Additional Health Department Forms

Forms for Workplace Health & Safety

Occupational Health Surveillance Unit
Form # Form Name/Title Linked File Instruction/ Comments
OCC-31 Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider
(Updated December 14, 2016)
pdf (20k)
doc (59k)
Additional Information for Completing the OCC-31 Form (New) (pdf 16k)
Additional Information for Completing the OCC-31 Form (New) (doc 28k)
 
OCC-34 Clinical Laboratory Report of Elevated Levels of Heavy Metals:Lead: In Adults (Greater than 16 Years of Age)Arsenic, Cadmium, Mercury: In Persons of Any Age
pdf (15k)
doc (48k)
 
Public Employees Occupational Safety Health (PEOSH)
Form # Form Name/Title Linked File Instruction/ Comments
OCC-1 Sharps Injury Log
pdf (8k)
doc (8k)
 
OCC-2 Exposure Incident Report
pdf (10k)
doc (45k)
 
OCC-3 Request for Source Individual Evaluation
pdf (11k)
doc (38k)
 
OCC-4 Employee Exposure Determination
pdf (8k)
doc (31k)
 
OCC-5 Employee Exposure Follow up Record
pdf (8k)
doc (35k)
 
OCC-6 Hepatitis B Vaccine Immunization Record
pdf (7k)
doc (32k)
 
OCC-8 Hepatitis B Declination Statement
pdf (7k)
doc (24k)
 
OCC-9 Employee Education and Training Record
pdf (11k)
doc (31k)
 
OCC-12 Public Employees Occupational Safety and Health (PEOSH) Unit Request for On-Site Consultation
pdf (20k)
doc (54k)
On-Line Form
 
OCC-15 Cleaning Schedule
pdf (7k)
doc (26k)
 
OCC-16 EMS Respiratory Protection Program Evaluation Questionnaire
pdf (11k)
doc (41k)
 
OCC-22 Documentation of Respirator Training
pdf (7k)
doc (25k)
 
OCC-23 PEOSH Respirator Medical Evaluation Questionnaire
pdf (32k)
doc (158k)
 
OCC-24 Firefighter Respirator Medical Evaluation Questionnaire
pdf (34k)
doc (162k)
 
OCC-25 Documentation of Medical Evaluation for Respirator Use
pdf (8k)
doc (29k)
 
OCC-30 Firefighter Respirator Fit Test Record
pdf (11k)
doc (30k)
 
OCC-32 EMS Responder Fit Test Record
pdf (7k)
doc (29k)
 
OCC-33 Firefighter SCBA After Use/Daily Inspection Checklist
pdf (13k)
doc (89k)
 
OCC-37 PEOSH Hazard Communication Standard, Documentation of Training
pdf (10k)
doc (43k)
 
OCC-38 PEOSH Hazard Communication Standard
Brief Self-Inspection Checklist
pdf (743k)
NEW! fillable PDF form - use Adobe Reader (click to download Reader)  
OCC-40 Worksheet for Hazardous Chemical List
pdf (109k)
NEW! fillable PDF form - use Adobe Reader (click to download Reader)
 
OCC-41 Sample Letter for Requesting Safety Data Sheets (SDS's)
pdf (2676k)
NEW! fillable PDF form - use Adobe Reader (click to download Reader)  
OCC-57 Public Employees Occupational Safety and Health (PEOSH) Unit Complaint
pdf (18k)
doc (53k)
 
Right to Know (RTK)
County Lead Agencies
Form # Form Name/Title Linked File Instruction/ Comments
FS-45 Grant Progress Report
pdf (11k)
doc (30k)
 
OCC-46 Worker and Community Right to Know Act / Employer Outreach Survey
pdf (14k)
doc (75k)
 
OCC-54 Quarterly Report of RTK County Lead Agencies
pdf (12k)
doc (47k)
 
PV 6-93 Payment Voucher (Vendor Invoice)
(Updated May, 2016)
pdf (32k)
doc (74k)
Instructions (pdf 8k) Instructions (doc 20k)  
Go to Workplace Health & Safety     Additional Health Department Forms