PURPOSE: This rule outlines theproeedures for obtaining certification as a certified safetyengineeringand management program.

1. (1) An application for certification must be made on a form provided by the Missouri Workers’ Safety Program. Application forms may be obtained by requesting a copy from the Missouri Workers’ Safety Program, P.O. Box 58, Jefferson City, MO 65102. The application must be filed within sixty (60) days of the date the insurance company is authorized to sell workers’ compensation insurance in the state of Missouri. If the insurance company is authorized to sell workers’ compensation insurancepriorto theeffective dateofthisrule, the sixty (60) days shall run from notification by the program manager.

2. (2) An application must be typewritten and signed by a” authorized representative of the insurance canier.

   CODE OF STATE REGULATIDNS

   Division SO-Workers’ Compensation

3. (3) A written outline of the insurance carriers proposed certified safety engineering and management program must be on file before a” application will be considered complete and officially filed.
4. (4) The Missouri Workers’ Safety Program shall conduct random on-site visits with the insureds of the insurance carrier as part of the certification or renewal process.

5. (5) Following the Missouri Workers’ Safety Program review process, the applicant will be informed by letter of the approval or denial of cetication. The denial letter will identify the reaso”~ for denial and the appeal process. Auth: sections 287.123 and 287.650, RSMo (Cum. Supp. 19931.’ Emergency rule filed July 7, 1994, effectiue July 17, 1994, expired Nou. 13,1994. Emergency rule filed Oct. 24,1994, effectiue Now 14, 1994, expired March 13, 1995. Original rule filed July 6, 1994, effective Jan. 29, 1995. *Original authority: 287.123, RSMo (1993) and 287,650, RSMo (19391, amended 1949, 1961, 1980,1993

   (U/30/94) MISSOURI semtary Of state

Missouri Department of Labor and Industrial Relations Division of Workers’ Compensation

Application

Missouri law RSMO 287.123, requires all insurance carriers writing workers’ compensation in the state of Missouri to submit a written outline of their comprehensive safety management and engineering program for certification.

Please submit your written outline within 60 days to this o&e

Type or print answers to all questions and mail in DUPLICATE Program, 3315 W. Truman Blvd., P. 0. Box 58, Jefferson City, MO 65109.

Undersigned Insurance Carrier hereby requests that the written outline of their comprehensive safety engineering and management services available to their insureds be certified.

Name of Insurance Carrier

Mailing Address

Principal location

Other Missouri locations

Other Missouri locations

Other Missouri locations

Other Missouri locations

Other Missouri locations

*List additional locations, if any, on supplemental page

Name of contact person

Number of loss control reps.

ws 003

MlSSOlJRl (12/30/94) semaly Of state for Insurance Carriers Certified Safety Programs

INSURANCE CARRIER INFORMATION

(Street)

(No)

(Street)

(No)

1. (No) (Street)

   (Street)

jN0)

1. (No) (Street)
2. (No) (Street)

3. (No) (Street)

   (Title) (Phone No.)

   CODEOFSTATE REGULATIONS for review.

   to The Missouri Workers’ Safety

(City) (State)

(City) (State)

(City) (State)

(City) (State)

(City) (State)

(City) (State)

(City) (State) 8 CSR 50-7 m

(Phone)

(Zip)

(Phone)

(Zip)

(Phone)

(Zip)

(Phone)

(Zip)

(Phone)

(Zip)

(Phone)

(Zip)

(Phone)

1. (Zip) m 8 CSR 50-74ABOR & IND. RELATIONS

,.Missouri Department of Labor and Industrial Relations Division of Workers’ Compensation

Insurance Carrier Acknowledgment

The undersigned acknowledges that it understands the terms of the Program as outlined in the rules.

Authorized Signature and Title Date

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(12/30/94) MISSOURI sEata!y Of slab

Division !iO-Workers’ Compensation

m 8 CSR 50-7-LABOR & IND. RELATIONS Missouri Department of Labor and Industrial Relations Division of Workers’ Compensation

APPLICATION FOR ACADEMIC REQUIREMENT EXEMPTION

Pursuant to RSMo. 287.123 and 8 CSR 50-7.060(4)(G) the following information is required in order to process 80 application for academic requirement exemption. lf applicant is found qualifed for the exemption the Missouri Workers’ Safety Program will credit the applicant with meeting the educational requirements established under the nde for qualification for inclusion oo the Registry of Safety Engineers and Coosultants.

OCCUPATIONAL SAFETY AND HEALTH EXPERIENCE IN LIEU OF ACADEMIC REQUIREMENT

Employers may be contacted to verify information provided. List each position in chronological order beginning with your present position. Account for all occupational safety and health experience in the last three years. Use a separate space for each position. Attach additional sheets if necessay

Employer

Address (City) (St4 (Zip) ww

Dates of Employment Titk Type of Business or industry to

Description of Experience: Indicate the percentage of time spent in the following areas: Torn, sha,, not exceed 100%

Safety~4th administration &management safetyulealth training and education Accident investigation and statistical reporting Safety~~th program evaluation Safetybdth program design Hazard identification Hazard elimination and control Environmental protection None of the above

ws 005

CODE OF STATE AEGLltATlONS

3315w. Tlllman Blvd. P.0. sax 58 .le*enon my, mti 65102

(12/30/94) MISSOURI SlWtarj Of state

Missouri Department of Labor and Industrial Relations Division of Workers’ Compensation

Employer

Address (Street)

Dates of Employment to

Supervisors name and phone number

Description of Experience: Indicate the percentage of time spent in the following areas: Total shall not exceed 100%

SafetyIhealth administration & management SafetyUwalth training and education Accident investigation and statistical reporting Safetykahh program evaluation Safetybalth program design Hazard identification Hazard elimination and control Environmental protection None of the above

For the three areas in which you spend the most time, provide a brief description of your duties and give specific examples.

I certify that the statements above (inAudi@ any attachments submitted) are accurate to the best of my knowledge. autboriz~ the Missouri Workers’ Safety Program to verify any information submitted. infonnatlon in tie application (or attachments) may be cause for rejection or withdrawal of certification. the Miss$ Workers’ Safety Program harmless born any and all liability informetlon furnished to the Missouri Workers’ Safety Program by me or third persons which would, in the judgment ofthe Missouri Workers’ Safety Program, make me ineligible

Signature

ws 005

MISSOURI (U/30/94) SCIdaty Of state (City)

Title

in the event this application

for certification.

COOEOFSTATE REGULATIONS 8 CSR 50-7 1(J4

(St&) (Zip)

Type of Business or industry

I hereby

I understand that any falsification of I fruther agree to hold is rejected on the basis of

Date m 8 CSR 50-74ABOR & IND. RELATIONS

6 CSR 50-7.070 Application for Certification: Certified Safety Consultant/Certified Safety Engineer PURPOSE: This rule outlines theprocedims forapplicationforcertificationasa certified safety engineer or certified safety consultant. (1) Applications for certification as a certified safety consultant or certified safety engineer must be made on the forms provided by the Missouri Workers’ Safety Program. Applieation forms may be obtained by requesting a copy from the Missouri Workers’ Safety Program, P.O. Box 58, Jefferson City, MO 65102. (2) An application, including the applicant’s Social Security number, must be typewritten, signed and notarized. (3) The following documents must be on file with the division or must accompany the application: (A) Authenticated copy of diploma or c&ifieate; (B) Proof of certification by a recognized professional agency as set out in 8 CSR 50. 7,060(4)(B)-(F); and (C) Any additional information as the division deems necessary. (4) If an applicant has been a defendant in a civil suit involving his/her professional activity or conduct, the applicant shall submit a certiiied copy of the final judgment. If the case is not yet final, the applicant shall submit acertified copy ofthecomplaint andthe clerk’s docket sheet. (5) Following the Missouri workers’ safety review process, the applicant will be informed by letter of the approval or denial of certification. The denial letter will identify the reasons for denial and the appeal process. Auth: sections 287.123 and 287.650, RSMo (Cum. Supp. 1993).* Emergency rule filed July 7,1994, effectiue July 17, 1994, expired Nov. 13,1994. Emergency rule filed Oct. 24,1994, effective Nou. 14, 1994, expired March 13, 1995. Original rule filed July 8, 1994, effective Jan. 29, 1995. *Original authority: 287.123, RSMo (19931 and 287.650, RSMo (19391, amended 1949, 1961, J980,1993.

