Request For Consultation Assistance
Establishment: # of Employees:
Contact Person: Title:
Type of Business: GI Const. SIC: NAICS
Phone # Fax #
Cell Phone # E-Mail
Source: (check all that apply)
Enforcement Media/Newsletter Publication
Association/Organization Seminar Other:
Service(s) Requested: (check all that apply)
Abatement Assistance General Safety Assistance Hazard Survey
Air Quality Hazard Communication (RTK) PPE Training
Bloodborne Lockout/Tagout Recordkeeping
Confined Space Machine Guarding Safety & Health Prog. Training
Ergonomics Mech. Power Press Training Self-Help Equipment Loan
Fall Protection Noise 10-Hour Construction Program
Assigned To: Date Assigned: Assigned By:
Date Approved: Approved By:
Consultation Contact Completed
Date Received: Initial Contact Date:
Send Follow-up Letter
Check appropriate box if customer service standard is not meet!
(responded to within 3 business days / scheduled training within 30 calendar days)
New RCA - consultant not available due to leave/illness
beyond 30 days at employer's request
First available date
MIOSHA/CET/HO-20 (Rev. 5-17-07)
Instructions for Completing and Sending Electronic RCA
For easy access, save the master RCA file to your desktop.
(You may want to right click the file icon on your desk top, drag it to the task bar, and create a short cut on the
When opening the RCA file, ALWAYS enable macros!
Step One - Create New RCA
Fill in blank master RCA form as completely as possible.
1 Fill in the electronic form as you take the request.
2 Use the tab key to move between cells.
3 After entering date, tab out of date cell and then use your mouse to check the box for either onsite or
4 After tabbing out of the cell for citation #, the curser will be in the cell to the right of the "Other" check box.
5 Use the mouse to check the desired boxes for "Source" and "Service(s) Requested".
6 If you check any boxes, you need to click in the cell to the right of the "Other" check box to continue.
Enter info or tab to remarks cell.
7 In order to send RCA via e-mail, you need to tab out of the last cell with new entry prior to e-mailing form.
8 Save new RCA using company name and city. Example: RCA - Co Name - city
Step Two - E-Mail New RCA
Send all RCA e-mails as high priority
Support staff & e-mail the new RCA form to the office supervisor for assignment to appropriate consultant.
23(g) Field Staff: Note: When sending new RCA, the subject line of the e-mail shall read: RCA - Company
Name - City, Ex. RCA - ABC Co - Lansing
21(d) Field Staff: e-mail the new self-assigned RCA to your supervisor for approval.
Step Three - Assign and Approve New RCA
Office Supervisor: e-mail assigned RCA to appropriate supervisor for review and approval.
23(g) Supervisors: e-mail approved RCA to assigned staff. If not assigned by office supervisor, cc RCA to
e-mail approved RCA to assigned staff. Cc approved RCA to office supervisor and 21(d) secretary.
21(d) Supervisors: e-mail approved RCA to assigned staff. cc approved RCA to office supervisor and 21(d) secretary.
Step Four - Return Completed RCA
When consultation contact is made:
1 enter date received
2 enter initial contact date
3 enter action taken
4 If after several attempts you are unable to make contact with company, enter the dates you called the company
in the "Action" box and check the box next to "Send Follow-up Letter"
5 If customer service standards are not meet, check the appropriate box to indicate reason standard not meet.
6 consultant should save completed RCA for their records. File name should be the company name, city
and consultant last name. Ex. ABC Co - Lansing - Long
7 e-mail completed RCA form back to your supervisor.
Step Five - Review Completed RCA
review completed RCA assigned staff. cc approved RCA to office supervisor and 21(d) secretary.
21(d) Supervisors: e-mail approved RCA to and forward to 21(d) secretary
23(g) Supervisors: review completed RCA and forward to student assistant