OSHA Form 4-50.5 R On-Line Outreach Training Program Report

U .S. Department of Labor			Form No. 4-50.5
Occupational Safety and Health Administration			Omb No. 1218-0262
Outreach Training Program Report Online Outreach Training			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 Emphasis (check all that apply)

8. Number of Students

Spanish

Language other than English or Spanish (specify):

Youth (age 18 or less)

     

Other (specify):

OSHA Alliance or Partnership (specify):

     

9. Course Conducted

10-Hour Construction 30-Hour Construction

10-Hour General Industry 30-Hour General Industry

10. Course Duration

Course Reporting Date:

Course End Reporting Date

11. 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.

12. Student Name		13. Date Training Complete	14. Number of attempts to pass Final Test	15. Final Test Score Percentage	16. Time Spent Online
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17. Topic Outline Construction
CONSTRUCTION
10-Hour Topics		30-Hour Topics
*Indicate the amount of time spent on each topic in the class.		*Indicate the amount of time spent on each topic in the class.
Required		Required
Hours*		Hours*
______	Introduction to OSHA	______	Introduction to OSHA
______	OSHA Focus Four Hazards – note the total time spent on the line to the left, and indicate the time breakdown on each line below:	______	OSHA Focus Four Hazards – note the total time spent on the line to the left, and indicate the time breakdown on each line below:
______ Falls		______ Falls
______ Electrocution		______ Electrocution
______ Struck By		______ Struck By
______ Caught-in or Between		______ Caught-in or Between
______	Personal Protective and Lifesaving Equipment	______	Personal Protective and Lifesaving Equipment
______	Health Hazards in Construction	______	Health Hazards in Construction
Elective		______	Managing Safety and Health
______	Total hours on elective topics	______	Stairways and Ladders
Optional		Elective
______	Total hours on optional topics	______	Total hours on elective topics
______	TOTAL HOURS	Optional
		______	Total hours on optional topics
		______	TOTAL HOURS
18. Topic Outline General Industry
GENERAL INDUSTRY
10-Hour Topics		30-Hour Topics
*Indicate the amount of time spent on each topic in the class.		*Indicate the amount of time spent on each topic in the class.
Required		Required
Hours*		Hours*
______	Introduction to OSHA	______	Introduction to OSHA
______	Walking and Working Surfaces	______	Walking and Working Surfaces
______	Electrical	______	Electrical
______	Personal Protective Equipment	______	Personal Protective Equipment
______	Hazard Communication	______	Hazard Communication
______	Exit Routes, Emergency Action Plans, Fire Preventative Plans, and Fire Protection	______	Exit Routes, Emergency Action Plans, Fire Preventative Plans, and Fire Protection
Elective		______	Materials Handling
______	Total hours on elective topics	______	Managing Safety and Health
Optional		Elective
______	Total hours on optional topics	______	Total hours on elective topics
______	TOTAL HOURS	Optional
		______	Total hours on optional topics
		______	TOTAL HOURS

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 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, Road, etc., place an “x” next to “Other” and denote the specific area of emphasis on the line below “Other.”

Item 8 Number of Students

Indicate the number of students who completed the course.

Item 9 Course Conducted

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

Item 10 Course Duration

Enter the reporting period start date and end date for the course.

Item 11 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 12 Student Names

List the first and last name of each student who completed the entire course. Ensure the names are legible.

Item 13 Date Training Completed

List the date the student completed the course.

Item 14 Number of attempts to pass Final Test

Indicate the number of attempts the student required to pass the final test for the course.

Item 15 Final Test Score Percentage

Indicate the student’s final test score percentage.

Item 16 Time Spent Online

Indicate the total time the student spent online to complete the course.

Item 17 Topic Outline, Construction

Complete the applicable 10- or 30-hour topic outline. The trainer must complete this part of the form. Indicate the specific amount of time, in hours, the students spent on each of the required topics, the overall amount of time the students spent on elective topics, the overall amount of time the students spent on optional topics, and the combined total amount of time the students spent on program topics.

Item 18 Topic Outline, General Industry

Complete the applicable 10- or 30-hour topic outline. The trainer must complete this part of the form. Indicate the specific amount of time, in hours, the students spent on each of the required topics, the overall amount of time the students spent on elective topics, the overall amount of time the students spent on optional topics, and the combined total amount of time the students spent on program topics.

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 4-50.5 to this address.