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:

Reason For Requesting Visit:

OSHA Inspection Date: Received informal/formal complaint letter Received letter from Department of Labor Received letter from area OSHA Office

Number of Employees on Site:

SIC/NAICS Number(s):

Unionized:

Requesting Safety Review:

Requesting Health Review:

Air Monitoring Requested:

Noise Monitoring Requested:

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

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