Occupational Safety and Health Administration National Fall Prevention Safety Stand Customer Feedback

Certificate of Participation
Thank you for joining thousands of employers in the 2017 Fall Prevention Stand-Down. This certificate of
participation is yours in recognition of the time and effort you devoted to talk about preventing falls with your
crew. Of course, every day should be fall prevention day, so I challenge you to build on the steps you took
today. I hope you will keep talking to your employees and dedicating yourself to preventing falls at your
worksites.
Sincerely,
Dean McKenzie, Director
Directorate of Construction

To download 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 (a printable PDF document will appear) with your business name, project title and level of participation (depending on the number of years of participation).
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).

Items marked * are mandatory to print the certificate.
1. Name of Business*:
1. Project Title:

Optional

2. State*:

Select One

3.

Type of Industry*:

Select One

4. Number of Employees who participated*:
5.

Number of years of participation: Select One

[Commercial Construction, Residential Construction, Highway, Other Construction, Non-Construction, Government]

(Numbers only field)
[1, 2, 3, 4]

6. 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. Limit entry to 4000 characters.)
Limit entry to 4000 characters.

7. How can we improve future initiatives like this? What could have been better? (Optional. Limit entry to 4000 characters.)
Limit entry to 4000 characters.

OMB Control Number 1225-0088
Expiration date: 08/31/2017
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, please send them to [email protected] or to US Department of
Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue, NW, Washington, DC 20210.