ARKANSAS WORKERS’ COMPENSATION COMMISSION Form HS-32-A HS32-A HEALTH & SAFETY DIVISION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 Ark. Code Ann. §11-9-409 & AWC C Rule 32 Rev. 1-1-2008 Hazard Survey Report AWC C File No. ____________ Employer Information 1) Company name: 2) M ailing Address: 3) City: 4) State: 5)Zip: 6) Physical A ddress: 7) City: 8) State: 9) Zip: 10) Employer Representative: 11) Title: 12) A ddress: 13) City: 14) State: 15) Zip: 16) Telepho ne no.: ( ) 17) Fax no: ( ) 18) e-M ail: Consultant Information 19) Name: 20) A ddress: 21) AW CC/APSS no.: 22) City 25) Telepho ne no.: ( ) 26) Fax no.: ( 23) State: ) 24) Zip: 27) e-M ail: Identification of Hazards 28) List hazards, reference, recommendations and anticipated correction date for deficiencies found during consultation (use additional sheets if necessary). No. Hazard Reference 29) Employer Representative signature: Recomm enda tion(s) Date: 30) Consultant signature: TargetedCorrection Date Date: HS-32A American LegalNet, Inc. www.FormsWorkflow.com