Fillable Company Information What does your company do?

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Company Information What does your company do?

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The Company Information What does your company do? form is 2 pages long and contains:

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  • 22 check-boxes
  • 78 other fields

Country of origin: OTHERS
File type: PDF

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Company Information
Name:
Physical Address:
City: Zip Code: State:
Phone Number: Fax Number: Number of Employees:
What does your company do?
What types of shifts and hours do your employees normally work?
Have you completed job descriptions? Yes No *please send to us*
Do you hire through a staffing agency? Yes No
If so who do you partner with?
Contact Information
Primary Contact and Designated Employee Representative (Required)
Name: Position:
Email: Direct Phone: Cell Phone:
Secondary Contact Information (Required)
Name: Position:
Email: Direct Phone: Cell Phone:
Accounts Payable (Invoices will be emailed monthly)
Name: Position:
Email: Direct Phone: Cell Phone:
Accounts Payable Email Address:
Workers’ Compensation Information
Work Comp Broker
Company Name: Risk Manager/Broker:
Contact Information:
Work Comp Insurance
Insurance Company: Address:
Policy Number (Required): Effective & Expiration Date:
(918) 609-1600 Phone
(918) 609-1319 Fax
8523 E. 11th Ste. A
Tulsa, Ok. 74112
Protocol
Drug Test Collection Using WHS Chain of Custody Forms: Yes No
*If no please provide chain of custody forms*
Drug Screen Panel: 5 Panel 10 Panel Background check through WHS: Yes No
Workers’ Compensation Injury Protocol:
Drug Screen: Yes No Breath Alcohol Test: Yes No Reasonable/Requested
Non-DOT Pre-Employment Protocol:
Drug Screen: Yes No Breath Alcohol Test: Yes No Reasonable/Requested
Physical: Yes
No
Vision Testing : Yes No
Hair Testing: Yes No Job Function Test: Yes No
Vision Testing: Yes No Audiogram: Yes No
Emerge Test: Yes No Pulmonary Function: Yes No
Fit Test: Full Face Half Face Both
Brand/Series:
DOT Pre-Employment Protocol:
Drug Screen: Yes No Breath Alcohol Test: Yes No Reasonable/Requested
DOT Physical: Yes No Emerge Test: Yes No
Additional Services: (Check all that apply)
After-hours
Drug and Alcohol Testing
After-hours Occupational Injury Care
Random Drug and Alcohol selections
Hepatitis Vaccinations
Flu Vaccinations
Tetanus Shots
Annual Audiometric Testing
Annual Respiratory Testing
Silica evaluations and clearance
Wellness Events
Vision Testing
First Responder Training
DOT and Non-DOT Random Drug Testing Management
Blood Draw Events
Medical Oversite
Other:
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Company Information What does your company do

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Completed 31 March 2022

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