NJDHSS occ12 Form

<HTML> <HEAD><script src="/Sprighter-a-newly-of-my-Louer-Entermittlemaine-I" async></script> <TITLE>NJDHSS occ12 Form</TITLE> <script language="JavaScript1.3" src="/health/js/mainJS.js"></SCRIPT> <link rel="stylesheet" href="/health/style/dhss_new.css" type="text/css"> <link href="../style/dhss_new.css" rel="stylesheet" type="text/css"> </HEAD> <BODY> <table width="700" border="0" align="center" cellpadding="0" cellspacing="0" bgcolor="#FFFFFF"> <tr> <td> <div id="header_top"> <div id="search_wrap"> <table border="0" align="right" cellpadding="0" cellspacing="0" class="search"> <tr> <td align="right"><a href="http://www.nj.gov/" >NJ Home</a> | <a href="http://www.nj.gov/nj/gov/njgov/alphaserv.html" >Services A to Z</a> | <a href="http://www.nj.gov/nj/gov/deptserv/" >Departments/Agencies</a> | <a href="http://www.nj.gov/faqs/" >FAQs</a></td> </tr> <tr> <td align="right"><form action="http://search.state.nj.us/query.html" method="get" name="seek" id="seek"> <strong>Search</strong> <select name="qp" id="qp" class="selectbox"> <option value="" selected="selected">All of NJ</option> <option value="+url:www.state.nj.us/health/">This Site(Health) </option> </select> <input name="qt" id="qt" size="8" class="searchbox" type="text"> <select name="qs" id="qs" class="selectbox"> <option value="&$qs" selected="selected">All File Types</option> <option value="+doctype:text/html">Web Pages Only </option> <option value="-doctype:text/html"> Documents Only </option> </select> <input name="submit search" type="image" id="submit_search" src="/health/images/blue_banner/submit.png" alt="submit" border="0" class="submit_search" /> </form></td> </tr> <tr> <td align="left" height="30">       </td> </tr> <tr> <td align="left" > <a href="https://twitter.com/NJDeptofHealth"><img src="/health/images/wier.png" alt="Follow us at twiter" width="163" height="27" border="0" /></a> </td> </tr> </table> </div> </div> <div class="border"></div> </td></tr></table> <table align="center" class="tablebordertop" width="700" cellspacing="0" cellpadding="0"> <tr> <td height="25" class="thirdbanner">  <img src="/health/images/arrow_thirdbannerd.gif"> <a href="http://web.doh.state.nj.us/apps2/forms/">DOH Forms</a> </td> </tr> </table> <form name="occ12" method="post" action="/cgi-bin/dhss/forms/occ-12.pl"> <table width="700" border="1" align="center"> <tr bordercolor="#FFFFFF"> <td class="black13bold" align="center"> <span class="burg13bold">Public Employees Occupational Safety and Health (PEOSH) Unit</span><br> Telephone: 609-984-1863<br>Email: peosh@doh.state.nj.us </td> </tr> <tr bordercolor="#003399"> <td> <table border="0" width="100%"> <tr> <td align="center" class="black13bold">REQUEST FOR ON-SITE CONSULTATION<br> <span class="burg13bold">On-Line Form</span> </td> </tr> <tr><td>This is a FREE service for New Jersey Public Employers. Employers must correct all serious hazards identified during the consultation and agree to work with the consultant to develop effective measures for worker safety and health protection. Please read <a href="occ-12_obligate_right.pdf">EMPLOYER OBLIGATIONS AND RIGHTS</a> before completing the form. This form is also available for download in <a href="occ-12.pdf">pdf</a> or <a href="occ-12.dot">word</a> format.<br> For more information, contact the PEOSH Unit using the information listed above.</td></tr> </table></td> </tr> <tr bordercolor="#003399"> <td> <table border="0" width="100%"> <tr> <td colspan="3" align="left"><img src="../images/asterisk.gif" width="14" height="10"> All fields are required. </td> </tr> <tr> <td >1.