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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)

North American Industry Classification System Code

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

If you have questions email dol.consultation@illinois.gov or call 800-972-4216.

The 21(d) On-Site Consultation Cooperative Agreement is funded by a federal grant, which constitutes ninety percent of the overall budget. Ten percent is financed by State funds.

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