Form OSHA-182 Student Data Form

FORM APPROVED OMB NO. 1218-0172
Expiration Date: XX-XX-2026

Registration
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1.Legal First Name*:

Legal First Name*
2.Legal Middle Name:

Legal Middle Name
3.Legal Last Name*:

Legal Last Name*
4.Select Job Specialization*:

Select Job Specialization*
5.Work Email*:

Work Email*
6.Confirm Work Email*:

Confirm Work Email*
7.Work Phone Number*:

Work Phone Number*
8.Cell Phone:

Cell Phone

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9.Are you a State Plan OSHA or Consultation Employee*?

Yes
10.Select Affiliation (Org Name)*:

Select Affiliation (Org Name)*...
11.Work Street Address 1*:

Work Street Address 1*
12.Work Street Address 2:

Work Street Address 2
13.Work City*:

Work City*
14.Select Work State*:

Select Work State*
15.Work Zip*:

Work Zip*
16.Supervisor Work Email*:

Supervisor Work Email*
17.Confirm Supervisor Work Email*:

Confirm Supervisor Work Email*

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18.Password*:

Password*
19.Confirm password*:

Confirm password*

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Already Have an Account? (/PublicWelcome.aspx)
Public reporting burden for this collection of information is voluntary and is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the 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 Office of Training Institute, OSHA Office of Training and Education, 2020 S. Arlington
Heights Road, Arlington Heights, Illinois 60005-4102. Persons are not required to respond to the collection of
information unless it displays a current valid OMB control number.

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