Board of Certified Safety Professionals
208 Burwash Avenue, Savoy, Illinois 61874
Certified Safety Professional®
•
Phone: 217-359-9263 Fax: 217-359-0055 PROFESSIONAL SAFETY
•
Email: bcsp@bcsp.org Web: www.bcsp.org
EXPERIENCE FORM
Type or print legibly. You must complete a Professional Safety Experience Form for each position for which you are seeking professional safety experience credit.
Positions must meet all five criteria listed in the CSP Application Guide to receive credit. Use a separate form for each position or time period, including
different positions for the same employer. Additional copies may be viewed and printed from www.bcsp.org/downloads.
APPLICANT
Applicant
Name
First MI Last/Family /Maiden Name (if applicable) Other Legal Name (if applicable)
Social Security Number
POSITION
Position Title Dates Employed in Position Total Months
(MM/YY) In Position
From / To /
Was the Primary Function of this Position Safety Practice (protecting people, property, and the Did Safety-Related Duties Comprise
environment from harm)? q Yes q No
at Least 900 hrs/yr
(75 hrs/mo or 18 hrs/wk)?
Was this Position? Number of Hours Portion of Job
per Week Duties Which
q Yes q No
q Full-Time q Part-Time on Average ___________hrs/wk Were Safety-Related _________%
EMPLOYER
Employer Employer’s Major
and Product or Service
Address
Name of
Supervisor
PROFESSIONAL SAFETY EXPERIENCE IN THIS POSITION - SUMMARY OF ACTIVITIES
Indicate the percentage of your time in this position devoted to each area listed below. The total for A - L must equal 100%.
A. % Hazard Identification D. % Hazard Control G. % Safety/Health J. % Environmental
Verification Communication Protection
B. % Hazard Evaluation E. % Safety/Health Program H. % Investigation and K. % Supervision of other
Design Statistical Reporting Safety, Health, and
Environmental
C. % Hazard Control Design F. % Safety/Health Program I. % Safety Training and Personnel
Evaluation Education
L. % Functions that are not
Safety, Health, or
Environmental
PROFESSIONAL SAFETY EXPERIENCE IN THIS POSITION (CONTINUED) - DETAILS FOR SELECTED JOB FUNCTIONS
Referring to the three areas in which you spend the most time, provide a detailed description of your work and then give one or more specific examples of work
activities or work products for each area. Do not provide a description for Area L (Functions that are not Safety, Health, or Environmental.)
Applicant Name: Position Title: Employer:
1. (Activity with Description of Activity
greatest time
from other side
of form.)
(Letter)
(% of time)
Example(s) of
Work Activity
or Work Product
2. (Activity Description of Activity
with second
highest time
from other side
of form.)
(Letter)
(% of time)
Example(s) of
Work Activity
or Work Product
3. (Activity Description of Activity
with third
highest time
from other side
of form.)
(Letter)
(% of time)
Example(s) of
Work Activity
or Work Product
12/08
