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# of People Needed
Company Name
Contact Person
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Address Line 2
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address (if different)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Job Description
Company Worker's Comp Code
Start Date
MM slash DD slash YYYY
Hours
Length of Assignment
Short-Term Temporary
Long-Term Temporary
Temp-to-Hire
Additional Information
Special Requirements
"Safety First" Screening Program
Some kind of description about this section can go here.
Does your company require contract employees to attend any special safety orientations or training?
Yes
No
Is Personal Protective Equipment (PPE) needed for our temporary employees, such as, hard hats, safety glasses, steel-toed shoes, gloves, etc.?
Yes
No
If yes, what equipment is needed?
Hard Hat
Steel-toed Boots
Work Boots
Safety Glasses
Back Brace
Gloves
Ear Plugs
Other
If "other" equipment is needed, please describe.
Does your company conduct regular safety meetings?
Yes
No
Could our temporary employees attend?
Yes
No
Do you plan to have any our temporary employees operate equipment, such as, forklifts, trucks, backhoes, company car, etc.?
Yes
No
If yes, what equipment will be operated?
Will any of our temporary employees be working from elevations, such as, scaffolds, platforms, rooftops, ladders, etc.?
Yes
No
If yes, what type of elevation?
Will any of our temporary employees be working at an excavation site over four (4) feet in depth?
Yes
No
Will any of our temporary employees be working within six (6) feet of the water's edge?
Yes
No
Will any of our temporary employees be operating electrical/pneumatic tools?
Yes
No
If yes, what type of tools?
Will any of our temporary employees be doing any type of electrical work?
Yes
No
If yes, what type of electrical work?
Will any of our temporary employees be required to enter a confined space, such as, tanks, boilers, vats, pits, vessels, hulls of ships, or any enclosures with limited entrances and exits?
Yes
No
If yes, what type of confined space?
Will any of our temporary employees be required to lift over 25 pounds?
Yes
No
If yes, what is the maximum weight that will be lifted?
Will any of our temporary employees be exposed to asbestos, dust, silica, noise, flammables, combustibles, biohazards, carcinogens, or chemicals?
Yes
No
If yes, what type of exposure will there be?
Will any of our temporary employees be exposed to hazardous chemicals?
Yes
No
If yes, would you like for our company to provide training?
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