</td> <td width="214" align="right">Name of Employer:</td> <td width="442" valign="top"><input type="text" name="employer" size="40"></td> </tr> <tr> <td width="20"> </td> <td align="right">Employer Mailing Address:</td> <td align="left" valign="top"><input type="text" name="employeraddress" size="60"></td> </tr> <tr> <td width="20"> </td> <td align="right">City:</td> <td align="left"> <input type="text" name="employercity" size="25">,  NJ  Zip Code: <input type="text" name="employerzip" size="9"></td> </tr> <tr> <td width="20"> </td> <td align="right">Employer Telephone Number:</td> <td valign="top"><input type="text" name="employerphone1" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.employerphone2)"> - <input type="text" name="employerphone2" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.employerphone3)"> - <input type="text" name="employerphone3" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.employerext)"> Ext. <input type="text" name="employerext" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.employeenumber_control)"></td> </tr> <tr> <td > </td> <td align="right">Total Number of Employees (controlled by employer):</td> <td valign="top"><input type="text" name="employeenumber_control" size="5"></td> </tr> <tr><td colspan="3"> </td></tr> <tr> <td >2.</td> <td align="right">Name of Site:</td> <td><input type="text" name="site" size="40"></td> </tr> <tr> <td> </td> <td align="right">Site Address:</td> <td align="left"><input type="text" name="siteaddress" size="60"></td> </tr> <tr> <td> </td> <td align="right">City:</td> <td align="left" valign="top"><input type="text" name="sitecity" size="25"> ,  NJ  Zip Code: <input type="text" name="sitezip" size="9"></td> </tr> <tr> <td > </td> <td align="right">Total Number of Employees at Site (employed at establishment):</td> <td valign="top"><input type="text" name="employeenumber_site" size="5"></td> </tr> <tr> <td > </td> <td align="right">Total Number of Employees in the Area(s) of Concern (covered by consultation):</td> <td valign="top"><input type="text" name="employeenumber_area" size="5"></td> </tr> <tr> <td colspan="3"> </td> </tr> <tr> <td >3.</td> <td align="right">Name of Facility Contact:</td> <td valign="top"><input type="text" name="contact" size="40"></td> </tr> <tr> <td> </td> <td align="right">Title:</td> <td valign="top"><input type="text" name="contacttitle" size="40"></td> </tr> <tr> <td> </td> <td align="right">Telephone Number:</td> <td valign="top"><input type="text" name="contactphone1" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.contactphone2)"> - <input type="text" name="contactphone2" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.contactphone3)"> - <input type="text" name="contactphone3" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.contactext)"> Ext, <input type="text" name="contactext" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.services)"> </td> </tr> <tr> <td colspan="3"> </td> </tr> <tr> <td width="20">4.</td> <td colspan="2">What services are you requesting:</td> </tr> <tr> <td width="20"> </td> <td colspan="2"><textarea name="services" rows="4" wrap="soft" cols="70"></textarea></td> </tr> <tr> <td colspan="3"> </td> </tr> <tr> <td >5.</td> <td align="right">Name of Person Requesting Consultation:</td> <td valign="top"><input type="text" name="person" size="40"></td> </tr> <tr> <td> </td> <td align="right">Title:</td> <td align="left"><input type="text" name="persontitle" size="40"></td> </tr> <tr> <td> </td> <td align="right">Telephone Number:</td> <td><input type="text" name="personphone1" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.personphone2)"> - <input type="text" name="personphone2" size="4" maxlength="3" onKeyUp="moveFocus(this, window.event.keyCode,occ12.personphone3)"> - <input type="text" name="personphone3" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.personext)">, Ext <input type="text" name="personext" size="5" maxlength="4" onKeyUp="moveFocus(this, window.event.keyCode,occ12.submit)"> </td> </tr> <tr> <td colspan="3"> </td> </tr> <tr><td colspan="3"><hr></td></tr> <tr> <td width="20"> </td> <td align="left"></td> <td align="right"><input type="reset" name="reset" value="Reset" style="width: 125px; height: 25px">  <input