OSHA-Participation in National Fall Prevention Safety Stand Down and VETS-Off Base Transition Training Participant Customer Feedback

Certificate of Participation

Thank you for participating in the 2014 construction fall prevention Stand-Down. I would like to present your business
with a certificate recognizing your commitment to workplace safety through your participation in this event. Raising
awareness of fall hazards and how to prevent them is an important step in protecting workers. Please build on this
step. Keep looking for fall hazards and take preventive measures to save lives.
Sincerely,
Thomas E. Perez
Secretary of Labor

To print a certificate for your business’s participation in the Stand-Down, please fill out the information below. Once
you submit this information, you will receive a certificate with your business name (a printable PDF document will
appear). We also hope that you will help us by answering a few optional questions about your Safety Stand-Down and
giving us feedback on our campaign. Please note that you are not required to request a certificate and that if you
choose to do so OSHA will not use the information or feedback you provide for any purpose other than evaluating the
Stand Down campaign and planning future outreach efforts. Also note that the certificate does not represent an
assessment of compliance with OSHA standards at your worksite(s).

*
1. Name of Business :

Text box

*
2. State :

drop down List

*
3. Primary Type of Construction :

drop down list [Commercial/Residential/Industrial/Roadway/Other]

*
4. Number of Workers who participated :

Number text box

5. Please tell us about your Stand-Down. What did you do? What materials did you use? How did it go?
What do you expect to happen as a result of the Stand Down? (optional)
[large text box]

6. How can we improve future initiatives like this? What worked? What could have been better? (optional)
[medium text box]



Items 1 to 4 marked * are mandatory to print the certificate.

Print Certificate
If the respondent clicks the “print certificate” button but missed any mandatory questions, the system
will display a message and sends them back to the skipped question.
OMB Control Number 1225-0088 Expiration date: 07/15/2014
PAPERWORK REDUCTION ACT
Public reporting burden for this voluntary 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. OSHA will use this information to evaluate the National Fall Prevention Safety Stand-Down. Persons
are not required to respond to the collection of information unless it displays a current valid OMB control number. If you have any
comments about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, contact: US
Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.

The United States Department of Labor
Occupational Safety and Health Administration
recognizes the employees and managers of

Business Name, State
for participating in the OSHA
2014 National Safety Stand-Down to Prevent Falls in Construction
June 2014

_________________
Thomas E. Perez
Secretary of Labor