Name

First                                                  Last

Company

Position

Street

Town/City

State/Province

Zip/Postal Code

Country

Your Website

Phone
(###) ###-####
extension:

Fax

(###) ###-####

EMail

Please tell us about your company

How did you find out about the Impacto Web Site?

Navigating the Web Received your postcard A colleague told me Trade Show Other

Other

For your company, do you have a person or comittee who handles plant safety issues?

Full time Part time No person or committee

If you do, how often do they dedicate time for this?

Daily More than once a week More than once a month Whenever they can

Number of People Employed in Your Company:

1-10 11-50 51-250 251-1000 More than 1000

Does your company currently use any other protective products?

Yes No

If Yes, which company's products do you now use?

How often do you buy new safety gloves and wrist protection products?

weekly monthly quarterly once a year

How often does your company evaluate each worker's work situation?

semi-annually annually every five years

How often does your company do a functional capacity evaluation (FCE) -- determining a person's physical limitations to get them back to work at their regular or a modified position?

semi-annually annually never

What type of pre-existing conditions are you most concerned about at your company?

Repetitive Strain Injuries Mechanical Stress (pressure points) Cumulative Trauma Impact and Vibration Heat Slash Other

How many of these kinds of injuries have you had at your company in the last year?

1-5 6-10 11-20 more than 20 none

What work related injury prevention issues do you want to address the most?

Are you planning a possible change to your plant safety situation right away? If this is...

URGENT for you, please click this checkbox and we will phone you to set up an evaluation right away.

Urgent

If you are planning a possible change to your plant safety situation SHORTLY, please click this checkbox and we will contact you by e-mail.

Shortly

Do you wish to receive Industrial Safety News from Impacto?

Yes No

What is the best time to contact you?

Please enter any additional information you require to make a decision about having us do an evaluation at your plant.