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U.S. D

. 4-50.1

EPARTMENT OF

ABOR

ORM

. 1218-0262

CCUPATIONAL

AFETY AND

EALTH

DMINISTRATION

Expiration: 1/31/17

UTREACH

RAINING

ROGRAM

EPORT

ONSTRUCTION

Submit completed forms to:

Trainer Name

2. ID Number

3. Most Recent Trainer Course

4. Expiration Date

Authorizing Training Organization

Trainer Address

Company

Address

City

State

ZIP

Phone No.

(

)

Course Conducted

8. Course Emphasis (check all that apply)

9. Number of

10-Hour

Spanish

Language other than English or Spanish (specify):

Students

30-Hour

Youth (age 18 or less)

Other (specify):

OSHA Alliance or Partnership (specify):

10. Training Site Address

Street Address

City

State

Country

11. Type of Training Site

Workplace

School

Office

Hotel

Union

Employer Association

Other (specify):

12. Course Duration

Start

End

Start

End

Start

End

Time:

End

Time:

Course Date:

13. Sponsoring Organization

Safety & Health

Employer

Labor/Union

Employer Association

Education

Community

N/A

Other (specify):

Statement of Certification

14.

I certify that I have conducted this Outreach Training Program class in accordance with the OSHA Outreach Training Program

Requirements and Procedures. I have maintained the training records as stated in the Requirements and I will provide these records to the

OSHA Directorate of Training and Education (or its designee) upon request. I understand that I will be subject to immediate dismissal

from the OSHA Outreach Training Program if information provided herein is not true and correct. I further understand that providing

false information herein may subject me to civil and criminal penalties under Federal law, including 18 U.S.C. 1001 and section 17(g) of the

Occupational Safety and Health Act, 29 U.S.C.666(g), which provides criminal penalties for making false statements or representations in

any document filed pursuant to that Act. I hereby attest that all provided is true and correct.

Trainer Signature:

Date:

If submitting this form by electronic means, by checking the box to the left or affixing signature, I attest that all information provided in

this submission is true and accurate.

Privacy Act Statement and Paperwork Reduction Act Statement

The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 30 to the US Code and 20 CFR 725.504 - 513 authorize collection of this information. The purpose of this information is to

determine whether the trainer is authorized and whether the training was properly completed. Completion of this form is not mandatory, however, this information is required to obtain OSHA

student course completion cards. Additional disclosures of this information are not required.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting

burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain OSHA student course completion cards as stated in

OSHA’s Outreach Training Program Requirements and Procedures. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for

reducing this burden, to the U.S. Department of Labor, Occupational Safety and Health Administration, Directorate of Standards and Guidance, 200 Constitution Avenue, NW, Room N3718,

Washington, DC 20210 and reference the OMB Control Number. Note: Please do not return the completed OSHA Form 4-50.1 to this address.