Form Lb-1010 - Request For Consultative Services

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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
Company Name: ____________________________________________________________
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
Limited Service
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
Print or Type Name
Job Title


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