Industry-Specific Safety Program Post on-site consultation survey Instructions You may submit the completed form in one of three ways listed below. o Online: www.bwc.ohio.gov o Fax: 614-365-4971 Company name Name of person completing the survey Name of consultant who performed the on-site service o Mail: Attention: Industry-Specific Safety Program Ohio Bureau of Workers' Compensation 13430 Yarmouth Drive Pickerington, OH 43147-8310 Policy number Service date Did you receive a report related to the on-site consultation/training? Yes No If you answered No, please wait until you have the consultant's report before completing this survey since several questions relate to the report you will receive. Select one service Company-specific safety training Customer-safety team development Ergonomics assessment Industrial hygiene assessment Safety-hazard assessment for construction Safety-hazard assessment for general industry Safety-management process evaluation Safety program/process development Excellent Good Fair Poor Rate the timeliness of the report. Rate the overall quality of the report. Rate the timeliness of the response to your request. Rate the knowledge of the consultant. Rate the likelihood that you will make changes based on the services provided? Rate the benefit and value of the service provided. Do you intend to use the Division of Safety & Hygiene for future on-site consultation/training? Comments Yes No Maybe BWC-6628 (Rev. 5/14/2012) SH-29 American LegalNet, Inc. www.FormsWorkFlow.com