Form 1 Stand Down Form Screenshot

Join the

National Safety

Stand-Down
XXXX XX, 20XX

clome

Sha,e with Us

Events

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Certificate of Participation
Thank you For joining thousands of employers in the XXXX Fall Prevention Stand-Down. This certificate of participation is yours in recognition of the time and effort
you devoted lo
about prevenbng falls with yourc:rew. Of course. every day shOuld be fall preventlon day. so I chanenoe you to build on tl1e steps you took today I
hope YOl.l will keep tallai011 011'� �u wbmit mis rorrnatiofl. y;,11 ,,1J rr-91•• • c neat• 1e pruua.l:!s
Or oocumamv.111 Cll•�I•YJ v,ith your 13Us!nass namo prajen
optlonolqu,s�ons obout your SefetY Stand•OO',m • d91V1ng us I...SbKl< on our cam.Oll!gn• .,toa,11 r.o\e rt
cl!oose 10 doss> OS ,,,U not use lhs I
,i.on or ee,!!)acl< you provfda for any purpose cmerthen awluaung Iha S:111Nlardl o\yourv.,irkslte(s)
Items marked 'are required to print the ce,tificate.

1. Name of Business�:
2. Project Trtle:
3. Slate·
4, Typo or Industry·:

Select one_
Select one

5, Nurnber of Employees
who participated":
6. Number of years or
participation:

(Numbers only "•IIJ)

Sale:tions S('a1ch!llg existing data '$0Urces galhenl'lg and m,1111taining lhe
dala needed a,nd r.orr.pleung and re,.,iewmg the ,:o!le:tion of information OSHA 1\111 use lli1s 1nronn111Jor1 to evaluale the National Fall Pre-.;enl1on Salety Slafld..Down Perso11s are not re-Quired to respond to lhe collection of
infcrim.l1�n un;ess ;! d:si;!ay-s a current valid Ot,18 control number lfy:;iu hive wv comments about this eslirra!e or any olher liSP6cls cf ttiis dalil collea:1:on ,l'l{:uding s1.Jgge3t1011s for reducing this burden please send Lhem
lo QC:.j,l,l}:,78c.J.,"· M• or to US Departrr.en� or Labor OSHA D1reclorate of Slanda1ds and 13wda11ce M-½� 200 Cl)l1slllut,onA'��nue NV,', Nasn1'lglon DC 20210
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