Set Up A Protocol | On-Site Health & Safety

General Company Information:

Company Name:*

Any dba’s, acronyms, sister companies, etc. that may be commonly used by your company when calling in for service? *
YesNo

If yes, please list them all

Please note that any names listed under this section will be connected to your account. In the event a dba, acronym, sister company, etc. calls in, we will follow this account information for services, reporting, and billing purposes.

Store/ Plant/ Jobsite/ Etc. Name or Number:

Company Phone:

Company Address Line 1:

Company Address Line 2:

City:

State:

ZIP Code:

Is the account you are setting up for a business that has fluctuating worksites or fixed locations?
Fluctuating WorksitesFixed LocationsI am not sure, please have a Customer Service Representative contact me to discuss.

If fluctuating worksites, please list the major cities/ areas that your company primarily operates in.

Fixed Location Store/ Plant/ Jobsite/ Etc. Name or Number:

Fixed Location Phone:

Fixed Location Address Line 1:

Fixed Location Address Line 2:

City:

State:

ZIP Code:

Would you like to add an additional Fixed Locations?
YesNo

2 Fixed Location Store/ Plant/ Jobsite/ Etc. Name or Number:

2 Fixed Location Phone:

2 Fixed Location Address Line 1:

2 Fixed Location Address Line 2:

2 City:

2 State:

2 ZIP Code:

Would you like to add an additional Fixed Locations?
YesNo

3 Fixed Location Store/ Plant/ Jobsite/ Etc. Name or Number:

3 Fixed Location Phone:

3 Fixed Location Address Line 1:

3 Fixed Location Address Line 2:

3 City:

3 State:

3 ZIP Code:

Would you like to add an additional Fixed Locations?
YesNo

4 Fixed Location Store/ Plant/ Jobsite/ Etc. Name or Number:

4 Fixed Location Phone:

4 Fixed Location Address Line 1:

4 Fixed Location Address Line 2:

4 City:

4 State:

4 ZIP Code:

Would you like to add an additional Fixed Locations?
YesNo

5 Fixed Location Store/ Plant/ Jobsite/ Etc. Name or Number:

5 Fixed Location Phone:

5 Fixed Location Address Line 1:

5 Fixed Location Address Line 2:

5 City:

5 State:

5 ZIP Code:

Do you have more than 5 fixed locations that you are signing services up for?
YesNo

If yes, a Customer Service Representative will reach out to you to discuss additional account details.

Main Protocol Contact:

Main Contact Name:

Main Contact Phone:

Main Contact Alternate Phone:

Main Contact Email:

Reporting Information:

Please list any company representatives that will need to receive service documentation.

Type of Report (hold CTRL to select multiple):

Contact Name:

Contact Phone:

Contact Alternate Phone:

Contact Email:

Additional Reporting Notes:

Would you like to add any additional reporting contacts?
YesNo

Type of Report:

2 Contact Name:

2 Contact Phone:

2 Contact Alternate Phone:

2 Contact Email:

2 Additional Reporting Notes:

Would you like to add any additional reporting contacts?
YesNo

Type of Report:

3 Contact Name:

3 Contact Phone:

3 Contact Alternate Phone:

3 Contact Email:

3 Additional Reporting Notes:

Would you like to add any additional reporting contacts?
YesNo

Type of Report:

4 Contact Name:

4 Contact Phone:

4 Contact Alternate Phone:

4 Contact Email:

4 Additional Reporting Notes:

Would you like to add any additional reporting contacts?
YesNo

Type of Report:

5 Contact Name:

5 Contact Phone:

5 Contact Alternate Phone:

5 Contact Email:

5 Additional Reporting Notes:

Billing Information:

Please list any company representatives that will need to receive invoices for services rendered. Invoices will only be sent via email to the below listed representatives.

Billing Contact Name:

Billing Contact Phone:

Billing Contact Alternate Phone:

Billing Contact Email:

Would you like to add an additional Billing Contact?
YesNo

2 Billing Contact Name:

2 Billing Contact Phone:

2 Billing Contact Alternate Phone:

2 Billing Contact Email:

Would you like to add an additional Billing Contact?
YesNo

3 Billing Contact Name:

3 Billing Contact Phone:

3 Billing Contact Alternate Phone:

3 Billing Contact Email:

Would you like to add an additional Billing Contact?
YesNo

4 Billing Contact Name:

4 Billing Contact Phone:

4 Billing Contact Alternate Phone:

4 Billing Contact Email:

Would you like to add an additional Billing Contact?
YesNo

5 Billing Contact Name:

5 Billing Contact Phone:

5 Billing Contact Alternate Phone:

5 Billing Contact Email:

Is a PO or Job number required on invoices?
PO NumberJob NumberBoth (PO and Job Number)Neither
*Disclaimer: We are a fee for service only. We send invoices via email to the designated contact(s) listed above. Our payment terms are Net
30. All accounts will be subject to credit hold for invoices more than 60 days past due. All invoices will incur a late fee of 2% after 30 days past due, 3% after
60 days past due, with an additional $20 collection fee after 90 days.

Protocol Information:

Services:
First Aid Injury ResponseDrug Screens

Post-Accident Drug Screens

DOT

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.

NON-DOT

We would like to use an immediate kit

5-panel immediate kit10-panel immediate kit

We would like to do a collection

5-panel collection.10-panel collection.

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.
Is breath alcohol testing needed?
AlwaysNeverSometimes

I am not positive. Please have a Customer Service Representative contact me to discuss options in further detail.

Pre-Employment Drug Screens

DOT

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.
Is breath alcohol testing needed?
AlwaysNeverSometimes

NON-DOT

We would like to use an immediate kit

5-panel immediate kit10-panel immediate kit

We would like to do a collection

5-panel collection.10-panel collection.

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.
Is breath alcohol testing needed?
AlwaysNeverSometimes

I am not positive. Please have a Customer Service Representative contact me to discuss options in further detail.

Random Drug Screens

DOT

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.
Is breath alcohol testing needed?
AlwaysNeverSometimes

NON-DOT

We would like to use an immediate kit

5-panel immediate kit10-panel immediate kit

We would like to do a collection

5-panel collection.10-panel collection.

We have our own paperwork and lab.

What is the lab?

What is the account number?

We would like to use your paperwork and lab.
Is breath alcohol testing needed?
AlwaysNeverSometimes

I am not positive. Please have a Customer Service Representative contact me to discuss options in further detail.

Please select all other services you are interested in.
Respiratory

Will your company always have the same mask(s)?
YesNo

If yes, what is/ are the make and models?

Audiometric Testing/ TrainingBlood DrawsWellness ScreeningsCPR/ AED/ Industrial First Aid TrainingHealth & Safety Training ClassesCovid TestingContract Safety ServicesEnvironmental Occupational Services
Other

Please Write

Please provide us with any additional details that we may not have asked below:

How did you hear about us?

If Broker, please provide their company name

If Trade Association, please provide the association name

If Technician, please provide their name

If Sales Rep, please provide their name

Other

Set Up Protocol Today!

General Company Information:

Main Protocol Contact:

Reporting Information:

Billing Information:

Protocol Information: