Dept. of Inspections, Appeals, and Licensing

oshaconsultation@dia.iowa.gov

6200 Park Ave., Suite 100 Des Moines, Iowa 50321

Request for Services

Request services from IOSHA safety and health, education staff.

Name of Company or Association Requesting Service

Company Street Address

Street Address 2

City

State

Zip Code

Phone Number

Training or Speech Location Address

Training or Speech Address Line 2

City

State

Zip Code

Requested Training Type

Conference

Speech

10-Hour Construction

10-Hour General Industry

Comments

Select the industry or construction trade in which attendees/trainees participate

Manufacturing

Construction

Agriculture

Education

Healthcare

Non-Profit

Union

Estimated number of attendees

Is the event date and time set?

Yes

If yes, enter the date of the training.

Contact Person Name

Title

Phone Number

Has your business had an IOSHA Enforcement Inspection or Consultation Visit in the last 12 months?

Yes

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I understand that consultation and education services are made available to me at no-cost through federal and State funds.

Title