COOEOFSTATEREGUl.ATlONS (12/30/94) MISSOURI secretlrY Of state

Missouii Department of Labor and Industrial Division of Workers’ Compensation

APPLICATION

REQUIREMENT EXEMPTION

Pursuant to R.S.Mo. 287.123 and 8 CSR 50-7.060(4)(G) the following information is required in order to process an application for academic requirement exemption. If applicant is found qualifed for the exemption the Missouri Workers’ Safety Program will credit the applicant with meeting the educational requirements established under the rule for qualification and C,rnsultants.

OCCUPATIONAL SAFETY AND HEALTH REQUIREMENT

Employers may be contacted 1” verify information provided. List each position in chronological order hcginning with your present position. Account for all occupational safety and he&h experience in the last lhree years. Use a separate space for each position. Attach additional sheets if necessary.

Employer

Address (SIreel)

Dates of Employment -.l”-

Supervisors name and phone number

Description of Experience: Indicate ‘Tma1 \hii, nili e,rcred ,OO%

MISSOURI SHhR d St& u2’30’g4’ 8 CSR 50-7

Relations ‘.

FOR ACADEMIC

for inclusion on the Registry of Safety Engineers

EXPERIENCE IN LIEU OF ACADEMIC

City) (Slate) (Zip1

Title Type of Business or industry

the percentage of time spent in the following areas: m 8 CSR 50-7-LABOR & IND. RELATIONS

Missouri Department Division of Workers’

Employer

Address (Sweet)

Dates of Employment

Supervisors name and phone number

Description Tad shall no, exceed 100%

Safety\heaJth administration & management Safetykealth Accident investigation and statistical reporting SafetyWealth program evaluation Safetykeahh program design Hazard identification Hazard elimination Environmental protection None of the above

For the three areas in which you spend the most lime, provide a brief description and give specific examples.

I certify that the statcmcnts above authorize the Missouri Workers’ Safely Program information in the application hold the Missouri Workcrs’ Safely Program harmless basis of information of the Missouri Workers’ Safety Progum. make me ineligible

Signature of Labor and Compensation

to

of Experience: Indicate

training and education

and control

(including any atlachments

(or attachments) may hc cause for rejection or withdrawal

furnished to Ihe Missouri Workers’ Safety Program by me or third persons which would.

Industrial Relations

(W)

Title

the percentage of time spent in the following

submitted) arc accurate Lo the best of my knowledge.

to verify any information submitted.

from any and all liability

for certification.

(State) (Zip)

Type of Business or industry

of your duties

I understand that any falsificalion of certification.

in the cvem this application

Date areas:

I herchy of

I further agree to is rejected on lhc in lhe judgment

(12/30/94) MISSOURI sscrctarr of Stab Missouri Department Division of Workers’ Compensation

APPLICATION FOR CERTIFICATION

SAFETY ENGINEERS AND CONSULTANTS

Pursuant to R.S.Mo. 287.123 and 8 CSR 50-7.060 the following information an application for certification of Safety Engineers and Consultants. If applicant is found qualifed for certification the Missouri Workers’ Safety Program will provide a letter which states the individual has met the qualilicatian for inclusion on the Registry of Safety Engineen and Consultants.

PART I: PERSONAL Application for:

NZillle

Present Employer

Title or Position

Business address

Home Address

Business phone (-)

PART II: PROFESSlONAL REGISTRATION Please check each applicable Information is subject to veriticalion by the Missouri Workers’ Safety Program.

( ) Registered Professional Engineer: ( ) Certified Safety Professional ( ) Certified Industrial Hygienist: ( ) Cenified Occupational Health Nurse ( ) Ccrtitied Occupational Health Physician

PART 111: COLLEGE EDUCATION: The applicant is responsible for requesting and submitting an authenticated copy of their diploma from each college or university. A copy of certification application.

CollegcVJniversity City and State

( ) Check here if the exemprion from academic requirements is requested and attach the application academic requiremen exemption.

MISSOURI (12/30/94) Seadaly of state of Labor and Industrial

INFORMATION Safety Engineer

(Street)

(SlPxl)

item. Enclose a copy of current registration or certification.

