- Host Employer Maintained
- Owner Operator Maintained
Type of Vehicles?
- Passenger Car
- Passenger Van
- Pick Up
- Limousine
- School Bus
- Passenger Bus
- Straight Box Truck
- Semi-Tractor & Trailer
- Tanker
- Light Tow Truck
- Heavy Tow Truck
- Delivery Van
Daily Pre Trip Vehicle Inspections Completed?
Daily Pre Trip Vehicle Inspections Documented and Maintained on File?
Daily Post Trip Vehicle Inspections Completed?
Daily Post Trip Vehicle Inspections Documented and Maintained on File?
Group Employee Transport?
Dedicated Route?
Total Number of Employees Transported?
CDL May be Required as well as State or Federal DOT Jurisdication
Total Distance (Miles) Driven Per Day
Explain driver demands.
Local Route?
Dedicated Route?
Overnight Travel?
Duration of Job Assignment and Job Duties
Crossing State Lines
State Lines Crossed?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Total Estimated Miles to Drive (Current Year)
Total Miles Driven (Previous Year)
No Touch Product/Freight Delivery?
Transporting HAZMAT, Hazardous Waste, Bio-Hazards, Alcohol, etc.?
Type of HAZMAT
- Yes
- No
- N/A

CDL/DOT Motor Vehicle Operation

Are Employees Required to Operate any Motor Vehicles Requiring CDL Designations or Endorsements?
Initial MVR Check?
Follow Up MVR Checks?
How Often?
- Monthly
- Quarterly
- Semi-Annual
- Annual
Defensive Driving Course Completion Certification?
List All Required CDL Designations
- Class A
- Class B
- Class C
CDL Drivers Require Special Endorsements?
H - HAZMAT Endorsement?
Provide Specific List of Hazardous Material, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.
N - Tanker
P - Passenger Vehicle Endorsement?
Provide Maximum Number of Passengers to Transport, Type of Vehicle(s), Local, Regional or Cross Country Dedicated Routes, Specific Job Duties, Distance Traveled, etc.
S - School Bus Endorsement?
Provide Maximum Number of Passenger to Transport, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc. School District Servicing.
T - Double or Triple Trailers Endorsement?
Provide Specific List of Freight, Material, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.
X - Combination of tank vehicle and hazardous materials endorsements?
Provide Specific List of Product Transported, Type of Vehicle(s), Specific Job Duties, Distance Traveled, etc.
CDL Vehicle Ownership?
- Client Owned
- Host Employer Owned
- Owner Operator
CDL Vehicle Maintained By?
- Client Maintained
- Host Employer Maintained
- Owner Operator Maintained
Daily Pre-Trip Vehicle Inspections Documented and Maintained on File?
Daily Post-Trip Vehicle Inspections Documented and Maintained on File?
USDOT# &/or MCDOT# Required?
Provide USDOT# &/or MCDOT#
Federal Motor Carrier Inspection History in Safety Measurement System Database(Current Year)?
Total Number of Inspections Current Year?
Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) (Current Year)?
Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Crash Indicators Violation(s) (Current Year)?
Crash Result in a Fatality?
Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?
Total Number of Driver Fitness Related Inspection Violation(s) (Current Year)?
Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) (Current Year)?
Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?
Total Number of Hours of Service Related Inspection Violation(s) (Current Year)?
Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Unsafe Driving Related Inspection Violation(s) (Current Year)?
Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Vehicle Maintenance Related Inspection Violation(s) (Current Year)?
Explanation of Vehicle Maintenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Federal Motor Carrier Inspection History in Safety Measurement System Database (Year 2013)?
Total Number of Inspections Year 2013?
Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) Year 2013?
Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Crash Indicators Violation(s) Year 2013?
Crash Result in a Fatality?
Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?
Total Number of Driver Fitness Related Inspection Violation(s) Year 2013?
Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) Year 2013?
Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?
Total Number of Hours of Service Related Inspection Violation(s) Year 2013?
Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Unsafe Driving Related Inspection Violation(s) Year 2013?
Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Vehicle Maintenance Related Inspection Violation(s) Year 2013?
Explanation of Vehicle Maintenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Federal Motor Carrier Inspection History in Safety Measurement System Database Year 2012?
Total Number of Inspections Year 2012?
Total Number of Controlled Substance &/or Alcohol Related Inspection Violation(s) Year 2012?
Explanation of Controlled Substance &/or Alcohol Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Crash Indicators Violation(s) Year 2012?
Crash Result in a Fatality?
Explanation of Crash Indicator Related Violation(s), Circumstances Regarding any Crash Resulting in a Fatality and Detail Any Corrective Measures Taken?
Total Number of Driver Fitness Related Inspection Violation(s) Year 2012?
Explanation of Driver Fitness Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of HAZMAT (HM) Compliance Related Inspection Violation(s) Year 2012?
Explanation of HAZMAT (HM) Related Inspection Violation(s), List of Hazardous Materials and Detail Any Corrective Measures Taken?
Total Number of Hours of Service Related Inspection Violation(s) Year 2012?
Explanation of Hours of Service Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Unsafe Driving Related Inspection Violation(s) Year 2012?
Explanation of Unsafe Driving Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Total Number of Vehicle Maintenance Related Inspection Violation(s) Year 2012?
Explanation of Vehicle Mainenance Related Inspection Violation(s) and Detail Any Corrective Measures Taken?
Interstate Driving (State to State)
Type of Commodity Transported?
- Auto Transport
- Commercial &/or Residential Moving
- Dry Freight
- HAZMAT
- Heavy Machinery &/or Equipment
- Livestock
- Passenger (Commercial Mass Transit)
- Passenger (Public Mass Transit)
- Non Perishables
- Perishables
- Produce
Travel To & Through Which States?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Types of Vehicles?
- Box Truck
- Charter Bus
- Dump Truck
- Flat Bed Trailer
- HAZMAT
- Limousine
- Semi-Tractor Trailer
- Semi Tractor Trailer w/Pup
- Straight Truck (+26 feet)
- School Bus
- Tanker
Total Estimated Miles to Drive (Current Year)
Total Miles Driven (Previous Year)
Total Estimated Miles to Drive (Current Year)
Total Miles Driven (Previous Year)
Assist With Load & Unload?
Describe Driver Load and Unload Assist Requirements
Dedicated Local Route?
Provide Dedicated Route Details
No Touch Freight?
Intrastate Driving (State of Origination Only)
Type of Commodity Transported?
- Auto Transport
- Commercial &/or Residential Moving
- Dry Freight
- HAZMAT
- Heavy Machinery &/or Equipment
- Livestock
- Passenger (Commercial Mass Transit)
- Passenger (Public Mass Transit)
- Non Perishables
- Perishables
- Produce
Travel To & Through Which States?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
Types of Vehicles?
- Box Truck
- Charter Bus
- Dump Truck
- Flat Bed Trailer
- HAZMAT
- Limousine
- Semi-Tractor Trailer
- Semi Tractor Trailer w/Pup
- Straight Truck (+26 feet)
- School Bus
- Tanker
Total Estimated Miles to Drive (Current Year)
Total Miles Driven (Previous Year)
Total Estimated Miles to Drive (Current Year)
Total Miles Driven (Previous Year)
Assist With Load & Unload?
Describe Driver Load and Unload Assist Requirements
Dedicated Local Route?
Provide Dedicated Route Details
No Touch Freight?

Loss Prevention & Control Philosophy

Acceptable Risk for Vensure Employer Services?
Provide Detailed Explanation
Demonstrated an Eagerness to Learn and Implement Other Policy & Procedures?
Provide Detailed Explanation
Demonstrated Strong Safety First Company Philosophy?
Provide Detailed Explanation
Exhibited a Production/Sales First Philosophy?
Provide Detailed Explanation
Expressed a Commitment to Form a Partnership with Vensure Loss Control Team?
Provide Detailed Explanation
Immediately Objected to OSHA/DOT and/or Industry Standard Compliance Issues?
Provide Detailed Explanation
Receptive to Scheduling In Person Loss Control Visit Within 30 Days of Onboarding?
Provide Detailed Explanation
Seemed Disengaged from Loss Prevention & Loss Control Processes?
Provide Detailed Explanation
Relies on Host Employer to Perform All Loss Prevention & Loss Control Compliance Requirements?
Provide Detailed Explanation
Voiced Any Objections to Issues That May Not Be OSHA/DOT Compliant or Industry Standard?
Provide Detailed Explanation