Use this form to have us contact your supervisor

We will then share with your supervisor your concerns about bodily injury prevention at your Company and let them know about Impacto protection solutions.

Choose "Yes" in answer to "Do we have permission to use your name?" if you would like us to use your name. If you wish us to keep your name confidential, choose "No".

To enable us to serve you better, please provide as much information as possible about your safety or injury concerns.

Your Supervisor

Name

First                                                 Last

Supervisor's Position

Supervisor's Phone

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

Fax

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

Supervisor's Ext:

EMail

Your Company

Company Name

Street

Town/City

State/Province

Zip/Postal Code

Country


Your Contact Information (optional)

Name

First                                                 Last

Position

Your work telephone

Fax

EMail

Do we have permission to use your name?

Yes No

 

Your protection needs

Type of work that you do

Do you currently wear protective gloves?

Yes No

Manufacturer?

 

Other protective covering you currently use in your job

 

What is the best time to contact your supervisor?

 

Describe your symptoms