Consultation Request Form

All fields are required unless otherwise stated.

Last OSHA Inspection Date
(Optional) [None]

SIC/NAICS Number(s)(Optional)

The PA/OSHA Consultation Program made a previous visit to this establishment

The establishment is unionized

Interested In

Number of Employees

On-site

Covered by Consultation

Controlled Corporate-wide by Employer

Reason for Requesting Visit

Contact Information

First Name

Last Name

Title

Establishment Name

Type of Business

Phone

Fax

E-mail Address

Site Address Line 1

Site Address Line 2 (optional)

City

State

Zip Code/Postal Code

Mailing Address Line 1 (if different)

Mailing Address Line 2 (if different)

City

State

Zip Code/Postal Code

Pennsylvania OSHA Consultation Office
Indiana University of Pennsylvania
Walsh Hall, Room 210
302 East Walk
Indiana, PA 15705
Phone: 1-800-382-1241
Fax: 724-357-2385

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