Board of Certified Safety Professionals Certified Safety Professional®
208 Burwash Avenue
Savoy, Illinois 61874
Phone: 217-359-9263 • Fax: 217-359-0055 REFERENCE FORM
Email: bcsp@bcsp.org • Web: www.bcsp.org
Please type or print legibly. Please complete both pages of this form. Return the form to the applicant or send directly to BCSP. Additional copies of this form 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)
The applicant is seeking the CERTIFIED SAFETY PROFESSIONAL (CSP) certification. Applicants must meet academic and experience requirements and pass
examinations. Your evaluation of the applicant’s qualifications provides very important information for BCSP in determining if the applicant is eligible for examinations
and ultimately the CSP credential. While the Board intends to hold your comments confidential, that cannot be guaranteed.
REFERENCE PERSON
Current Designations Held (Check all that apply.)
Reference Name qCSP qCIH qPE (specify state)_____________
qCEng (UK) qCHP qCMIOSH qCPMSIA/FSIA/CFSIA
Phone (Area Code ) (Number) qCOHN/SM qCOHN-S/SM qCRSP
Your Title qSISO (Ordinary Member)
or Position Identification Number
Company
Address Email
City State/Province Zip Code/Postal Code Country
Signature Date
BASIS FOR YOUR COMMENTS
Period during which you have personal FROM (MM/YY) TO (MM/YY) Are you a relative of this applicant?
knowledge of applicant’s professional safety q No
capabilities q Yes - Explain:
Nature of Your Relationship with Applicant: Briefly describe:
q Supervisor q Past Supervisor q Co-worker q Employee
q Professor q Friend q Other
FOR PROFESSORS OF STUDENT APPLICANTS
Do you consider the student applicant Is the student applicant in the last semester or The student is expected to graduate (MM/YY)
prepared for the safety profession? quarter of a safety degree program?
q Yes q No q Yes q No /
Comments
DEFINITIONS
CERTIFIED SAFETY PROFESSIONAL PROFESSIONAL SAFETY EXPERIENCE
An individual who utilizes the expertise derived from a • For a position to be accepted as qualifying with BCSP as professional safety experience, professional
knowledge of the various sciences and professional experience, to safety work must be the primary function and account for at least 50% of the position’s responsibilities.
create or develop procedures, processes, standards specifications, • Positions in which safety is an inherent responsibility but not the primary function are not considered by
and systems to achieve optimal control or reduction of the hazards BCSP as professional safety experience.
and exposures which are detrimental to people and/or property and • Professional safety experience differs from non-professional safety experience in the degree of responsible
the environment by the utilization of analysis, synthesis, investigation, charge and ability to defend analytical approaches and engineering or administrative control
evaluation, research, planning, design, and consultation and who recommendations.
has met all of the requirements for certification established by the • The safety professional must be able to demonstrate to the satisfaction of his peers, employer, and clients the
Board of Certified Safety Professionals. ability to use analysis, synthesis, design, investigation, planning, and communication to optimally control or
reduce the risk of exposures that would be detrimental to people, property, and the environment.
Applicant’s Name Reference’s Name
VALIDATION OF APPLICANT’S EXPERIENCE
(Refer to definitions on the reverse side of this form. This section does not apply to student applicants.)
Applicant’s Position Title What were the average What is/was the applicant’s primary function in this position?
hours per week the applicant
worked in this position?
Does the applicant have professional level responsibility in safety, What percent of the position duties are in safety, industrial
industrial hygiene, environmental, and/or fire protection? hygiene, environmental, and/or fire protection?
q Yes q No q I do not have the knowledge to evaluate.
Briefly describe this position and the applicant’s responsibilities in the position.
Does/did the applicant have other work activities (beside professional safety, industrial hygiene, fire protection, and/or environmental control)
assigned to his/her job? q No q Yes (If yes, please describe.)
To your knowledge, does the applicant have any significant technical deficiencies? q No q Yes (If yes, please describe.)
To your knowledge, does the applicant have any deficiencies in professional ethics? q No q Yes (If yes, please describe.)
If you have additional comments about the applicant, please note them below.
12/08 References: Don’t forget to sign and date this form on reverse.
