Dental Health & Safety Policy Manual Order Form
Name/Location of Business
Street Address Line 2
State / Province
Postal / Zip Code
Name of Individual Completing the Form
Nature of Business;
Healthcare Provider (ie. Medical/Dental)
Distribution (ie. Warehouse)
Services (ie. Trucking, Professional Offices, Educational Institution, etc.)
How many employees do you have?
Does your business have health & safety as part of staff meetings?
Never, there are a lot of other meetings
Do your employees complete a pre-assessment upon hiring?
How many computers/workstations are in your office/practice?
Does your business/practice currently have a Health & Safety Policy Statement?
Please provide a copy of your Health & Safety Policy Statement;
When was the last workplace injury/illness incident reported?
Last 7 days
Who is responsible if an employee was to become injured at work?
Who is Responsible for the Management/Reporting of your H&S Program?
First & Last Name
Please provide the location of your Health & Safety Bulletin Board;
Please provide the location of your First Aid Kit;
Please provide the location of your SDS (Safety Data Sheets) Binder;
Please provide the location of all Sharps Containers;
Please provide the Location and Class of all Fire Extinguishers;
Please provide the Location and Make/Model of Eyewash Stations;
Do you currently have a specific procedure for the following (click all that apply); if not, a generic policy will be included in your manual.
Roles & Responsibilities
WHMIS/ Chemical Safety
Workplace Violence & Harassment Policy
Return to Work
JHSC (20+ Employees)
Please provide a copy of your Roles & Responsibilities Policy;
Please provide a copy of your WHMIS/Chemical Safety;
Please provide a copy of your Violence & Harassment Policy;
Please provide a copy of your Return to Work;
Please provide a copy of your Incident/Injury/Illness Reporting;
Please provide a copy of your JHSC (20+ Employees);
Should be Empty: