EOLWD

Massachusetts OSHA Workplace Safety Consultation Request Form

To request a free Private-Sector OSHA Workplace Safety Consultation site visit, complete the form below or call (508) 616-0461 and select option 2.

Fields marked with a red asterisk * are required fields and must be filled out or the form can not be submitted.

Choose a request type:(Required)

Safety Inspection

Health Inspection

Both

Company's Name:(Required)

Company's Address 1:(Required)

Company's Address 2:(Required)

Company's State:(Required)

Company's Zip Code:(Required)

Company's Mailing Address 1: (if different than company address)

Company's Mailing Address 2:

Company's Mailing City:

Company's Mailing Zip Code:

Company's Contact Name:(Required)

Company Contact's Job Title:(Required)

Company Contact's phone number:(Required)

Company Contact's Email:(Required)

Company Contact's Fax:(Required)

Type of Business: (please describe)(Required)

Does the Company have Union employees?(Required)

Yes

Number of employees at this location:(Required)

Number of all employees controlled by the employer:(Required)

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

Yes

If yes, is the case still open?(Required)

Yes

Reason for request:(Required)

Evaluation and identification of safety and health hazards

Assistance with a specific process or work area

Part of an OSHA settlement agreement

Assistance with OSHA-required programs

Air sampling

Other

Are you authorized by the company to make this request?(Required)

Yes

Name of person completing this request form:(Required)

Position/Title of the person completing this request form:(Required)