Form OSHA Online Outreach Training Program Report

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

FORM APPROVED
OMB NO. ####-####
[Form Expiration Date]

Attachment I

OUTREACH TRAINING PROGRAM REPORT
ONLINE OUTREACH TRAINING PROGRAM REPORT

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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.



Trainer: __________________________________
Online Group Affiliation: _____________________________________
ID Number: __________
Total Students: __________
End Date: ____________


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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 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. 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 XXXX to this address.

26+$)RUP4-50.5
January 10