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DOL Logo U.S. DEPARTMENT OF LABOR
OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
FORM APPROVED
OMB NO. 1218-0262
Expiration: 10/31/2013

OUTREACH TRAINING PROGRAM REPORT
MARITIME
Read instructions before completing this form
Submit completed forms to:



1. Trainer Name

2. ID No.

3. Recent Trainer Course

4. Expiration Date
          /         /
5. Authorizing Training Organization
6. Trainer Address Check if this is a new address

Company

 
Address

 


 


City State Zip

Phone No.
(          ) Email  
7. Course Conducted
10-hour #7615-Shipyards
10-hour #7617-Marine Terminals
10-hour #7618-Longshoring
30-hour #7635-Shipyards
30-hour #7637-Marine Terminals
30-hour #7638-Longshoring
8. Course Information (check all that apply)
Spanish

Language other than English or Spanish (specify:
Youth (age 18 or less)

OSHA Alliance or Partnership (specify):
9. No. of Students
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 Date End Date Start Time End Time
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 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.

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
*Indicate the amount of time spent on each of the topics in the class.
REQUIRED
Hours *  
  Introduction to OSHA (#7615, #7617, #7618)
  Walking & Working Surfaces (#7615, #7617, #7618)
  Personal Protective Equipment (#7615, #7617, #7618)
  Fall Protection / Scaffolding (#7615)

Electrical (#7615)
  Confined and Enclosed Spaces (#7615)
  Fire Protection (#7615)
  Managing Safety and Health (#7635, #7637, #7638)
ELECTIVE
Hours *  
  Hazard Communications / Hazardous Materials
  Lockout / Tagout
  Respiratory Protection
  Fall Protection (#7617, #7618)
  Electrical (#7617, #7618)
  Confined and Enclosed Spaces (#7617, #7618)
  Fire Protection (#7617, #7618)
OPTIONAL
Hours *  
  Hot Work – Welding, Burning & Cutting
  Material Handling
  Bloodborne Pathogens
  Machine Guarding
  Ergonomics and Proper Lifting Techniques
OPTIONAL
Hours *  
   
   
   
   
   
   
   
   
  TOTAL
16. Student Names
Note: ensure that names are legible
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Instructions for Outreach Trainer

The 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
Indicate the number of students who completed the course. Note: If you held a class that contained more or less students than allowed by OSHA policy, include a copy of the prior approval received from your authorizing training organization.

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 start date, end date, start time, and end time of the course.

Item 13 Sponsoring Organization
Place an "x" in the box to indicate the sponsor of the training, if applicable. If you had a sponsor, but that type of organization is not a choice, check "Other" and specify the type of sponsoring group or 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 OSHA’s guidelines 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. You 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. Your course records must include sign-in sheets for each day and a copy of each completed card.

OSHA Form 4-50.3
March 2011


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.