Form WSP-11 "Annual Certification Renewal - Safety Consultant / Safety Engineer" - Missouri

What Is Form WSP-11?

This is a legal form that was released by the Missouri Department of Labor and Industrial Relations - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Missouri Department of Labor and Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WSP-11 by clicking the link below or browse more documents and templates provided by the Missouri Department of Labor and Industrial Relations.

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Download Form WSP-11 "Annual Certification Renewal - Safety Consultant / Safety Engineer" - Missouri

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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
P.O. Box 58
MISSOURI WORKERS’ SAFETY PROGRAM
Jefferson City, MO 65102-0058
ANNUAL CERTIFICATION RENEWAL
573-526-5757
www.labor.mo.gov/DWC
Safety Consultant / Safety Engineer
Pursuant to RSMo 287.123 and 8 CSR 50-7.080, consultants seeking re-certification must submit proof of continuing education
annually. This application must be typewritten. If the applicant is found qualified for re-certification, the Missouri Workers’ Safety
Program (MWSP) will send an approval letter and continue to include the consultant’s name on the Registry of Safety Consultants and
Engineers.
PART I: PERSONAL INFORMATION
APPLICATION FOR:
DATE
Safety Engineer
Safety Consultant
NAME
PRESENT EMPLOYER
DATE OF BIRTH
TITLE OF POSITION
HOME ADDRESS (Street, City, State, Zip)
BUSINESS ADDRESS (Street, City, State, Zip)
HOME PHONE
BUSINESS PHONE
PERSONAL E-MAIL
WORK E-MAIL
FAX
Do you prefer to receive correspondence from the MWSP at:
Home
Work
If “Yes,” you must provide a certified copy of the judgment.
Have you been a defendant in a
civil suit involving your
Yes
No
If the case is not final, you must provide a certified copy of
the complaint and the clerk’s docket sheet.
professional activity or conduct?
Upon certification, your name will be placed on the Missouri Registry of Safety Professionals. The Registry is available
online and upon request to any Missouri employer. Employers use the Registry as a resource when seeking consultation
services. Which contact information do you prefer to be used on the registry?
Home
Work
Do you wish to be identified as an available independent consultant/engineer?
Yes
No
If “Yes,” please provide your area(s) of expertise:
PART II: CHANGES AND UPDATES
Please provide in the space below any updates, additions, or changes to your certifications, education, or safety and
health experience that have occurred during the last year. Attach documentation or certificates where necessary.
WSP-11 (08-13) AI
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
P.O. Box 58
MISSOURI WORKERS’ SAFETY PROGRAM
Jefferson City, MO 65102-0058
ANNUAL CERTIFICATION RENEWAL
573-526-5757
www.labor.mo.gov/DWC
Safety Consultant / Safety Engineer
Pursuant to RSMo 287.123 and 8 CSR 50-7.080, consultants seeking re-certification must submit proof of continuing education
annually. This application must be typewritten. If the applicant is found qualified for re-certification, the Missouri Workers’ Safety
Program (MWSP) will send an approval letter and continue to include the consultant’s name on the Registry of Safety Consultants and
Engineers.
PART I: PERSONAL INFORMATION
APPLICATION FOR:
DATE
Safety Engineer
Safety Consultant
NAME
PRESENT EMPLOYER
DATE OF BIRTH
TITLE OF POSITION
HOME ADDRESS (Street, City, State, Zip)
BUSINESS ADDRESS (Street, City, State, Zip)
HOME PHONE
BUSINESS PHONE
PERSONAL E-MAIL
WORK E-MAIL
FAX
Do you prefer to receive correspondence from the MWSP at:
Home
Work
If “Yes,” you must provide a certified copy of the judgment.
Have you been a defendant in a
civil suit involving your
Yes
No
If the case is not final, you must provide a certified copy of
the complaint and the clerk’s docket sheet.
professional activity or conduct?
Upon certification, your name will be placed on the Missouri Registry of Safety Professionals. The Registry is available
online and upon request to any Missouri employer. Employers use the Registry as a resource when seeking consultation
services. Which contact information do you prefer to be used on the registry?
Home
Work
Do you wish to be identified as an available independent consultant/engineer?
Yes
No
If “Yes,” please provide your area(s) of expertise:
PART II: CHANGES AND UPDATES
Please provide in the space below any updates, additions, or changes to your certifications, education, or safety and
health experience that have occurred during the last year. Attach documentation or certificates where necessary.
WSP-11 (08-13) AI
PART III: PROOF OF CONTINUING EDUCATION
Attach proof of one continuing education unit (CEU) obtained within the last year. One CEU is 10 contact hours of
instruction. One contact hour equals 50 minutes. It must be related to occupational safety and health. Acceptable topics
include safety management, industrial hygiene, industrial safety, general safety, driver safety, fire safety, aviation safety,
transportation safety, occupational safety and health administration, accident and statistical reporting, safety training,
safety engineering, system safety analysis, construction safety, legal and ethical issues related to safety, chemical or
biological safety, or environmental safety.
If you are using courses that have not been preapproved or provided with CEUs, then the documentation must include
the topics presented and the length of time of the class. If you are using a conference to meet this education requirement,
you must indicate which individual sessions you attended.
I certify that the statements above, including any attachments submitted, are accurate to the best of my knowledge. I hereby authorize the Missouri
Workers’ Safety Program to verify any information submitted. I understand that any falsification of information in the application, or statements,
may be cause for rejection or withdrawal of certification. I agree to hold the Missouri Workers’ Safety Program harmless from any and all liability in
the event this application is rejected on the basis of information furnished to the Missouri Workers’ Safety Program by me or third persons which
would, in the judgment of the Missouri Workers’ Safety Program, make me ineligible for certification.
Notary Seal
SIGNATURE
Notary Signature
DATE
SIGNATURE MUST BE NOTARIZED
Missouri Division of Workers’ Compensation is an equal opportunity employer/program.
Auxiliary aids and services are available upon request to individuals with disabilities.
WSP-11-2 (08-13) AI
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