Safety Summary

Employer Information

Company Name *

Company Address

Company Address Line 2

City

Company State

Company Zip Code

Contact Person Name

Contact Person Title

Contact Person Email Address

Contact Person Phone

Contact Person Fax

SIC Code Category 1

System SIC Filter

SIC Code Category 2

SIC Code

Number of Employees

Federal ID #

Nature or type of business in New Hampshire

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Safety Summary

Additional New Hampshire Locations

Enter the requested information for all additional NH Company Locations. To add a Location, click "Add New Row".

	Name	Street	City	Number of Employees	Federal ID #
1	Name	Street	City	Number of Employees	Federal ID #

Name

Street

City

Number of Employees

Federal ID #

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Name

Street

City

Number of Employees

Federal ID #

Safety Summary

Summary of Safety and Health Program

1. List potential safety and health hazards of your company.

2. Who is responsible for your inspections and how are they done?

3. List the members of your company's joint loss management committee by name and job title. Please indicate which members represent the employer and those which represent employees. Identify chairperson.

Management Members

Member Name

Member Title

Represents

Member Name

Member Title

Represents

Employee Members

Member Name

Member Title

Represents

Member Name

Member Title

Represents

4. Specify your emergency response procedures.

5. Identify person(s) by name and title responsible for safety and health instruction for your employees and your joint loss management committee.

Name

Title

Name

Title

6. Identify person(s) by name and title qualified to take corrective actions on safety and health hazards.

Name

Title

Name

Title

7. Indicate your policy to communicate safety and health concerns with the activities of sub-contractors or outside service providers, when, or if, utilized.

8. Summarize your disciplinary policy with regard to violations of your safety and health policies.

9. Summarize your policy for providing adequate resources dedicated to safety.

10. How are employees provided access to your safety and health policies?

Safety Summary

Form Completed By

Name

Email Address

Title

Date

Safety Summary

Employer Information

Safety Summary

Additional New Hampshire Locations

Safety Summary

Summary of Safety and Health Program

Management Members

Employee Members

Safety Summary

Form Completed By

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