APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE

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
State of Connecticut, Department of Labor

Division of Occupational Safety and Health

38 Wolcott Hill Road, Wethersfield, CT 06109

860-263-6900
Should be Empty:

APPLICATION FOR INDUSTRIAL HEALTH FACILITY LICENSE

PERSONNEL

Physical examinations

Treatments

Special services

CERTIFICATION:

CERTIFICATION: