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U.S. DEPARTMENT OF LABOR
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

FORM NO.5-50.2
OMB NO. 1218-0262
Expiration: 10/31/2013

OUTREACH TRAINING PROGRAM REPORT
DISASTER SITE WORKER

Read instructions before completing this form.

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 Conducted 8. Course Emphasis (check all that apply) 9. Number of Students




 
10. Training Site Address
Street Address City State Country
11. Type of Training Site
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




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, 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:


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 4-50.4 to this address.

OUTREACH TRAINING PROGRAM REPORT
DISASTER SITE WORKER

15. Topic Outline

*Indicate the amount of time spent on each topic in the class.

REQUIRED

Hours *  
  Introduction/Overview
  Incident Command System/Unified Command System
  Safety Hazards
  Health Hazards
  CBRNE Agents
  Traumatic Incident Stress Awareness
  Respiratory Protection
  Other Personal Protective Equipment
  Decontamination
  Final Exercise

16. Student Names Names must be legible.

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OUTREACH TRAINING PROGRAM REPORT

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
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 a blank sheet of paper 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.

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