Attended From\lo

Relations

FOR

is required in order to process

Safety Consultant

Date of Birth

(State)

WY)

(Stave)

WY) Home phone-(_)

OR CERTIFICATION

Registration# Cenificate# CertXicate# Cenificate# Certificate#

1. (s) must also be submitted with the

H0lJr.S

Completed Major 8 CSR 50-7 , m

(Zip)

(Zip)

State Issued by issued by issued by Issued by

Degree Earned

for

m 8CSR50-7-LABOR&IND.RElATlONS

Missouri Department Division of Workers’ Compensation

Areas of Study: college or’ university. The lranscripl must be received by the Missouri Workers’ Safety Program directly from the college or university. List all courses taken in the following areas or other related subjects.

Enviromental Health & Safety /Fire Safety I Safety Program Adminisrration General Occr~palional Health & Safety/Safety Engineering & Applied Science / Tmmpo~-rorion Safety

PART IV: OCCUPATIONAL Employerj may be conlacted to verify information provided. List each position in chronological order beginning with your present position. Account for all occupational safety and health experience in the last three years. Use a separate space for each position. Attach additional sheets if necessary.

Employer

Dates of Employment

Supervisors name and phone number

Description of Experience: TOId rho,, no, exceed IOO% SafetyVlcalth administration & management Safety\heakh training and education Accident investigation and statistical reporting Safety&&h Safety&&h Hazard identitication Hazard elimination and control Environmental protection None of the above

For the three areas in which you spend the most time, provide a brief description of your duties and give specific examples. of Labor and Industrial Relations

The applicant is responsible for requesting a certified transcript

/ lndrrsrriol Snfery /

SAFETY AND HEALTH EXPERIENCE

Address

Title Type of Business or industry

to

Indicate the percentage of time spent in the following areas:

program evaluation program design

CODE OF STATE REGUlATlONS

Division SO-Workers’ Compensation

33,s 1”. Truman “l”d. P.O. aox 58 Jemrron my, Miss”“ri 6510~ Paw .2- from each

(U/30/94) MISSOURI SHr&lq Of state

Department of Labor and Induslrial Relations Division of Workers’ Compensation

Recerlificarion is required nnnually. You we required Losubmit proof of one Continuing Education Unit or ten mntacl hours annually. A certificale or writlen notice on the orgnnizations letter head is acceplable. The content of the wursc should be relaled 10 occupational safety and heallh such as Environmenlal Health and Safety, Safety Program Administration and Manngement. General Occupa~ianal Safety and Health, Transporlation Safely, lndustriil Safely, Safety Engineering and Applied Science, etc. Tbe Missouri Workers’ Safety Progrsm reserves the right 10 con~i(c1 the organizalion 10 wrify

PART I. PERSONAL DATA

Reccnilication for:

NZIX

Business Address (SUCCI)

(Slm)

(CIIY)

Business Phone (-)-

Job title _ Please check one of the below that best describes your current position.

( ) Consullanl ( ) Coordinalor ( ) Supervisor

PART II _ CERTIFICATIONS AND WORK EXPERIENCE (ATTACH A CURRENT COPY)

Cerlilicalions: Check each applicable item:

( ) Regislered Professional Engineer ( ) Certified Safely Professional f ) Certified lndusuial Hygienist ( ) C&lied Occupadonal HeaId, Norse ( ) Certified Occupalional Health Physician

ws 002

MISSOURI (12/30/94) SICIMR Of sata ANNUAL CERTIFICA1’ION Safety Engineer/Safety

Safety Engineer

(zip)

-,.__-

( ) Direcmr ( ) Adminiwakx ( ) Manager Consultant

Safety Consulram

Present Employer

Home Address

(CilY)

Home Phone (

( ) Engineer ( ) Educamr

Rcgisua&x# Ccnitica~e# Cenilicalcll

Cerlificate# 8 CSR 50-7 ,

m

RENEWAL

the information provided.

cJmee1)

mate) (zip)

)

Sb3lC Issued by Issued by - Issued by __ Issued by ~

m 8,CSR 50-74ABOR & IND. RELATIONS Missouri I)epar.lmenl of Lahr md Industrial Relaku~s 33,s \“,‘rr”ln~n lllld P.0. ““X 58 Division OT Workers’ Compensation ,cffcrmn city. Missouri 65102 /bPC -2.

For the three areas in which you spend the most time, provide a briefdescriplion of your duties and give specific examples.

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(12/30/94) MISSOURI