Hazard Survey Report {HS-32-A}

ARKANSAS WORKERS' COMPENSATION COMMISSION Form HS-32-A HEALTH & SAFETY DIVISION Ark. Code Ann. §11-9-409 & AWC C Rule 32 Rev. 1-1-2008 AWC C File No. ____________ 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 HS32-A Hazard Survey Report Employer Information 1) Company name: 2) M ailing Address: 6) Physical A ddress: 10) Employer Representative: 12) A ddress: 16) Telepho ne no.: ( ) 17) Fax no: ( ) 3) City: 7) City: 11) Title: 13) City: 18) e-M ail: 14) State: 15) Zip: 4) State: 8) State: 5)Zip: 9) Zip: Consultant Information 19) Name: 20) A ddress: 21) AW CC/APSS no.: 25) Telepho ne no.: ( ) 22) City 26) Fax no.: ( ) 23) State: 27) e-M ail: 24) Zip: Identification of Hazards 28) List hazards, reference, recommendations and anticipated correction date for deficiencies found during consultation (use additional sheets if necessary). No. Hazard Reference Recomm enda tion(s) TargetedCorrection Date 29) Employer Representative signature: Date: 30) Consultant signature: Date: HS-32A American LegalNet, Inc. www.FormsWorkflow.com