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Human Capital Management
#190206-J31C-02


Supplemental Questionnaire

Last Name First Name
 

 

ATTENTION!

 Please verify that you meet the education and experience requirements listed in the job bulletin before completing the following supplemental questionnaire. The questions below will be used for scoring purposes in lieu of a written exam.


1.

Check all of the following certifications or training courses you have satisfactorily completed.

Current certification as a Certified Safety Professional by the Board of Certified Safety Professionals
Current certification as an Associate Safety Professional by the Board of Certified Safety Professionals
Current certification as an Occupational Health and Safety Technologist by the Council on Certificate of Health Environmental and Safety Technologist
Current certification as a Construction Health and Safety Technician by the Council on Certificate of Health Environmental and Safety Technologist
Current certification as a Certified Safety and Health Official by an authorized Occupational Safety and Health Administration (OSHA) education center
Occupational Safety and Health Administration (OSHA) "Basic Onsite Consultative Training" course
Occupational Safety and Health Administration (OSHA) "The Initial Compliance Course for Safety Officers"
Associate in Risk Management (ARM)
None of the above
 

Please provide the name of the institution and the city and state where each checked item in the previous question was obtained.

2.

Please check all experience you have developing occupational health and safety programs.

I have experience developing occupational health and safety programs.
I have experience implementing occupational health and safety programs.
I have experience with occupational health and safety programs independently.
I have experience with occupational health and safety programs as part of a group.
I have experience with occupational health and safety programs as an intern.
I have no experience with occupational health and safety programs.
 

Please list the programs you have developed or implemented and list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

3.

What experience do you have in preparing and revising job hazard analysis?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please provide an example and list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

4.

What experience do you have inspecting facilities and work processes to determine where hazards exist?

I have primary responsibility for performing this task independently as a regular part of my job.
I have performed this task as part of a group.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below

5.

What experience do you have documenting hazardous conditions and following up to ensure corrections are made?

I have primary responsibility for performing this task independently as a regular part of my job.
I have performed this task as part of a group.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

6.

What experience do you have developing and evaluating hazard abatement methods?

I have primary responsibility for performing this task independently as a regular part of my job.
I have performed this task as part of a group.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

7.

What experience do you have providing safety and health training?

I have primary responsibility for performing this task independently as a regular part of my job.
I have performed this task as part of a group.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

8.

What experience do you have providing advice and guidance to management regarding inspection procedures and statutory regulations?

I have primary responsibility for performing this task independently as a regular part of my job.
I have performed this task as part of a group.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

9.

Please check all experience you have investigating workplace fatalities, injuries, illnesses, accidents, near misses and safety and health complaints.

I have performed this task independently.
I have performed this task as part of a group.
I have performed this task as an intern.
I have never performed this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

10.

What experience do you have conducting safety analyses with the use of pre-calibrated equipment?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the equipment used and provide the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

11.

What is your experience performing trend analysis?

I have performed this task independently as a regular part of my job.
I have performed this task as a regular part of my job with some supervision.
I have performed this task as an intern.
I am familiar with this task or have received some training or education on it.
I have no experience with this task.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

12.

Please check all the industries with which you have experience in safety and health.

Construction
Oil and gas
General industry
Safety and security
Law enforcement
Manufacturing
Fire protection
I have no safety and health experience in any of the listed industries.
 

Please list the employer and job title, school and location, or internship location where you gained your experience as indicated in the response above.  If you indicated "no experience", then please type N/A below.

13.

How many consensus standards do you have experience following?

I have followed more than four consensus standards.
I have followed three to four consensus standards.
I have followed one to two consensus standards.
I have never followed consensus standards.
 

Please list the consensus standards you followed as indicated above and provide the employer and job title, school and location, or internship location where you gained your experience.  If you indicated "no experience", then please type N/A below.