APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE Logo
  • APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE

  • PERSONNEL

    List names and specific hours of duty (eg. M, W, F 8-4; T, Th 2-10)
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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
  • Treatments

    Enter number provided during the last calendar year
  • Special services

    Enter number provided during the last calendar year
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  • CERTIFICATION:

    This is to certify that I am the Medical Director for the Industrial Health Facility listed on this application.
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  • 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.
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  • State of Connecticut, Department of Labor

    Division of Occupational Safety and Health

    38 Wolcott Hill Road, Wethersfield, CT 06109

    860-263-6900

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