Submit completed forms to:
      
1.     Trainer  Name
2.  ID  Number 
3.  Most Recent Trainer Course
4.  Expiration Date 
	          
                                          
                                         
                             /      /         
5.  	Authorizing Training Organization
		          
6.  	Trainer Address  	

		Company

          

		Address

          


          



City   

          

State

          

ZIP

          

		Phone No.

(                    )              

Email  

          

7.  Course Emphasis (check all that apply)
8.   Number of Students
                                       
	  Spanish
  Language other than English or Spanish (specify):
                                       
	  Youth (age 18 or less)

          
                                       
  Other (specify):
  OSHA Alliance or Partnership (specify):
    
          


9.  Course Conducted 
    
  10-Hour Construction

  30-Hour Construction 

  10-Hour General Industry
  
  30-Hour General Industry

10.  Course Duration

Course Reporting Date:

Course End Reporting Date
11.  Statement of Certification

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, 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.


                                       
                                       
                                       
                                       
                               12. Student Name
                                       
                          13. Date Training Complete
                                       
                   14. Number of attempts to pass Final Test
                                       
                        15. Final Test Score Percentage
                                       
                             16. Time Spent Online
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                        17. Topic Outline Construction
                                 CONSTRUCTION
                                10-Hour Topics
                                30-Hour Topics
        *Indicate the amount of time spent on each topic in the class.
        *Indicate the amount of time spent on each topic in the class.
                                   Required
                                   Required
                                    Hours*
                                       
                                    Hours*
                                       
                                    ______
Introduction to OSHA
                                    ______
Introduction to OSHA
                                       
                                       
                                    ______
OSHA Focus Four Hazards  -  note the total time spent on the line to the left, and indicate the time breakdown on each line below:
                                       
                                       
                                    ______
OSHA Focus Four Hazards  -  note the total time spent on the line to the left, and indicate the time breakdown on each line below:
                         ______ Falls
                         ______ Falls
                         ______ Electrocution
                         ______ Electrocution
                         ______ Struck By
                         ______ Struck By
                         ______ Caught-in or Between
                         ______ Caught-in or Between
                                    ______
Personal Protective and Lifesaving Equipment 
                                    ______
Personal Protective and Lifesaving Equipment
                                    ______
Health Hazards in Construction
                                    ______
Health Hazards in Construction
                                   Elective
                                    ______
Managing Safety and Health
                                    ______
Total hours on elective topics
                                    ______
Stairways and Ladders
                                   Optional
                                   Elective
                                    ______
Total hours on optional topics
                                    ______
Total hours on elective topics
                                       
                                       
                                    ______


TOTAL HOURS
                                   Optional
                                       
                                       
                                    ______
Total hours on optional topics
                                       
                                       
                                    ______
TOTAL HOURS
                      18. Topic Outline General Industry
                               GENERAL INDUSTRY
                                10-Hour Topics
                                30-Hour Topics
        *Indicate the amount of time spent on each topic in the class.
        *Indicate the amount of time spent on each topic in the class.
                                   Required
                                   Required
                                    Hours*
                                       
                                    Hours*
                                       
                                    ______
Introduction to OSHA
                                    ______
Introduction to OSHA
                                    ______
Walking and Working Surfaces
                                    ______
Walking and Working Surfaces
                                    ______
Electrical
                                    ______
Electrical
                                    ______
Personal Protective Equipment
                                    ______
Personal Protective Equipment
                                    ______
Hazard Communication
                                    ______
Hazard Communication
                                       
                                    ______
Exit Routes, Emergency Action Plans, Fire Preventative Plans, and Fire Protection
                                       
                                    ______
Exit Routes, Emergency Action Plans, Fire Preventative Plans, and Fire Protection
                                   Elective
                                    ______
Materials Handling
                                    ______
Total hours on elective topics
                                    ______
Managing Safety and Health
                                   Optional
                                   Elective
                                    ______
Total hours on optional topics
                                    ______
Total hours on elective topics
                                       
                                       
                                    ______


TOTAL HOURS
                                   Optional
                                       

                                    ______
Total hours on optional topics
                                       

                                    ______
TOTAL HOURS
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
              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 Industry-Specific Procedures issued by the Directorate of Training and Education (DTE).  The Outreach Training Program Requirements and Industry-Specific Procedures can be found online at the OSHA.gov Web site under Training, OSHA Outreach Training Program.


Item 1	Trainer Name 
	List the trainer's full name.  When completing student course completion cards; print or type the trainer's name on each card.  Names must be legible.


Item 2	ID Number
	This applies only to trainers who have already received student cards.  New trainers do not have an ID number.  ID numbers are issued to trainers after their initial course is documented.  If this is the trainer's first class, or if the trainer has an updated trainer status, include a copy of the trainer card.


Item 3	Most Recent Trainer Course
	Indicate the most recent applicable course number you have completed.


Item 4	Expiration Date
	Enter the trainer authorization expiration date as listed on the bottom right of the Authorized Outreach Training Program Trainer card.


Item 5	Authorizing Training Organization 
	The trainer's Authorizing Training Organization (ATO) is the OSHA Training Institute (OTI) or the OTI Education Center that conducted the trainer's most recent trainer or update course.  List the name of the Authorizing Training Organization.  


Item 6	Trainer Address
	Provide an address where to send the cards.  The cards must be sent directly to the trainer.  


Item 7	Course Emphasis (check all that apply)
 	Place an "x" next to all the information that applies to the majority of this course.  If the course included a special emphasis such as Cal/OSHA, Road, etc., place an "x" next to "Other" and denote the specific area of emphasis on the line below "Other."
 
	
Item 8	Number of Students
	Indicate the number of students who completed the course.

Item 9	Course Conducted
	Place an "x" in the appropriate box.  A separate report must be completed for each course completed.
Item 10  	Course Duration
	Enter the reporting period start date and end date for the course.

  Item 11	Statement of Certification
	The authorized trainer must sign the statement of certification to verify that the class was conducted in accordance with the OSHA Outreach Training Program Requirements and Procedures and attest to the accuracy of the documentation submitted. If requesting cards electronically, the trainer must place an "x" in the box or affix a signature.  

  Item 12	Student Names
	List the first and last name of each student who completed the entire course.  Ensure the names are legible. 

  Item 13	Date Training Completed
	List the date the student completed the course.

  Item 14	Number of attempts to pass Final Test
	Indicate the number of attempts the student required to pass the final test for the course.
	
  Item 15	Final Test Score Percentage 
	Indicate the student's final test score percentage. 

  Item 16	Time Spent Online
	Indicate the total time the student spent online to complete the course. 

  Item 17	Topic Outline, Construction
	Complete the applicable 10- or 30-hour topic outline.  The trainer must complete this part of the form.  Indicate the specific amount of time, in hours, the students spent on each of the required topics, the overall amount of time the students spent on elective topics, the overall amount of time the students spent on optional topics, and the combined total amount of time the students spent on program topics.

  Item 18    Topic Outline, General Industry
	Complete the applicable 10- or 30-hour topic outline.  The trainer must complete this part of the form.  Indicate the specific amount of time, in hours, the students spent on each of the required topics, the overall amount of time the students spent on elective topics, the overall amount of time the students spent on optional topics, and the combined total amount of time the students spent on program topics.


