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    1. Which of the following products, if any, do you recommend, select and/or buy in your job? (check all that apply) 

    • Safety Equipment
    • Emergency Response
    • Environmental Compliance
    • Industrial Hygiene
    • Security
    • Ergonomics
    • Training
    • Fire Protection
    • None of the above
    • Software
    • Occupational Health

    2. Please indicate ALL functions for which you are responsible: 

    • Safety
    • Security/Fire Protection
    • Law Enforcement
    • Executive Management/Administration
    • Industrial Hygiene/Environment
    • Safety Product Distributor
    • Production/Operations
    • Personnel Management
    • Medical: Nurse
    • Facility Management
    • Risk Management
    • Medical: Physician
    • Engineering
    • Emergency Planning
    • Medical: Other Medical Professional
    • Purchasing
    • First Responder
    • Other (please specify)

    3. Which category best describes the primary end product manufactured or service performed at your business? 

    Other (please specify)

    4. Number of employees at this location: (optional) 

    5. Which of the following products/services do you plan to purchase in the next 12 months and would like more information on?
    (check all that apply)(optional)

    • Emergency Response
    • Fall Protection
    • Training/Software
    • Hazmat Handling
    • Head Protection
    • Workers' Comp Insurance
    • First Aid
    • Eye & Face Protection
    • Ergonomics
    • Protective Clothing
    • Hearing Protection
    • Instr/Monitoring Equip
    • Hand Protection
    • Safety Incentives
    • Plant Maintenance
    • Foot Protection
    • Respiratory Protection
    • Gas Detectors/Monitors
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    Is there anyone else at your location who should receive a copy of Occupation Health & Safety? (optional)

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