Submit completed forms to:
      
1.   	Trainer  Name
2.  Trainer  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 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 
Time:            
End 
Time:            
Start 
Time:            
End 
Time:            
Start 
Time:            
End 
Time:            
Start 
Time:            
End 
Time:            
Course Date:            
Course Date:           
Course Date:            
Course Date:            
13. 	Sponsoring Organization
		 Safety & Health                    
 Employer
 Labor/Union
 Employer Association 
		 Education
 Community
 N/A
 Other (specify):
          


14.  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.


15.  Topic Outline
                                10-Hour Topics
        *Indicate the amount of time spent on each topic in the class.
                                   Required
                                    Hours *

                                       
                                         
                                       
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:
                                       
                                       
                                       

                                       
                                       
                                       
           Falls
                                       
                                       
                                       
           Electrocution
                                       
                                       
                                       
           Struck By 
                                       
                                       
                                       
           Caught-In or Between
                                       
                                         
                                       
Personal Protective Equipment
                                       
                                         
                                       
Health Hazards in Construction
                                   Elective 
                                       
                                         
                                       
Cranes, Derricks, Hoists, Elevators, and Conveyors
                                       
                                         
                                       
Excavations
                                       
                                         
                                       
Materials Handling, Storage, Use and Disposal
                                       
                                         
                                       
Scaffolds
                                       
                                         
                                       
Stairways and Ladders
                                       
                                         
                                       
Tools  -  Hand and Power
                                   Optional
                                       
                                         
                                       
          
                                       
                                         
                                       
          
                                       
                                         
                                       
          
                                       
                                         

TOTAL HOURS
                                       
                                30-Hour Topics
        *Indicate the amount of time spent on each topic in the class.
                                   Required
                                    Hours *

                                       
                                         
                                       
Introduction to OSHA
                                       
                                         
                                       
Managing Safety and Health
                                       
                                         
                                       
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
                                       
                                       
                                       
           Electrocution
                                       
                                       
                                       
           Struck By
                                       
                                       
                                       
           Caught-In or Between
                                       
                                         
                                       
Personal Protective Equipment
                                       
                                         
                                       
Health Hazards in Construction
                                       
                                         
                                       
Stairways and Ladders
                                   Elective 
                                       
                                         
                                       
Concrete and Masonry Construction
                                       
                                         
                                       
Confined Space Entry
                                       
                                         
                                       
Cranes, Derricks, Hoists, Elevators, and Conveyors
                                       
                                         
                                       
Ergonomics
                                       
                                         
                                       
Excavations
                                       
                                         
                                       
Fire Protection and Prevention
                                       
                                         
                                       
Materials Handling, Storage, Use and Disposal
                                       
                                         
                                       
Motor Vehicles, Mechanized Equipment and Marine Operations; Rollover Protective Structures and Overhead Protection; and Signs, Signals and Barricades
                                       
                                       
                                       

                                       
                                       
                                       

                                       
                                         
                                       
Powered Industrial Vehicles
                                       
                                         
                                       
Safety and Health Programs
                                       
                                         
                                       
Scaffolds
                                       
                                         
                                       
Steel Erection
                                       
                                         
                                       
Tools  -  Hand and Power
                                       
                                         
                                       
Welding and Cutting
                                       
                                         
                                       
Foundations for Safety Leadership
                                   Optional
                                       
                                         
                                       
          
                                       
                                         
                                       
          
                                       
                                         
                                       
          
                                       
                                         

TOTAL HOURS

16.  Student Names
                            Names must be legible.


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              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 Conducted 
	Place an "x" in the appropriate box.  A separate report must be completed for each course completed.
	
Item 8	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, ET&D, etc., place an "x" next to "Other" and denote the specific area of emphasis on the line below "Other."
Item 9	Number of Students
	Indicate the number of students who completed the course.  Note:  If the trainer held a class that contained more or fewer students than allowed by OSHA policy, include a copy of the prior approval received from the trainer's ATO.

Item 10	Training Site Address
	Provide the address, city, state, and country where the course was conducted.

Item 11	Type of Training Site
	Place an "x" next to the type of site where the training was held.  If none of the choices apply, specify the type of training site.

Item 12	Course Duration
	Enter the date, start time, and end time of each day the course was conducted.  Trainers must attach supplemental sheets with the additional course dates, start times, and end times if further space is needed.

Item 13	Sponsoring Organization
	Place an "x" in the box to indicate the sponsor of the training, if applicable.  If the trainer had a sponsoring organization, but that category is not listed, check "Other" and specify the type of sponsoring organization.
	
Item 14	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 15	Topic Outline
	Complete the applicable 10- or 30-hour topic outline.  The trainer must complete this part of the form.

Item 16	Student Names
	List the first and last name of each student who 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.


