1 Optional Trainee Data Form

OPTIONAL TRAINEE DATA FORM OMB Approval No. 1218-0100

U.S. DEPARTMENT OF LABOR Expiration Date: xx/xx/2026

Occupational Safety and Health Administration

Training Title

Training Date

Last Name/Surname

First Name, Middle Initial

Age (Select One)

Under 18 18 – 24 25 – 34 35 – 44

45 – 54 55 – 64 65 + Decline to Answer

Gender (Mark All That Apply) The gender markers used are “M” (male), “F” (female), and “X” (transgender, non-binary, or another gender).

M F X Decline to Answer

1. Ethnicity: Are you Hispanic or Latin/a/o?

Yes No Decline to Answer

2. Race: Select one or more that apply to you

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Decline to Answer

Course Evaluation Please complete the following statements about the course.	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
1. Training materials were easy to understand.
2. I would recommend this Training to others.
3. The instructor was knowledgeable on the subject.
4. The instructor involved participants in activities and discussions.
5. The instructor presented information in a clear, understandable manner.

To Be Completed By GRANTEE ONLY

Grantee Identification #

Privacy Act Statement

Ethnicity and race information is requested under the authority of 42 U.S.C. Section 2000e-16 and in compliance with the Office of Management and Budget’s 1997 Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Providing the information is voluntary and has no impact on your employment and training status, but in the instance of missing information, your training agency will attempt to identify your race by visual observation.

This information is used as necessary to plan for federal agencies in their separate or combined format for civil rights and other compliance reporting from the public and private sectors and all levels of government, and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies.

PAPERWORK REDUCTION ACT NOTICE

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. This information is being collected so that OSHA can monitor grantee progress in meeting grant workplans, to evaluate the overall effectiveness of the grant program, and, when applicable, to be used as one factor in determining continued funding of the grant. The grant program provides training for employers and employees in the recognition, avoidance, and prevention of unsafe and unhealthful working conditions in accordance with Section 21(c) of the Occupational Safety and Health Act. This collection of information is required to obtain or retain a benefit (29 CFR 95.51 (b) and (d)). This collection of information is not confidential. We estimate it will take an average of 5 minutes to complete this information collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Administrative Programs, Office of Training and Education, 2020 S. Arlington Heights Road, Suite 100, Arlington Heights, IL 60005, and/or to the Department of Labor, Office of IRM Policy, Room N-1301, 100 Constitution Avenue, NW, Washington, DC 20210.