Assess Your Company's Needs

Since every company is unique, we would like to assist you in assessing your specific needs concerning employee health and safety. CCOM provides the following questionnaire to help you evaluate all aspects of your employee occupational health status. 

Upon completion of this questionnaire, you may choose to submit it electronically. If you choose submit, this form will be emailed to a customer services representative from your closest CCOM office, who will contact you to discuss how CCOM can best serve your needs by providing a free assessment based on your answers.You are under no obligation to work with CCOM, though we are confident we are the best at what we do.

Click here to download a .pdf form instead of filling the form out online.

Thank you for taking the time to complete this questionnaire.

 

* Company Name:

* Contact First Name:

* Contact Last Name:

* Contact Email:

* Contact Phone:

* Type of Business:

* Number of Employees:

Choose a CCOM office location:

* Please select the job title that best describes your business:

CDL Licensed Drivers

Assembly Workers

Machine Operators

Office Workers

Medical Professionals

Housekeeping

Construction

Railroad

Drivers

Teachers/Day Care

Facilities Maintenance

Sales

Do your employees handle money?

Do your employees greet the public?

Do you have more than one shift?

 

If you have more than one shift, please discuss what shifts are worked by your employees?

 

Do your employees handle potentially biohazardous, toxic or dangerous materials or equipment?

 

Do your employees employ standard safety precautions routinely as part of their job?

 

Do you need assistance in interpeting laws concerning employee safety and health for both your management staff and employees?

 

Is it important that you promote a drug/alchol free work environment?

 

Does your company use the internet and email?

 

Do you require a pre-employment physical as a condition of employment?

 

Would it be of benefit to qualify potential employees for a specific job description including such functions as lifting, range of motion, weightbearing and others?

 

Are vaccinations or specific testing requirements part of your normal business function?

 

Do you consider each employee to be critical to the function of his/her job and to your company's success?

* Required Fields
 

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