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Workplace Safety Training Intake Form

To schedule a training, fill out the intake form below and we will contact you to set up a training. If you have any questions, email safety@naswma.org or call (617) 227-9635 x24.

Agency Information

Has an incident(s) occurred in the last year? Please include threats and attacks that did not hit their target (e.g. something thrown at a worker but missed).

Does your agency have any written safety policies? If so, do you want NASW Trainers to review and comment?
(If yes, please attach a copy of your safety policies below.)




Training Information

Training Location - Address where the training will take place:

Approximately when would you like the training/consultation to occur?

Contact Person - Who should we contact about setting up this training?

What is it that you would like training/consultation on? Please be as specific as possible.

Would you like trainees to receive social work CEs for the training?



Trainee Information

Are you seeking training for state/federal employees?



If participants are paid employees of the agency, are they covered under the agency's workers' compensation policy?



How many trainees will be in the training?






Level of training/education of trainees:







Have the trainees had any safety training? If so, please describe.

Have the trainees received training provided by a grant from the Massachusetts Department of Industrial Accidents? If so, what were the topics covered?

How Did You Hear About Us?

How did you hear about the NASW-MA Workplace Safety Training Program?

National Association of Social Workers - Massachusetts Chapter
14 Beacon Street, Suite 409, Boston MA 02108
tel: (617)227-9635 fax: (617)227-9877 email: chapter@naswma.org
Copyright 2001, NASWMA. All rights reserved.

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