Texas Department of Insurance Division of Workers’ Compensation Workplace Safety, MS-27 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 512-804-4686 512-804-4619 fax www.tdi.state.tx.us APPROVED PROFESSIONAL SOURCE SAFETY CONSULTANT APPLICATION Section 1. 1. Name (Last, First, M.I.) 2. Total Number of Years & Months Experience as a Safety Professional 3. Date of Birth 4. Social Security Number 5. Primary Address 6. City, State, Zip Code 7. Telephone (Indicate Primary and Alternate) Primary ( ) Alt. ( ) 8. Alternate Address (if different from above) 9. City, State, Zip Code 10. List the North American Industry Classification System (NAICS) Code(s) that best describe(s) your area(s) of safety expertise (list a maximum of five). _ _ _ ___ _ _ _ ___ _ _ _ ___ _ _ _ ___ _ _ _ ___ 11. Describe your specific training or specialization within the NAICS Code(s) listed above. Section 2. CURRENT PROFESSIONAL REGISTRATIONS OR CERTIFICATES Please check appropriate items. Information will be verified through respective organizations. ENCLOSE A COPY OF CURRENT MEMBERSHIP CARD. Registered Professional Engineer Certificate No. ____________ ___ Certified Safety Professional Certificate No. ________________ Certified Industrial Hygienist Certificate No. ________________ Other Certifications Specify Section 3. (Texas Only) COLLEGE EDUCATION/PROFESSIONAL TRAINING NOTE: A certified transcript must be sent directly from the college or university to the Texas Department of Insurance, Division of Workers' Compensation at the address shown at the top of this application. College or University City, State Attended From/To Semester Hrs. Completed Course/Major Degree Earned I certify that the information provided by me in connection with this application is true and complete to the best of my knowledge and authorize the Texas Department of Insurance, Division of Workers' Compensation to verify the information. I understand that any misrepresentation of information in this application, including attachments, may be cause for rejection or revocation of the Professional Source Designation. Date ___________________ Applicant's Signature (please use ink) DWC103 Rev. 08/06 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 Section 4. PROFESSIONAL SAFETY EXPERIENCE List each assignment in reverse chronological order, beginning with your present position. Account for all time for at least the past 10 years, including any non-safety related assignments. * Make as many copies of this section as needed. Use a separate block for each change in position, regardless of whether or not there was a change of employers. Applicant Name Name, Address, & Phone No. of Employer Start Date/End Date with this Employer To From Mo/Yr Mo/Yr Position/Title with this Employer ( ) Major Product or Service of this Employer Name of Immediate Supervisor Phone Number of Immediate Supervisor ( Description of Safety Experience ) Indicate the percentage of your time spent in the following areas Hazard Identification Hazard Evaluation Hazard Control Design Hazard Controls Verification Safety/Health Program Design Safety/Health Program Evaluation Safety/Health Communication Investigation and Statistical Reporting Safety Training/Education Supervision of other Safety Professionals Environmental Protection Neither Safety/Health nor Environmental Functions For the three (3) areas above where you spent the most time, provide a brief description of your work in the area and at least one (1) specific example Applicant Name Name, Address, & Phone No. of Employer Start Date/End Date with this Employer From Mo/Yr To ___________ Mo/Yr Position/Title while with this Employer Name of Immediate Supervisor ( ) Major Product or Service of this Employer Phone Number of Immediate Supervisor ( Description of Safety Experience Hazard Identification Hazard Evaluation Hazard Control Design Hazard Controls Verification ) Indicate the percentage of your time spent in the following areas Safety/Health Program Design Safety/Health Program Evaluation Safety/Health Communication Investigation and Statistical Reporting Safety Training/Education Supervision of other Safety Professionals Environmental Protection Neither Safety/Health nor Environmental Functions For the three (3) areas above where you spent the most time, provide a brief description of your work in the area and at least one (1) specific example DWC103 Rev. 08/06 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 INSTRUCTIONS FOR PREPARING APPROVED PROFESSIONAL SOURCE SAFETY CONSULTANT APPLICATION Section 1: Block 1 - 9: Self-Explanatory Block 10: Reference source for North American Industry Classification System (NAICS) Code is NORTH AMERICAN INDUSTRY CLASSIFICATION SYSTEM (2002) EXAMPLE 1 - NAICS Code 236100 – Residential Building Construction EXAMPLE 2 - NAICS Code 325110 – Petrochemical Manufacturing EXAMPLE 3 - NAICS Code 236115 – New single-family General Contractors EXAMPLE 4 - NAICS Code 622110- General Medical and Surgical Hospitals Block 11: EXAMPLE 1 - NAICS Code 236100- Residential Building Construction - 5 years experience with or servicing sub-contractors in building construction. EXAMPLE 2 - NAICS Code 325110-Petrochemical Manufacturing - Bachelor of Science degree from an accredited college in Chemical Engineering EXAMPLE 3 - NAICS Code 236115 - New single-family General Contractors - 3 years experience with prefabricated single-family house erection - General contractors. EXAMPLE 4 – NAICS Code 622110- General medical and surgical Hospitals - Specialty training at Texas Women's University as LVN and 3 years experience as doctors aid at medical clinic. ALL BLOCKS MUST BE COMPLETED. Failure to provide required information may cause a delay in the approval process. Section 2: Current Professional Registrations or Certificates Complete this section and Section 4 if you are qualifying as a professional source by professional certification. Information provided will be verified. Check the appropriate items and complete associated information. If more space is needed, add additional sheets with the appropriate information and state, "See attached statement." Section 3: College Education/Professional Training Complete this section and Section 4 if you are qualifying through education with a degree in safety engineering or science. List information requested. If more space is needed, add additional sheets with the appropriate information and state, "See attached statement." Information provided will be verified. Section 4: Professional Safety Experience. All applicants must complete this section. Be as accurate as possible. List all assignments in reverse chronological order, beginning with your present position. Account for all time for at least the past 10 years, including any non-safety related assignments. Use a separate block for each change in position, regardless of whether or not there was a change of employers. If additional space is needed make as many copies of Section 4 as needed and attach. Description of Safety Experience Percentage(s) must Total 100%, i.e. Hazard Identification 50, Safety Training 35, Neither Safety/Health 15. DWC103 Rev. 08/06 INSTRUCTIONS American LegalNet, Inc. www.FormsWorkFlow.com DWC FORM-103 (Approved Professional Source Safety Consultant Application) The DWC FORM-103 is to be completed by persons desiring to provide safety consultations under the Rejected Risk Requiring Injury Prevention Services Program. Specific instructions are provided to assist the applicant. The two-sided form should be mailed to Texas Department of Insurance, Division of Workers' Compensation, Workplace Safety, MS-27, Workplace Safety, 7551 Metro Center Drive, Suite 100, Austin, Texas 78744. The form may also be faxed to DWC at (512) 804-4619. [Art. 5.76-3, Section 8, Texas Insurance Code] DWC103 Rev. 08/06 COVER SHEET American LegalNet, Inc. www.FormsWorkFlow.com