Division of Labor and Industry
Maryland Occupational Safety and Health (MOSH)
Instructions for Completing the MOSH Speaker Request Form - Maryland Occupational Safety and Health (MOSH)

Instructions for Completing the MOSH Speaker Request Form

 
Summary:

MOSH speakers are provided for professional and trade associations, employer and employee organizations, and other groups, and generally are not available for individual employers.   A minimum of 20 participants is required.
The presentations provide an overview of the topic requested and are not a substitute for training required by MOSH standards.
To request that a MOSH representative be our guest speaker or participate in our event, complete the online form.  Please be sure to enter a response in each field of form.  An example of the format to use for most fields is included immediately after the field.  Below you will find instructions that may assist you when completing the form.

All the fields on this form, excluding the Extension, are REQUIRED fields.  Each field must be completed in order to submit your seminar registration request.

 
Personal Information:
 
First Name (required field)
- Enter the contact person's first name.
 
Last Name (required field)
- Enter the contact person's last name.
 
Address (required field)
- Enter the contact person's mailing address.
 
City (required field)
- Enter the city of the contact person's mailing address.
 
State (required field)
- The form will default to Maryland as the state for the contact person's mailing address.  If the contact person is located in a state other than Maryland, click on the arrow to the right of the word, Maryland, and a drop down menu will appear. Click on the state of the contact person's mailing address.
 
Zip Code (required field)
- Enter the five-digit or nine-digit zip code of the contact person's mailing address.
 
Telephone (required field)
- Enter the telephone number where the contact person can be reached during the day, including area code.  Enter the phone number with dashes, like this 410-555-1212. Please do not use parentheses.
 
Extension (optional field)
- Enter the extension number for the contact person's telephone number, if applicable.
 
Fax (required field)
- Enter the fax number of the contact person. Please include the area code. Enter the phone number with dashes, like this 410-555-1212.¬†Please do not use parentheses.  If you do not have a fax number, please enter 444-444-4444 in this field.
 
E-mail (required field)
- Enter the contact person's e-mail address.
 
How did you hear about this? (required field)
- Click on the arrow to the right of the words, Select an item, and a drop down menu will appear. Click on the method by which you learned about this MOSH service.
 
Please describe (required field certain selections are made in the prior field)
- If you selected a certain response in the prior field, this field will appear.  Please type in the source from which you obtained the information.  For example, if you learned about the service from the Baltimore Sunpaper, and you selected Newspaper for the prior field, please type in Baltimore Sun in this field.
 
Organizational Information:
 

Organization Name (required field)

- Enter the name of the contact person's organization/company.
 
Employer Type (required field)
- Click on the arrow to the right of the sentence and a drop down menu will appear. Click on the term that most closely applies to the type of industry of the contact person's organization/company.
 

Employer Primary Business (required field) - 

- Click on the arrow to the right of the sentence and a drop down menu will appear. Click on the term that most closely applies to the primary business of the contact person's organization/company.

 

Number of Maryland Employees Less Than 250? (required field)

- Click on the arrow to the right of the sentence and a drop down menu will appear. Click on either Yes or No on the drop down menu, indicating whether the contact person's organization/company has less than 250 employees in Maryland.

 

Number of National Employees Less Than 500? (required field)

- Click on the arrow to the right of the sentence and a drop down menu will appear. Click on either Yes or No on the drop down menu, indicating whether the contact person's organization/company has less than 500 employees in the entire United States.
 
Event Details:
 
Location (required field)
- Enter the location where the event is to take place.
 
Event Date (required field)
- Click on the calendar icon to the right of the field.  A calendar will open.  Click on the appropriate date.  If the event is scheduled in a future month, click on the arrow symbol on the upper right corner of the calendar to page through to the correct month.
 
Start Time (required field)
- Click on the arrow key to the right of Select An Item.  A drop down menu will appear.  Click on the start time of your event.
 
End Time (required field)
- Click on the arrow key to the right of Select An Item.  A drop down menu will appear.  Click on the end time of your event.
 
Proposed Topic (required field)
- Enter the proposed topic of the MOSH presentation.
 
Number of Attendees (required field)
- The form will default to 15 as the number of persons who will attend the event.  There is a minimum requirement of 15 attendees.  Remove the number 15 and enter the number of persons who will attend the event if the number is more than 15 attendees.
 
Audience Type (required field)
- Enter a description of the type of audience that will attend the event, for example, the type of industry for which the attendees work.
 
Event Purpose (required field)
- Enter the purpose of the event.
 
Special Requirements (required field)
- Enter any special requirements.  If there are no special requirements, please enter N/A or none.
 
Click on Request Speaker and an e-mail message containing all the information that you entered will be sent to MOSH.  Someone will get back to you as soon as possible to schedule the speaker.

 

 
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Please direct any questions about Maryland Occupational Safety and Health (MOSH) to mosh@dllr.state.md.us.
Please direct any questions about the Division of Labor and Industry to dli@dllr.state.md.us.
Questions or comments regarding the DLLR website may be directed to webmaster@dllr.state.md.us.

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