Arkansas > Workers Comp
Occupational Safety And Health Work Experience HS-31-A - Arkansas
| Occupational Safety And Health Work Experience Form. This is a Arkansas form and can be used in Workers Comp . |
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Form HS-31-A Ark. Code Ann. ยง119-409 & AWCC Rule 31 Rev. 1-1-2008 ARKANSAS WORKERS' COMPENSATION COMMISSION 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 HS31-A Application for (check all that apply) `Approved Professional Safety Source (APSS) `Field Safety Representative (FSR) (Note: Attendance at an on-site AWCC class is mandatory for APSS certification) Section 1. Personal Information 1) Name (include all names referenced in submitted materials): Last: ____________________________________ First: ______________________MI: _______ Secondary: (_______) _____________________ 5) Mailing address: 9)E-Mail address: 6) City: 7) State: 8: Zip: 2) Telephone no.: Primary: (________) ______________________ 3) Social Security no.: 4) Total no. of years occupational health and safety experience :_____ 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 must be sent directly from the granting institution to the Arkansas Workers' Compensation Commission, Health and Safety Division, P.O. Box 950, Little Rock, AR 72203-0950, ATTN: FSR/APSS. College or University City, State Attendance Dates (From/To) Sem. Hrs. Completed Major Degree Earned Section 4. Occupational Safety and Health Professional Experience Using Attachment 1, list each occupational health and safety work assignment in chronological order, beginning with present position. Section 5. Signature I certify that the preceding statements, including attachments, are accurate to the best of my knowledge, and authorize the Arkansas Workers' Compensation Commission to verify the information. I understand that any falsification of information is this application, including attachments, may be cause for rejection or withdrawal of the Field Safety Representative and/or Approved Professional Safety Source designation. Applicant Signature: _________________________________________________ Date:______________ (please use ink) HS-31-A HS-31-A Attachment 1 Occupational Safety and Health Work Experience Use a separate copy of Attachment 1 for each change in position, regardless of whether or not there was a change in employers. 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
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