Skip to content

Search for:

Natural Gas Safety
Electrical Safety
Natural Gas Safety Certification
Electrical Safety Certification
Free Safety Kit
Resources
Home

Natural Gas Safety
Electrical Safety
Natural Gas Safety Certification
Electrical Safety Certification
Free Safety Kit
Resources
Home

Materials Order FormJennifer Reece2024-04-09T13:47:42+00:00

Call 811 before you dig

In case of emergency, call 911 and {Utility Name} at {XXX-XXX-XXXX}.

Order Free Safety Materials

Would you like a USB Drive or DVD?*
- USB
- DVD
First Name*
Last Name*
Title*
Organization*
Address*
Check if this is a home address.
- This is a home address.
City*
State*
Zip Code*
Phone*
Email*
How many employees in your organization:
- 0-5
- 6-10
- 11-20
- 21-50
- 51+
- NA
What is the nature of your organization? (Check all that apply)
- Police
- Fire
- EMS
- Search/Rescue
- Sheriff
- Volunteer Fire
- Combined Fire/EMS
- Highway Patrol
- Other (please explain)
Other organization (please explain)
How will you use these safety materials? (check all that apply)
- Safety meeting/training
- New recruits
- Other (please explain)
Other uses (please explain)
What do you feel are the most important safety topics that need to be covered in training materials?
How much do you agree with each of the following statements?
{Utility Name} is committed to the safety of first responders like me.
Strongly agree Agree Neutral Disagree Strongly disagree
The information {Utility Name} provides is valuable for keeping first responders safe around electricity and natural gas.
Strongly agree Agree Neutral Disagree Strongly disagree
I expect {Utility Name} to provide first responders the information necessary to get our jobs done safely around {Utility Name} electric and natural gas infrastructure.
Strongly agree Agree Neutral Disagree Strongly disagree
The first responders at my organization use {Utility Name} safety information to work more safely around electricity and natural gas.
Strongly agree Agree Neutral Disagree Strongly disagree
The first responders materials provided by {Utility Name} help me and/or my coworkers perform our jobs more safely.
Strongly agree Agree Neutral Disagree Strongly disagree
Internal Use Only
ID
BRC Code
Date (mm/dd/yy)
Hidden
Project Category
- school
- contractor
- first responder
- other
Name
This field is for validation purposes and should be left unchanged.

Call 811 before you dig

In case of emergency, call 911 and {Utility Name} at {XXX-XXX-XXXX}.

Order Free Safety Materials

The 2023 program is now closed. Please check back in 2024 for the new program.

First Responder Emergency Number: {XXX-XXX-XXXX}

NOTE: This number is for Emergency Officials Only.

Privacy Terms of Use

Copyright © Culver Media, LLC. All rights reserved.