Missouri On-Site Safety & Health Consultation Service - Application for Consultation Service (LS-25)

Missouri Department of Labor
& Industrial Relations
Division of Labor Standards

PO. Box 449
Jefferson City, MO
65102-0449
Phone: 573-751-3403
Fax: 573-751-3721
safetyconsultation@labor.mo.gov
labor.mo.gov/onsite

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a PDF version of this form.

 

Form

COMPANY INFORMATION

Company Mailing Address

SITE INFORMATION

(If different from Company Name above)
Site Address

PERSON TO CONTACT

PERSON MAKING REQUEST

COMPANY DETAILS

Is OSHA including you in any type of targeting program?
Are you a construction company?
Is the facility union or non-union?
Have you had an OSHA Compliance visit in the last 12 months?
Are any of the following used in the production processes at your facility?
Check the box of each applicable category.
Are any of the following present at your facility?
Do you own or rent your building?
Are you completing this application as part of the Consultation Rapid Transfer (CRT) program?

NOTICE OF OBLIGATION

If an Occupational Safety and Health Administration (OSHA) inspection should occur at your facility, the OSHA Compliance Officer will not know about this consultation visit. You are not required to inform the Compliance Officer of our service, but you must provide a copy of our chemical sampling or noise monitoring results if it is requested (29 CFR 1910.1020(e)(3)). The OSHA Compliance Officer will not be legally bound by the advice given by our consultant, nor will the consultant be legally responsible for any OSHA citations.

Before accepting this service from the state of Missouri, the company agrees to correct all hazards identified as serious within the established time frame. Also, when feasible, the company agrees to implement temporary protective measures for serious hazards until the hazards can be corrected permanently. Extensions may be granted if you encounter difficulties, but these extensions must be requested in writing on or before the correction due date. The Missouri Safety and Health Consultation Service has a legal obligation to inform OSHA of serious hazards not corrected within the agreed upon time frame (29 CFR 1908.6(f)).


I hereby authorize the Missouri Safety and Health Consultation service to take pictures of both hazardous situations and good examples of safety and health control measures, for documentation purposes and also for use in training and promotional activities

SIGNATURE AND TITLE OF COMPANY OFFICIAL AUTHORIZING THIS CONSULTATION SERVICE

Draw your signature in the field below.