APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE

State of Connecticut, Department of Labor

Division of Occupational Safety and Health

38 Wolcott Hill Road, Wethersfield, CT 06109
APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE
Type of License*

InitialRenewal
License number (if Renewal)
Establishment Name*
Number of employees eligible for service*
Address of Industrial Health Facility*
Telephone Number*
Number of hours facility is open per week*
PERSONNEL

List names and specific hours of duty (eg. M, W, F 8-4; T, Th 2-10)
Medical Director (name and hours worked)*
Other physician (name and hours worked)
Registered nurse (name and hours worked)
Licensed Practical Nurses or Physician's Assistants (names and hours worked)
Please upload the following files: Medical Director license, Registered Nurse license, and American Heart Association/American Red Cross First Aid Certificates. *

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TYPES OF HEALTH SERVICES PROVIDED

(Include data regarding services provided in the Industrial Health Facility only)
Physical examinations

Enter number provided during the last calendar year
Pre-Placement*
Periodic - General*
Periodic - Employees exposed to health hazards*
Periodic - Employees exposed to accident hazards*
Return to work from sick leave or leave of absence*
Retirement or termination*
Other (specify)
Treatments

Enter number provided during the last calendar year
Occupational injuries and illnesses*
Non-occupational injuries and illnesses*
Other (specify)
Special services

Enter number provided during the last calendar year
X-ray examinations*
EKG*
Physiotherapy*
Audiometric examinations*
Tonometric eye examinations*
Pulmonary function tests*
Immunizations*
Clinical laboratory tests *
Health counseling *
Other (specify)
List prescription drugs stocked and used here (applicants may alternatively upload a file below):
Upload a list of prescription drugs stocked and used.

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CERTIFICATION:

This is to certify that I am the Medical Director for the Industrial Health Facility listed on this application.
Type name here:*
Signature*

Clear
Date*

MonthDayYear
Date
CERTIFICATION:

This is to certify that I am the Administrator for the Industrial Health Facility listed on this application. Application is hereby made under the provisions of Section 31-374 of the General Statutes for a license to operate this Industrial Health Facility.
Type name here:*
Signature*

Clear
Date*

MonthDayYear
Date
Email*
example@example.com
Should be Empty:

APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE

PERSONNEL

Physical examinations

Treatments

Special services

CERTIFICATION:

CERTIFICATION: