Form 1 Certificate of Participation

3/28/22, 9:17 AM

National Safety Stand-Down - Prevent Falls in Construction - Certificate of Participation | Occupational Safety and Health Adminis…

Certificate of Participation
Thank you for joining thousands of employers in the 2022 Fall Prevention Stand-Down. This
certificate of participation is yours in recognition of the time and effort you devoted to talk about
preventing falls with your crew. Of course, every day should be fall prevention day, so I challenge
you to build on the steps you took today. I hope you will keep talking to your employees and
dedicating yourself to preventing falls at your worksites.
Sincerely,
Scott Ketcham, Director

Directorate of Construction
NOTICE: The Fall Prevention Stand-Down certificate will download as a PDF. It is recommended that you
complete this form on a desktop or laptop computer with a screen resolution set at a MINIMUM of 1280 x 768
and the browser is maximized on the screen.

To download a certificate for your business's participation in the Stand-Down, please fill out the information below.
Once you submit this information, you will receive a certificate (a printable PDF document will display) with your
business name, project title and level of participation (depending on the number of years of participation). We also
hope that you will help us by answering a few optional questions about your Safety Stand-Down and giving us
feedback on our campaign. Please note that you are not required to request a certificate and that if you choose to
do so OSHA will not use the information or feedback you provide for any purpose other than evaluating the StandDown campaign and planning future outreach efforts. Also note that the certificate does not represent an
assessment of compliance with OSHA standards at your worksite(s).
1. Name of Business: * Required

2. Project Title:

3. State: * Required
Select

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For International businesses, please select "NA".
4. Type of Industry: * Required
Select one...

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5. Number of Employees who participated: * Required
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https://www.osha.gov/form/stop-falls-stand-down-certificate

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3/28/22, 9:17 AM

National Safety Stand-Down - Prevent Falls in Construction - Certificate of Participation | Occupational Safety and Health Adminis…

6. Number of years of participation
Select one...

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7. Please tell us about your Stand-Down.
What did you do? What materials did you use? How did it go?
What do you expect to happen as a result of the Stand-Down?
(Optional. Limit entry to 1500 characters.)
Please Indicate if you give the Agency consent to use your
comments in our program assessment and
promotional activities.
Yes

No

8. How can we improve future initiatives like this?
What could have been better? (Optional. Limit entry to
1500 characters.
Please Indicate if you give the Agency consent to use your
comments in our program assessment and
promotional activities.
Yes

No

Generate Certificate

OMB Control Number 1218-0271
Expiration date: 6/30/2022
PAPERWORK REDUCTION ACT

Public reporting burden for this voluntary collection of information is estimated to average 10 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. OSHA will use this information to evaluate the National Fall Prevention Safety Stand-Down. Persons are not
required to respond to the collection of information unless it displays a current valid OMB control number. If you have any comments
about this estimate or any other aspects of this data collection, including suggestions for reducing this burden, please send them to
[email protected] or to US Department of Labor, OSHA Directorate of Standards and Guidance N-3609, 200 Constitution Avenue,
NW, Washington, DC 20210.

https://www.osha.gov/form/stop-falls-stand-down-certificate

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