APPLICATION FOR DIRECTORY OF SAFETY SERVICES Please complete the information requested below and mail to the Louisiana Workforce Commission, Office of Workers' Compensation, P.O. Box 94040, Baton Rouge, Louisiana 70804-9040. The application may also be faxed to our office, at (225) 342-6756, or emailed to sbowers@lwc.la.gov. Name Street Address City State Zip Organization Position Title Telephone Number E-mail address (1) Additional Contact Information: E-mail address (2) EDUCATION: Circle appropriate numbers 01 02 03 04 05 06 07 08 09 10 A.A. A.S. A.A.S. A.B. B.A.E. B/B/A B.CH.E B.Ed. B.I.E. B.M.E. 11 12 13 14 15 16 17 18 19 20 B.S. B.S.E.E. B.S.M.E. Ed.D. Ed.M. J.D. L.L.B. M.A. M.A.E. M.B.A. 21 22 23 24 25 26 27 28 29 M.D. M.M.E. M.P.H. M.S. M.S.I.E. M.S.M.E/ P.H.B. Ph.D. Sc.D. 01 02 03 04 CERTIFICATION: CHCM CIH CSP Other: SPECIALTY: Circle appropriate numbers 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 Agricultural Aviation/Space Air Pollution Audiometry Biological Biomedical Technology Chemical / Hazardous Compressed Gas / Air Equipment Construction Consumer Activities Design Engineering (Products) Electircal Emergency Services Ergonomics / Human Factors Fire Protection Generalist Hand and Power Tools Health Care Laboratory / Chemical Ladders/Scaffolds 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Lasers Legal Machine Guarding Marine Material Handling Medical Treatment Mining Motor Vehicle Noise Nuclear Physical/Personnel Security OSHA Activities Petroleum Pipeline Product Psychological / Behavior Physiological Quality / Reliability Recreation Regulatory Complete both pages 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 Research/ Development Radiological Protection Rail/Transit Risk Management / Insurance Sanitation Standards / Compliance Operating Room (Hospital) System Safety (MORT) Toxicology Training / Education Ventilation Vibration Walking/Working Surfaces Waste Disposal Water Pollution Management Dust (respirable) Industrial Hygiene 1 American LegalNet, Inc. www.FormsWorkFlow.com SAFETY EXPERIENCE (INDICATE A MINIMUM OF TEN YEARS) FIRM YEARS TITLE SUPERVISOR SUBSPECIALTIES Within each specialty circled above, a consultant may designate sub-specialties per the examples below: Specialty: Aviation / Space Subspecialty: Failure analysis; Structural design and analysis; Operational procedures; System Safety Specialty: Product Subspecialty: Design review; Reliability; Liability; Warnings; Packaging; Storage; Recalls ENTER SUBSPECIALTIES BELOW: Office Use: Notes on verification Attach copies of diplomas, certifications, or other verification records. Notarized verification of ten years professional safety experience will be accepted in lieu of college degree. 2 American LegalNet, Inc. www.FormsWorkFlow.com