Your Name (required)
Your Email (required)
Your Phone Number
Your Company Name
Company Name
Industry Type
Number of full time employees
Number of part-time employees
Number of contractors
Number of known worksite locations
What are your company’s current opening and closing times
What are your company current shift times (eg 0600-1400, 0900-1700)
How many staff do you have working on each shift
What is the most commonly reported injury on your worksite neckbackshoulderpsychother
Who is your current worker’s compensation insurer
Who is your return to work coordinator (please provide email address and contact phone number)
Who is your current injury management provider (if company preferred)
Who is your current rehabilitation provider (if company preferred)
Do you have an active health surveillance programme YesNo
Do you carry out any work that requires immunization, vaccination or health monitoring (if yes, what type of work)
Are there any workplace hazards in particular that you would like assessed (if yes, please list them all)
Who carries out your preemployment medicals? (Please attach a blank or sample proforma)
Do you run toolbox talks (if so how often and where is the frequency and topic documented)
Do you run safety presentations at work (if so how often and where is the frequency and topic documented)
Do you have safety manuals prepared for staff for induction and refresher updates (if so, please advise what they are named)
Do you have easy-to-access MSDS sheets on-site YesNo
Attach Documents
