Consultation Request – Chesapeake Region Safety Council

Consultation Request

Company Name

Name

First

Last

Phone

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Number of Employees

Has your company/organization been through a regulatory compliance inspection such as OSHA?

Are you interested in on-site inspections to determine compliance with applicable standards and best practices?

Are you interested in having your Safety Program reviewed and/or written?

Does your company/organization consider itself Construction or General Industry?

What do you think would benefit your company/organization? Select all that apply

Improved Safety Culture
Compliance in the field and/or in your facility
Employee training on equipment use? Forklift? Scaffolds? Fall Protection? Machine Guarding?
Emergency Preparedness
Leadership/Supervisor Training
Incident Investigation
Other

Are you interested in private on-site training for employees?

Is your company/organization interested in Driver Improvement courses?

Email the completed nomination form and supportive
documentation to safety@chesapeakesc.org.