ARKANSAS WORKERS' COMPENSATION COMMISSION Form HS-31-A HEALTH & SAFETY DIVISION Ark. Code Ann. §11-9-409 & AWC C Rule 31 Rev. 1-1-2008 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS31-A Application for (check all that apply) Approved Professional Safety Source (APSS) Field Safety Representative (FSR) (Note: Attendance at an on-site AW CC class is mandatory for APSS certification) Section 1. Personal Information 1) Name : Last: ____________________________________ First: ______________________MI: _______ Secondary: (_______) _____________________ 5) Mailing address: 6) City: 2) Telephone no.: Primary: (________) ______________________ 4) Total no. of years occupational health and safety experience :_____ 7) State: 8) Zip: 3) Social Security no.: 9) E-Mail address: Section 2. Professional Certifications Check all that apply. Enclose copy of current membership card. Information will be verified. Certification Certified Safety Professional (CSP) Certified Industrial Hygienist (CIH) WSO Certification (specify Certified Safety Manager or Certified Safety Specialist) Certificate No. State (if applicable) Section 3. Education and Professional Training Note: A certified transcript m ust be se nt directly from the granting institution to the Arkansas W orkers' Compensation Commission, Health and Safety Division, P.O. Box 950, Little Rock, AR 72203-0950, ATTN: FSR/APSS. College o r Un iversity City, State Attendance Dates (From/To) Sem . Hrs. Com pleted Major Degree Earned Section 4. Occupa tional Safety and H ealth Professional Experience Using Attachment 1, list each occupational health and safety work assignm ent in chrono logical orde r, beginning with prese nt position. Section 5. Signature I certify that the preceding statements, including attachments, are accurate to the best of my knowledge, and authorize the Arkansas W orkers' Comp ensation Commission to verify the information. I understand that any falsification of information is this application, including attachments, may be ca use for rejection or withdra wal of the Field S afety Rep resentative and/or App roved Professio nal Safety Source designation. Applicant Signature: _________________________________________________ Date:______________ (please use ink) HS -31-A American LegalNet, Inc. www.FormsWorkflow.com HS-31-A Attachment 1 Occupational Safety and Health Work Experience Use a separate copy o f Attachment 1 for ea ch cha nge in p osition, regard less of whether o r not there was a chan ge in em ployers. 1) Name during employment: 2) Position with this employer:: 3) Employer: Name Address: City: 4) Employment dates (Mo/Yr.): From:____/_____ To:____/_______ 6) Immediate supervisor: Name 5) Major product or service of this company: Telephone no.: ( ) State: Zip: Telephone No.: ( ) 7) Description of occupational health and safety work experience. Indicate the percentage of your time spent in the following areas: _____ Hazard identification _____ Hazard evaluation _____ Hazard control design _____ Environmental _____ Safety & health program design _____ Safety & health program evaluation _____ Safety & health communication _____ Incident investigation _____ Safety training & education _____ Supervision of other health & safety professionals _____ Neither health & safety or environmental _____ Hazard control verification For the three (3) areas above where you spent the most time, provide a brief description of your work in those areas: HS -31-A American LegalNet, Inc. www.FormsWorkflow.com