On-Site Consultation Request Form

Please complete the information below to request a free On-Site Consultation Visit.

* indicates required field

Title

Request Type

Employer Legal Name

DBA Name (If Applicable)

Business or Site Address

City

State

Zip Code

Total Number of Employees On-Site

Total Number of Employees Corporate Wide

Type of Work

Employer Has Union Employees

Union Local Name and Number

NAICS Code (Optional)

Employer Contact Name

Employer Contact Title

Employer Contact E-Mail

Employer Contact Phone

Reason For Request (In order to better serve you, please select the area of interest that applies)

OSHA Compliance Assessment

Assistance with an OSHA Complaint

Assistance with OSHA Required Written Programs

Air Sampling (if so, please note what substances in the comment box)

Noise Sampling

Respiratory Protection Selection and Compliance

COVID-19

The employer had an OSHA/IDOL inspection in the past 12 months.

If Yes to OSHA/IDOL inspection, Status of Citation?

How did you hear about our services?

Other Comments

Illinois On-Site and Health Consultation Program

524 South 2nd Street, Suite 400
Springfield, IL 62701

800-972-4216

800-785-6055 TTY