Request a Workplace Safety Consultation visit

Workplace Safety Consultation has safety and health professionals available at no cost to you. Please fill in the following request form if you are interested in receiving a free safety and health consultation at your facility.

Fields marked by * are required and cannot be left blank. If you have any questions, please call (651) 284-5060 or toll-free at 1-800-657-3776.

Establishment information

Company/establishment name: *

NAICS: *

(search for NAICS code)

Ownership: *

Number of employees in establishment: *

Total number of employees in state: *

On-site consultation services requested:

Number of employees affected by the consultation: *

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Site address

Mailing address (if different)

Site address line 1: *

Address line 1: Address line 1 must be less than or equal to 40 characters

Site address line 2: Site address line 2 must be less than or equal to 40 characters

Address line 2: Address line 2 must be less than or equal to 40 characters

Site city: * Site city is required

City: City must be less than or equal to 40 characters

Site State: * Site state is required Enter the 2 character abbreviation for site state

State: Enter the 2 character abbreviation for state

Site ZIP code: *

ZIP code: ZIP code must be a number and no more than 10 digits

Site phone number: *

Phone number: Phone number must be a number and no more than 13 digits

Site cell number: Site cell phone number must be a number and no more than 13 digits

Cell phone number: Cell phone number must be a number and no more than 13 digits

Description of business: * Description of business is required Description of business must be less than or equal to 250 characters

Check if in business for over 3 years

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Employee data (previous 3 years)

Year (row 1) Year (row 1) must be a number and no more than 4 digits

Total Hours Worked (row 1) Total hours worked (row 1) must be a number and no more than 8 digits

Average No Employees (row 1) Average number of employees (row 1) must be a number and no more than 6 digits

Year (row 2) Year (row 2) must be a number and no more than 4 digits

Total Hours Worked (row 2) Total hours worked (row 2) must be a number and no more than 8 digits

Average No Employees (row 2) Average number of employees (row 2) must be a number and no more than 6 digits

Year (row 3) Year (row 3) must be a number and no more than 4 digits

Total Hours Worked (row 3) Total hours worked (row 3) must be a number and no more than 8 digits

Average No Employees (row 3) Average number of employeese (row 3) must be a number and no more than 6 digits

Employer contact information

Salutation:

First name: *

First name is required First name must be less than or equal to 30 characters

Last name: *

Last name is required Last name must be less than or equal to 30 characters

Title: *

Title is required Title must be less than or equal to 30 characters

E-mail: *

E-mail is required Invalid email format

How did you learn about Workplace Safety Consultation (WSC) services? How did you learn about Workplace Safety Consultation (WSC) services is required

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