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.

 

COMPANY INFORMATION

SITE INFORMATION

(If different from Company Name above)

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?

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.



You may fax or mail the completed application to our office. Please fax both sides.  If you do not receive an acknowledgment letter within two weeks of submitting your application, call us at 573-751-3403.

Missouri Department of Labor and Industrial Relations is an equal opportunity employer/program. TDD/TTY: 800-735-2966 Relay Missouri: 711

The Missouri On-Site Consultation Program is funded by a federal grant of $1,090,200, which constitutes ninety percent of the overall budget for the program.

Disclaimer: The mention of the name of any company or specific products by the consultant does not constitute an endorsement by the Missouri Safety and Health Consultation Service. Also, the results and recommendations in this report are based on the conditions which were present during our survey and on the best information available to the consultant at the time of the survey, and do not replace any other needed or required safety or health monitoring for your facility.