Form Lb-1010 - Request For Consultative Services

Download a blank fillable Form Lb-1010 - Request For Consultative Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Lb-1010 - Request For Consultative Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Request for Consultative Services

Please mail, fax, or email this request form:

Tennessee Dept. of Labor & Workforce Development – TOSHA Consultation

220 French Landing Drive

Nashville, TN 37243-1002

Fax: 615-532-2997

Email:

Garrett.Rea@tn.gov

Company Name: ____________________________________________________________

NAICS*:_____________________

Contact Name:

_______________________________

Title: ____________________________________________________

Site Address:

_______________________________

Mailing Address: ___________________________________________

_______________________________

(if different)

___________________________________________

Telephone Number: __________________________ Ext: ______

Cell/Optional Number: _______________________________

Email Address: ________________________________________

TOSHA inspection in last 12 Months? Yes

Number of Employees on-site:___________

Number of Employees nationwide: _____________

*Note: Your NAICS code can be found at:

How can our team best serve you? Select one of three types of service we can provide:



Full Service

Both

Health

Safety



Limited Service

Health

Safety (Please list your specific need for assistance below)



Compliance/Abatement Assistance

TOSHA Inspection Number: __________________________

Please describe the nature of the business, including a site description, # of buildings, specific machines or processes

integral to operation, items of concern such as LO/TO, machine guarding, electrical, confined spaces, combustible

dust, respiratory protection, hazardous chemicals, bloodborne pathogens, spray booths, flammables, noise, etc.

I am authorized to request that Tennessee OSHA conduct a consultative survey of my company. I understand that this service is offered at no direct

cost and it does not increase the probability that my company will receive an inspection from Compliance. Following each survey, a written report of

the consultant’s findings will be provided. I understand that the company is obligated to correct any hazards observed by the consultant within the

agreed upon time, report the status of the hazards when extensions are needed every 30 days, to post the “List of Hazards” found for three days or

until corrected, and to allow the consultant to confer with employees. If you have not received confirmation of the receipt of this request via letter

within two weeks, please feel free to contact the Program Manager. Requests are prioritized by site hazardousness, size and our existing backlog.

Signature of Authorized Company Official

Date

Print or Type Name

Job Title

LB‐1010