Has the PA/OSHA Consultation Program made a previous visit to this establishment? yes no

Establishment Name:

Site Address:

Mailing Address (if different):

Type of Business:

Contact Name and Title:

Telephone Number:

Fax Number:

Last OSHA Inspection Date:

Number of Employees on Site:

Number of Employees Covered by Consultation:

Number of Employees Controlled Corporate-Wide by Employer:

I have read and agree to all of the Employer Obligations: yes no

/