OSHA Form 4-50.4 Outreach Trainig Program Report Disaster Site Worker

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

FORM APPROVED
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 No.

5.

Authorizing Training Organization

6.

Trainer Address

3. Recent Trainer Course

4. Expiration Date
/
/

Check if this is a new address

Company
Address

City

7.

Phone No.
(
Course Conducted
16-hour

State

ZIP

)
Email
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
11. Type of Training Site
Workplace
School

City
Office

Hotel

Union

State
Employer Association

Country
Other (specify):

12. Course Duration
Start Date
End Date
13. Sponsoring Organization
Safety & Health
Employer
Education
Community

Start Time
Labor/Union
N/A

End Time
Employer Association
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.
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 4-50.4 to this address.

OSHA Form 4-50.4
November 2010

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

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

OUTREACH TRAINING PROGRAM REPORT
DISASTER SITE WORKER
15. Training Certifications and Information
I certify that I taught all the required topics and met the Lesson
Objectives of the Disaster Site Worker Course #7600.
I certify that I conducted the training for a minimum of 16 hours.
I certify that I have maintained supporting documentation on the
respirator performance checklists and scores.
The range of scores that I recorded for the Operations Performance
Score in the respiratory protection performance test:

From

To

Trainer Signature
Date:

16. Student Names
(ensure that names are legible)
1.
2.
3.
4.
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Page 2
OSHA Form 4-50.4
November 2010

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

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

OUTREACH TRAINING PROGRAM REPORT
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. 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

Training Certifications and Information
Check each of the three boxes certifying that you
have accomplished each of these tasks. Also,
include the range of Operations Performance
Scores that you recorded for your students on
the respiratory protection performance test. Sign
to attest to the accuracy and truthfulness of this
information.

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.

Page 3
OSHA Form 4-50.4
November 2010