1) Please enter your first and last name in the space provided:

2) Please enter the name of your company in the space provided:

3) Please provide your primary daytime phone number as well as an alternate phone number in the space provided:

4) Using the space provided, please tell us the type of business your company performs i.e. forming, HVAC, electrician, etc.

5) Does your company have a safety department or a safety director?

6) Please share with us your compamy's top three (3) safety initiatives:

7) Does your company have a program to control your employees’ exposure to silica/wood/ or drywall dust?

8) If you answered No to the previous question does your company plan to implement one over the next year?

9) Does your company use dust extractor vacuums to control exposure to dust?

10) If you answered yes to the previous question what brands do you currently use?

11) Please tell us the number of dust extractors your company currently owns:

12) Have you ever been cited by OSHA or any other government agency for violating the PEL (Permissable Exposure Limits) for silica or any other hazardous dust?

13) If you answered Yes to the previous question, how much was the fine/citation?

14) Using the space provided, please list any other methods used to protect employees’ from silica exposure:

15) Does your company’s worker compensation insurance mandate the use of dust control methods for silica exposure?

16) Please share with us your company's level of concern regarding silica exposure where 1 = not concerned and 4 = extremely concerned: