Additional Health Department Forms

Forms for Workplace Health & Safety

Occupational Health Surveillance Unit
Form # Title PDF/WORD 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
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 # Title PDF/WORD 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
HazCom Compliance Checklist
pdf 24k
doc 95k
OCC-40 Worksheet for Hazardous Chemical List pdf 10k
doc 45k
OCC-41 Sample Letter for Requesting Material Safety Data Sheets (MSDS's) pdf 7k
doc 21k
OCC-57 Public Employees Occupational Safety and Health (PEOSH) Unit Complaint pdf 18k
doc 53k
Right to Know (RTK)
County Lead Agencies
Form # Title PDF/WORD 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
pdf 8k
doc 20k  
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