TESTING

This information is for the person completing this form. (Must be completed by Safety Department or Management if no full-time safety rep.)

If your company is required to follow OSHA Recordkeeping Requirements, please provide your organization’s injury and illness data for the last three years in the table below. The information provided must be for your organization as a whole, not an individual office/warehouse location. If you have any OSHA recordable cases in a given year, you are required to provide a copy of your relevant OSHA 300 Log to support your annual 300A summary.

• Even if you did not have a recordable injury or illness for any given year, under OSHA’s 29 CFR 1904 “a 300A summary must still be completed depicting “0” recordable in each category and then signed by the highest ranking official working at the establishment (i.e., owner, officer of company, etc.). Please follow the link for additional information on OSHA’s Q&A Recordkeeping web page.
• If your company is exempt from OSHA recordkeeping requirements (consult the above link for guidance if you have any questions as to whether or not you are exempt) you must still complete the table on the following page.
• Current year data is only required if you are completing this form after April 1 of the current year. This is not only a TEI requirement, but in many cases our customer’s requirement.
• For any lost time injuries/illness or fatalities in the past three (3) years, please attach a description of the incident, including root cause, lessons learned, action taken to prevent a recurrence of the incident.

Please ensure you have completed this checklist and provided the required copies. Incomplete applications or failure to submit the required documentation will result in the automatic rejection of your application until you have completed and submitted it in its entirety.

Do not email/submit partial application and documentation over several days or multiple emails.