New Jersey Department of Health	New Jersey Department of

Environmental Protection
Worker and Community Right to Know Act

EMPLOYER OUTREACH SURVEY
Name of Employer

Telephone No.

NJEIN NUMBER
Street Address, City, State, Zip Code

SIC Code
Co/Mun Code
Contact Person

Title

Union Name/Local Number

NAICS Code
Union Representative

Total Number of Employees
Total Number of Exposed Employees
Union Address

Telephone Number

Contact Dates
Type of Business Conducted at This Site

Method:

Phone

In Person

Mail
Method:

Phone

In Person

Mail
Method:

Phone

In Person

Mail

Comments

Review of Forms and Materials

With Employer	Employer Has?	Needs?	Number Needed	Sent?

Yes	Date Sent
Yes	No	N/A	Yes	No
RTK Survey
RTK Regulations - NJDOH
RTK Hazardous Substance List
Hazardous Substance Fact Sheets-English
Hazardous Substance Fact Sheets-Spanish
RTK Brochures-English
RTK Brochures-Spanish
RTK Posters-English
RTK Posters-Spanish
Other

Name of County Representative (Print)

Signature of County Representative
County Lead Agency

Date

Distribution: White - NJDOH

OCC-46	Canary-County Lead Agency

JUL 12	Pink-NJDEP

OCC-46 Employer Outreach Survey

OCC-46, employer Outreach Survey, RTK, right to know, occupational health

EWhite

2003-07-07

NJDOH