OSHA Form 4-50.4 R Outreach Training Program Report Disaster Site Worker

U .S. Department of Labor			Form No. 4-50.4
Occupational Safety and Health Administration			Omb No. 1218-0262
Outreach Training Program Report Disaster Site Worker			Expiration: 07/31/2017
Read instructions before completing this form.

Submit completed forms to:

1. Trainer Name

2. ID Number

3. Most Recent Trainer Course

4. Expiration Date

     

     

    

   /    /     

5. Authorizing Training Organization

     

6. Trainer Address

Company

     

Address

     

     

City

     

State

     

ZIP

     

Phone No.

(     )      

Email

     

7. Course Conducted

8. Course Emphasis (check all that apply)

9. Number of

7.5 hour

Spanish

Language other than English or Spanish (specify):

Students

15-hour

Youth (age 18 or less)

     

Other (specify):

OSHA Alliance or Partnership (specify):

  

     

     

10. Training Site Address

Street Address

     

City

     

State

  

Country

     

11. Type of Training Site

Workplace School Office Hotel Union Employer Association Other (specify):

     

12. Course Duration

Start Time:      

End Time:      

Start Time:      

End Time:      

Start Time:      

End Time:      

Start Time:      

End Time:      

Course Date:      

Course Date:      

Course Date:      

Course Date:      

13. Sponsoring Organization

Safety & Health

Employer

Labor/Union

Employer Association

Education

Community

N/A

Other (specify):

     

14. Statement of Certification

I certify that I have conducted this Outreach Training Program class in accordance with the OSHA Outreach Training Program Requirements and Procedures. I have maintained the training records as stated in the Requirements and I will provide these records to the OSHA Directorate of Training and Education (or its 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, 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.

15. Topic Outline
*Indicate the amount of time spent on each topic in the class.
Required
Hours *
	  			Introduction/Overview
	  			Incident Command System/Unified Command System
	  			Safety Hazards
	  			Health Hazards
	  			CBRNE Agents
	  			Traumatic Incident Stress Awareness
	  			Respiratory Protection
	  			Other Personal Protective Equipment
	  			Decontamination
	  			Final Exercise
	     			TOTAL HOURS

16. Student Names
(Names must be legible)
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Instructions for Outreach Training Program Trainer

The Occupational Safety and Health Administration (OSHA) Outreach Training Program is a voluntary orientation training program aimed at workers. It provides workers with information about OSHA and an overview of job hazards. Trainers authorized through the OSHA Outreach Training Program must conduct Outreach Training Program classes in accordance with the current Outreach Training Program Requirements and Industry-Specific Procedures issued by the Directorate of Training and Education (DTE). The Outreach Training Program Requirements and Industry-Specific Procedures can be found online at the OSHA.gov Web site under Training, OSHA Outreach Training Program.

Item 1 Trainer Name

List the trainer’s full name. When completing student course completion cards, print or type the trainer’s name on each card. Names must be legible.

Item 2 ID Number

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 the trainer’s first class, or if the trainer has an updated trainer status, include a copy of the trainer card.

Item 3 Most Recent Trainer Course

Indicate the most recent applicable course number you have completed.

Item 4 Expiration Date

Enter the trainer authorization expiration date as listed on the bottom right of the Authorized Outreach Training Program Trainer card.

Item 5 Authorizing Training Organization

The trainer’s Authorizing Training Organization (ATO) is the OSHA Training Institute (OTI) or the OTI Education Center that conducted the trainer’s most recent trainer or update course. List the name of the Authorizing Training Organization.

Item 6 Trainer Address

Provide an address where to send the cards. The cards must be sent directly to the trainer.

Item 7 Course Conducted

Place an “x” in the appropriate box. A separate report must be completed for each course completed.

Item 8 Course Emphasis (check all that apply)

Place an “x” next to all the information that applies to the majority of this course. If the course included a special emphasis such as Cal/OSHA, ET&D, etc., place an “x” next to “Other” and denote the specific area of emphasis on the line below “Other.”

Item 9 Number of Students

Indicate the number of students who completed the course. Note: If the trainer held a class that contained more or fewer students than allowed by OSHA policy, include a copy of the prior approval received from the trainer’s ATO.

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 date, start time, and end time of each day the course was conducted. Trainers must attach supplemental sheets with the additional course dates, start times, and end times if further space is needed.

Item 13 Sponsoring Organization

Place an “x” in the box to indicate the sponsor of the training, if applicable. If the trainer had a sponsoring organization, but that category is not listed, check “Other” and specify the type of sponsoring 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 the OSHA Outreach Training Program Requirements and Procedures 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 Topic Outline

Complete the topic outline. The trainer must complete this part of the form.

Item 16 Student Names

List the first and last name of each student who completed the entire course. Ensure the names are legible. The course records must include sign-in sheets for each day, student contact information, topic outline, a copy of the distributed student course completion cards, and a list of guest trainers if applicable.

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 Requirements and Industry-Specific Procedures. 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.