Form No. 4-50.1 - Outreach Training Program Report - Construction - U.s. Department Of Labor Page 3
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2
3U.S. D
L
F
N
. 4-50.1
EPARTMENT OF
ABOR
ORM
O
O
S
H
A
O
N
. 1218-0262
CCUPATIONAL
AFETY AND
EALTH
DMINISTRATION
MB
O
Expiration: 1/31/2017
O
T
P
R
UTREACH
RAINING
ROGRAM
EPORT
Instructions for Outreach Training Program Trainer
The Occupational Safety and Health Administration (OSHA) Outreach Training Program is a voluntary orientation training
program aimed at workers. It provides workers with information about OSHA and an overview of job hazards. Trainers
authorized through the OSHA Outreach Training Program must conduct Outreach Training Program classes in accordance with
the current Outreach Training Program Requirements and Procedures issued by the Directorate of Training and Education
(DTE). The Outreach Training Program Requirements and Procedures can be found online at the OSHA.gov Web site under
Training, OSHA Outreach Training Program.
Item 1
Trainer Name
Item 9
Number of Students
List the trainer’s full name. When completing
Indicate the number of students who completed
student course completion cards, print or type
the course. Note: If the trainer held a class that
the trainer’s name on each card. Names must be
contained more or fewer students than allowed
legible.
by OSHA policy, include a copy of the prior
approval received from the trainer’s ATO.
Item 2
ID Number
This applies only to trainers who have already
Item 10
Training Site Address
received student cards. New trainers do not
Provide the address, city, state, and country
have an ID number. ID numbers are issued to
where the course was conducted.
trainers after their initial course is documented.
Item 11
Type of Training Site
If this is the trainer’s first class, or if the trainer
Place an “x” next to the type of site where the
has an updated trainer status, include a copy of
training was held. If none of the choices apply,
the trainer card.
specify the type of training site.
Item 3
Most Recent Trainer Course
Item 12
Course Duration
Indicate the most recent applicable course
Enter the date, start time, and end time of each
number you have completed.
day the course was conducted. Trainers must
Item 4
Expiration Date
attach a blank sheet of paper with the additional
Enter the trainer authorization expiration date as
course dates, start times, and end times if further
listed on the bottom right of the Authorized
space is needed.
Outreach Training Program Trainer card.
Item 13
Sponsoring Organization
Place an “x” in the box to indicate the sponsor of
Item 5
Authorizing Training Organization
The trainer’s Authorizing Training Organization
the training, if applicable. If the trainer had a
(ATO) is the OSHA Training Institute (OTI) or
sponsoring organization, but that category is not
the OTI Education Center that conducted the
listed, check “Other” and specify the type of
trainer’s most recent trainer or update course.
sponsoring organization.
List the name of the Authorizing Training
Item 14
Statement of Certification
Organization.
The authorized trainer must sign the statement
of certification to verify that the class was
Item 6
Trainer Address
Provide an address where to send the cards. The
conducted in accordance with the OSHA
cards must be sent directly to the trainer.
Outreach Training Program Requirements and
Procedures and attest to the accuracy of the
Item 7
Course Conducted
documentation submitted. If requesting cards
Place an “x” in the appropriate box. A separate
electronically, the trainer must place an “x” in
report must be completed for each course
the box or affix a signature.
completed.
Item 15
Topic Outline
Item 8
Course Emphasis (check all that apply)
Complete the applicable 10- or 30-hour topic
Place an “x” next to all the information that
outline. The trainer must complete this part of
applies to the majority of this course. If the
the form.
course included a special emphasis such as
Cal/OSHA, ET&D, etc., place an “x” next to
Item 16
Student Names
“Other” and denote the specific area of emphasis
List the first and last name of each student who
on the line below “Other.”
completed the entire course. Ensure the names
are legible. The course records must include
sign-in sheets for each day, student contact
information, topic outline, a copy of the
distributed student course completion cards, and
a list of guest trainers if applicable.
Page 3
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