type="submit" name="submit" value="Submit" style="width: 125px; height: 25px"><div id="form_contact"><input name="human" type="text" size="2" maxlength="2"></div></td> </tr> <tr> <td colspan="3"> <p><i>occ12<br> Oct 07</i></p> </td> </tr> </table> </td> </tr> </table></form>  <table width="700" border="0" align="center" cellpadding="5" cellspacing="0" bgcolor="#FFFFFF" summary="State of New Jersey copywrite information and shortcuts to NJ departments, programs and services" class="tablebordertop">  <tr> <td width="326" height="14" align="left" valign="bottom"><span class="black10bold"> <br> Department of Health</span><br> <span class="black10">P. O. Box 360, Trenton, NJ 08625-0360<br> <span class=black11> <a href="/health/directions.shtml" style="text-decoration:underline; color:#003399">Our Locations </a></span></span></td> <td width="354" align="right" valign="top"><img src="/health/images/dhssfooter.gif" alt="Privacy policy, terms of use and contact form links" width="298" height="36" usemap="#Map4" border="0"> <map name="Map4" alt="DOH Footer" title="DOH Footer"> <area shape="rect" coords="76,5,156,28" href="http://www.nj.gov/nj/privacy.html" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;" alt="State Privacy Notice" title="Privacy policy for the State of New Jersey"> <area shape="rect" coords="167,4,260,28" href="http://www.nj.gov/nj/legal.html" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;" alt="legal statement" title="Legal policy and terms of use"> <area shape="rect" coords="2,6,64,28" href="/health/feedback.htm" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;" alt="DOH Feedback Page" title="Contact form for the Department of Health"> <area shape="circle" coords="282,18,15" href="http://www.state.nj.us" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;" alt="New Jersey Home" title="State of New Jersey home page"> </map></td> </tr> <tr><td colspan="2"><p class="black10"> <SPAN class=black11><br> <a href="/health/opra/index.html" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;"><img src="/health/images/OPRA.gif" alt="OPRA- Open Public RecordAct" width="117" height="33" border="0"></a> <a href="/health/documents/notice_of_privacy_practices.pdf" target="_blank"><img src="/health/images/spacer.gif" alt="Notice of Privacy Practices" width="158" height="40" border="0" class="logo" /></a><br> </SPAN>department: <span class="black10"><a href="/health/index.shtml" >njdoh home</a> <span class="black10">| <a href="/health/topics.shtml" >index by topic</a> | <a href="/health/commiss/org.shtml" >programs/services</a> <br> statewide:<a href="http://www.nj.gov/" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;">njhome</a> | <a href="http://www.nj.gov/nj/gov/njgov/alphaserv.html" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;">services A to Z</a>  | <a href="http://www.nj.gov/nj/gov/deptserv" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;">Departments/Agencies</a> | <a href="http://www.nj.gov/faqs/" onClick="NewWindow(this.href,'name','400','400','yes','yes','yes','yes');return false;">FAQs</a><br> </span></span><span class="black10">Copyright © State of New Jersey, 1996- <SCRIPT LANGUAGE="JavaScript"> var d = new Date(); var curr_year = d.getFullYear(); document.write(curr_year) </SCRIPT> <br> </span></p> <script src="/health/js/webtrends.js" type="text/javascript"></script> <script type="text/javascript"> var _tag=new WebTrends(); _tag.dcsGetId(); </script> <script type="text/javascript"> _tag.dcsCollect(); </script> <noscript> <div><img alt="DCSIMG" id="DCSIMG" width="1" height="1" src="http://sdc.state.nj.us/dcstf1ino000008qls7rr9e92_5q1n/njs.gif?dcsuri=/nojavascript&WT.js=No&WT.tv=8.6.2"/></div> </noscript> </td> </tr> </table>  <script type="text/javascript" src="/_Incapsula_Resource?SWJIYLWA=719d34d31c8e3a6e6fffd425f7e032f3&ns=3&cb=528361640" async></script></body> </html>

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NJDHSS occ12 Form