DOH Forms
Public Employees Occupational Safety and Health (PEOSH) Unit
Telephone: 609-984-1863
On-Line Form
This is a FREE service for New Jersey Public Employers. Employers must correct all serious hazards identified during the consultation and agree to work with the consultant to develop effective measures for worker safety and health protection. Please read EMPLOYER OBLIGATIONS AND RIGHTS before completing the form. This form is also available for download in pdf or word format.
For more information, contact the PEOSH Unit using the information listed above.
All fields are required.
1. Name of Employer:
  Employer Mailing Address:
  City: ,  NJ  Zip Code:
  Employer Telephone Number: - - Ext.
  Total Number of Employees (controlled by employer):
2. Name of Site:
  Site Address:
  City: ,  NJ  Zip Code:
  Total Number of Employees at Site (employed at establishment):
  Total Number of Employees in the Area(s) of Concern (covered by consultation):
3. Name of Facility Contact:
  Telephone Number: - - Ext,
4. What services are you requesting:
5. Name of Person Requesting Consultation:
  Telephone Number: - - , Ext


Oct 07

Department of Health

P. O. Box 360, Trenton, NJ 08625-0360
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