Statement of Compliance with Outreach Training Program Requirements

Statement of Compliance

Statement of Compliance with Outreach Training Program Requirements

I certify that I will conduct all Outreach Training Program training classes in accordance with the OSHA Outreach Training Program Requirements and Industry-Specific Procedures, including displaying the highest professional, ethical, and fiduciary behavior. I understand that it is my responsibility to ensure that I meet the requirements of the most recent edition of the OSHA Outreach Training Program Requirements and related procedures. I will maintain the training records as required by the Program requirements and procedures 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 Outreach Training Program if I provide information that is not true, complete and correct. I further understand that providing false information may subject me to civil and criminal penalties under Federal law, including 18 U.S.C. Sec. 1001 and 29 U.S.C. 666 (g), which provide criminal penalties for making any false statement, representation or certification.

Trainer Signature		Date
Trainer’s Typed or Printed Name		Authorized Trainer Expiration Date
Name of Course		Course Dates
(To be completed by OTI Education Center)
Name of OTI Education Center
(To be completed by OTI Education Center)

The prospective OSHA-authorized Outreach Trainer is responsible for listing all additional or concurrent Authorizing Training Organizations (ATOs) through which the Outreach Trainer is currently authorized to deliver OSHA Outreach Training Program Classes:

ATO Name	OSHA Outreach Trainer or Trainer Update Course (e.g., #500, #502, etc.)	Expiration date of Authorization

Revised 2/2017