CONN-OSHA On-Site Consultation Request Form

CONN-OSHA On-Site Consultation Request Form

Please complete the information below to request a free On-Site Consultation Visit.
Request Type *
Employer Legal Name *
DBA Name
(If applicable)
Business or Site Address *

Street Address

Street Address Line 2

City State

Zip Code
Mailing Address (If different from Business Address)

Street Address

Street Address Line 2

City State

Zip Code
Employer Contact Name *
Employer Contact Title
Employer Contact E-Mail *
example@example.com
Employer Contact Phone *
Total Number of Employees
Type of Work
NAICS Code (Optional)
North American Industry Classification System code
Legal Establishment Type
Employer Has Union Employees

Yes No
Reason For Request: In order to better serve you, please select all that apply:

General Walk Through Only Assistance with an OSHA Complaint Assistance with OSHA Required Programs Air Sampling (if so, please note what substances in the comment box) Noise Sampling Respiratory Protection Selection and Compliance
The employer had an OSHA/CONN-OSHA inspection in the past 12 months.

Yes No
If Yes to OSHA/CTDOL inspection, Status of Citation?
How did you hear about our services?
Other Comments:
Questions?

Contact us at:

Connecticut Department of Labor

Occupational Safety and Health Division

38 Wolcott Hill Rd.

Wethersfield, CT 06109

Telephone: (860) 263-6900

Fax: (860) 263-6940
Should be Empty: