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: *

Site address

Mailing address (if different)

Site address line 1: *

Address line 1:

Site address line 2:

Address line 2:

Site city: *

City:

Site State: *

State:

Site ZIP code: *

ZIP code:

Site phone number: *

Phone number:

Site cell number:

Cell phone number:

Description of business: *

Check if in business for over 3 years

Employee data (previous 3 years)

Year (row 1)

Total Hours Worked (row 1)

Average No Employees (row 1)

Year (row 2)

Total Hours Worked (row 2)

Average No Employees (row 2)

Year (row 3)

Total Hours Worked (row 3)

Average No Employees (row 3)

Employer contact information

Salutation:

First name: *

Last name: *

Title: *

E-mail: *

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

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