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14. Statement of Certification
I certify that I have conducted this outreach training class in accordance with the OSHA Outreach Training Program guidelines. I have maintained the training records as required by these guidelines and I will provide these records to the OSHA Directorate of Training and Education (or their 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.
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.
Instructions for Outreach TrainerThe Outreach Training Program is the Occupational Safety and Health Administration's (OSHA) voluntary orientation training program aimed at workers. It provides workers with information about OSHA and provides an overview of job hazards. Trainers authorized through the OSHA Outreach Training Program must conduct outreach training classes in accordance with the current Outreach Training Program Guidelines issued by the Directorate of Training and Education (DTE). The Outreach
Training Program Guidelines can be found online at the OSHA.gov website under Training, OSHA Outreach Training Program.
Item 1 Trainer Name
List your full name. When completing student course completion cards, print or type your name on each card to ensure it is legible.
Item 2 ID No.
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 your first class, or if you have updated your trainer status, include a copy of your trainer card.
Item 3 Recent Trainer Course
Indicate the most recent applicable course number you have completed.
Item 4 Expiration Date
Enter your trainer expiration date as listed on the bottom right of your Authorized Outreach Trainer card.
Item 5 Authorizing Training Organization
List the name of the OSHA Training Institute (OTI) Education Center responsible for your last trainer or update course, or indicate if your training was completed at the OSHA Training Institute.
Item 6 Trainer Address
Provide an address where to send the cards. The address you provide should ensure that the cards are sent directly to you. If you have an ID number and there are no address changes, you are not required to fill in this section.
Item 7 Course Conducted
Place an "x" in the appropriate box. A separate report must be completed for each course completed.
Item 8 Course Information (check all that apply)
Place an "x" next to all the information that applies to the majority of this course.
Item 9 No. of Students
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 guidelines. 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 4-50.1 to this address.