S+S Week Event Registration Form Questions_OMBX

Safe + Sound Week Event Registration Form

1. Name of Business or Organization* (Fill in Blank)

2. Industry* (drop down)

3. Email Address* (Fill in Blank)

4. Are you participating in the U.S.?* (Check box)

□ Yes

□ No

5. City/State AND Zip Code (Fill in Blank and Drop Down)

6. City/Country (Fill in Blank)

7. Are you hosting an event that is free and open to public? (Check box)

□ Yes

□ No

Note: Only details about events that are free and open to the public will be posted. For all other participants, only the name of the business or organization and the location will be posted.

8. Please provide details and contact information:

Event Name* (Fill in the Blank)

Event Date* (Fill in the Blank)

Event Start Time* (Fill in the Blank)

Event End Time* (Fill in the Blank)

Event Description* (Fill in the Blank)

Event URL (Fill in the Blank)

Contact Name* (Fill in the Blank)

Contact Email or Phone Number* (Fill in the Blank)

OMB Control Number XXXX-XXXX

Expiration date: XX/XX/XXXX

PAPERWORK REDUCTION ACT

Public reporting burden for this voluntary collection of information is estimated to average 1 minute per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. OSHA will use this information to evaluate participation in Safe + Sound Week. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, please send them to OSHAPRA@dol.gov or to US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.

Requirements for the form:

• Question 1, 2, 3, 4 required for all responses.

• Industry drop down should include the following:

Accommodation and Food Services

Agriculture, Forestry, Fishing and Hunting

Arts, Entertainment, and Recreation

Construction

Education Services

Financial Activities

Health Care and Social Assistance

Information

Manufacturing

Mining

Oil and Gas

Professional and Business Services

Public Administration

Real Estate Rental and Leasing

Trade (Wholesale/Retail)

Transportation and Warehousing

Utilities

Other: ___________________________________

• Question 5 required if answer “yes” to Question 4.

• Question 6 required if answer “no” to question 4.

• In Question 5, the “State” field will be a drop-down menu with full state and territory names.

• Question 8 required if answer “yes” to question 7.