VPP & C-VPP Pre-Screening Form

THE INDUSTRIAL COMMISSION OF ARIZONA DIVISION OF OCCUPATIONAL SAFETY AND HEALTH 800 WEST WASHINGTON STREET PHOENIX, ARIZONA 85007 VPP & C-VPP Pre-Screening Form
Submit the completed form below; * indicates required field

Employer Information

* Employer Name

* Point of contact for employer

* Title

* Email

* Type of Industry

* NAICS Code

* Address

* State

* City

* Zip Code

* Phone

* Three-year OSHA 300 log TCIR average

* Three-year OSHA 300 log DART average

* Last safety and health management system audit

* Audit was performed by

* Number of employees in Arizona

* Number of employees corporate wide

* Union

Yes No

Is your Company part of an independent third-party certification program(s)

* Is your company open to a Mentor in the VPP program

Yes No

* Briefly describe your work process and footprint:

The ADOSH Compliance Assistance services are provided free of charge to employers in Arizona. The VPP & C-VPP Pre-Screening Form is the preliminary step in working with ADOSH to become a VPP or C-VPP Star program participant.

Submitter Details

* Name

* Email