OSHA Form 4-50.12 OTIEC Out-of-Region Training Report

Course Number / Title

Education Center Name

Training Location City

Training Location State

(Foreign) Country

Name and Address of Contract Company

Training Location Address

Start Date

Start Time

End Date

End Time

Total Students (projected)

Contact Hours

Course Chairperson

Instructional Staff

Submitted By: (OTIEC POC)

Date Submitted

Comments

see burden box below

Paperwork Reduction Act Statement

OMB Control Number: 1218-0262 Expiration Date: 07/31/2017

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 0.50 hours per response, including time for reviewing instructions, searching for existing data sources, gathering and maintaining the data need, and completing and reviewing the collection of information. The obligation to respond to this collection is required for OTI Education centers to maintain OSHA's approval. The information is used to track performance measures and targets. OSHA provides no assurance of confidentiality on data collected on the Course Summary Report. 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 to this address.

OSHA Form 4-50.12 (July 2017)