U.S. DEPARTMENT OF LABOR
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
OMB NO. 1218-0262
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|
|7. Course Conducted||8. Course Emphasis (check all that apply)||9. Number of Students|
|10. Training Site Address|
|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.
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.
15. Topic Outline
*Indicate the amount of time spent on each topic in the class.
|Incident Command System/Unified Command System|
|Traumatic Incident Stress Awareness|
|Other Personal Protective Equipment|
16. Student Names Names must be legible.
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.
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