US Dept of Labor

Occupational Safety & Health AdministrationWe Can Help

Join the

National Safety
Stand-Down

To Prevent Falls in Construction

May 4-15, 2015

 
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Certificate of Participation

Thank you for joining thousands of employers in the 2015 fall prevention Stand-Down. I want to give you this certificate of participation to recognize that you took time to talk about falls with your crew. Your work is not done yet though, I challenge you to build on the big step you took today. Keep talking to your workers and dedicating yourself to preventing falls at your worksites.
Sincerely,
Thomas E. Perez
Secretary of Labor

Secretary of Labor Thomas Perez speaking with construction workers


To print a certificate for your business's participation in the Stand-Down, please fill out the information below. Once you submit this information, you will receive a certificate with your business name (a printable PDF document will appear). We also hope that you will help us by answering a few optional questions about your Safety Stand-Down and giving us feedback on our campaign. Please note that you are not required to request a certificate and that if you choose to do so OSHA will not use the information or feedback you provide for any purpose other than evaluating the Stand-Down campaign and planning future outreach efforts. Also note that the certificate does not represent an assessment of compliance with OSHA standards at your worksite(s).

Items marked * are mandatory to print the certificate.

1. Name of Business*:

2. State*:

3. Type of Industry*:

4. Number of Workers who participated*: (Numbers only field)

5. Please tell us about your Stand-Down. What did you do? What materials did you use? How did it go? What do you expect to happen as a result of the Stand-Down? (Optional. Limit entry to 4000 characters.)

6. How can we improve future initiatives like this? What could have been better? (Optional. Limit entry to 4000 characters.)

OMB Control Number 1225-0088

Expiration date: 08/31/2017

PAPERWORK REDUCTION ACT
Public reporting burden for this voluntary collection of information is estimated to average 10 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. OSHA will use this information to evaluate the National Fall Prevention Safety Stand-Down. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.

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