1 Safe and Sound Week Event Registration Form

2019 Safe + Sound Week Event Registration Form

1. How do you plan to participate in S+S Week?* (Check box – select one)

   • Private event at my workplace

   • Public event

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

3. Industry* (drop down)

4. Email Address* (Fill in Blank)

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

□ Yes

□ No

6. City/State (Fill in Blank and Drop Down)

7. City/Country (Fill in Blank)

8. How did you find out about S+S Week?* (Check box – select multiple)

   • Communication from industry/trade association

   • Communication from safety and health professional organization

   • OSHA QuickTakes

   • OSHA Website

   • Safe + Sound Campaign Email List Serv

   • National/Local/Trade Press

   • Social Media

   • Colleague

   • I don’t know/remember

   • Other (Fill in the blank)

9. How far along are you in developing a safety and health program?* (Check box – select one)

• We do not have a safety and health program

• We are just starting our safety and health program.

• Our safety and health program includes management leadership, worker participation, and a systematic approach to find and fix hazards.

• Our safety and health program follows OSHA’s Recommended Practices for Safety and Health Programs.

• Our safety and health program is certified to SHARP, VPP, ANSI Z10, and/or ISO 45001.

• Other (fill in the blank)

10. 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 1218-0269

Expiration date: 05/31/2021

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 required for all responses

• If Question 1 response is “private event at my workplace,” Questions 2, 3, 4, 5, 8, 9 required.

• If Question 1 response is “public event,” Questions 2, 4, 5, 8, 10 required.

• If “private event at my workplace” selected in Question 1, the following information would appear before Question 2:

Note: The name of your business or organization and the location will be added to the public Safe + Sound Week map on the website.

I want to register, but do not want any information about my private event posted on the public Safe + Sound Week map on the website. (Check box)

• If “public event at my workplace” selected in Question 1, the following information would appear before Question 2:

Note: All of the details about events that are free or offered at a discounted rate and open to the public will be posted on the public Safe + Sound Week map on the website.

• If “private event at my workplace” selected in Question 1, the following information would appear as a note with Question 4:

I want my email address posted on the public Safe + Sound Week map on the website so people can contact me about our private event. (Check box)

• Industry drop down should include the following:

Agriculture, Forestry, Fishing and Hunting

Construction

Government

Health Care and Social Assistance

Manufacturing

Maritime

Oil and Gas

Professional and Business Services

Transportation and Warehousing

Utilities

Other: ___________________________________ (Fill in Blank)

• Question 6 required if answer “yes” to Question 5.

• Question 7 required if answer “no” to Question 5.

• In Question 6, the “State” field will be a drop-down menu with full state and territory names.