OSHA Form 4-50.4 Outreach Training Program Report Disaster Site Worker

U .S. Department of Labor			Form No. 4-50.4
Occupational Safety and Health Administration			Omb No. 1218-0262
			Expiration: 5/31/2027
Outreach Training Program Report Disaster Site Worker

Submit completed forms to:

1. Trainer Name

2. Trainer ID Number

3. Most Recent Trainer Course

4. Expiration Date

5. Authorizing Training Organization

6. Trainer Address

Company

Address

City

State

ZIP

Phone No.

( )

Email

7. Course Conducted

8. Course Emphasis (check all that apply)

9. Number of

7.5-Hour

Spanish

Language other than English or Spanish (specify):

Students

15-Hour

Youth (age 18 or less)

10. Training Site Address

Street Address

City

State

Country

11. Type of Training Site

Workplace School Office Hotel Union Employer Association Other (specify):

_________________

12. Course Duration

Start Time:

End Time:

Start Time:

End Time:

Start Time:

End Time:

Start Time:

End Time:

Course Date:

Course Date:

Course Date:

Course Date:

13. Sponsoring Organization

Safety & Health

Employer

Labor/Union

Employer Association

Education

Community

N/A

Other (specify):

__________________________

14. Statement of Certification

I attest that I have conducted this Outreach Training Program class in accordance with the OSHA Outreach Training Program Requirements and Procedures. I have maintained the training records as stated in the Requirements and I will provide these records to the OSHA Office of Training and Education (OTE) (or its designee) upon request. I understand that I will be subject to immediate dismissal from the OSHA Outreach Training Program if information provided herein is not true and correct. I further understand that providing false information herein may subject me to civil and criminal penalties under Federal law, including 18 U.S.C. 1001 and section 17(g) of the Occupational Safety and Health Act, which provides criminal penalties for making false statements or representations in any document filed pursuant to that Act. I hereby attest that all provided is true and correct.

Trainer Signature:

Date:

If submitting this form by electronic means, by checking the box to the left or affixing signature, I attest that all information provided in this submission is true and accurate.

15. Topic Outline

7.5-Hour Topics *Indicate the amount of time spent on each topic in the class.
Required
Hours *
________	Characteristics of a Disaster
________	Hazard Awareness (Physical)
________	Hazard Awareness (Health)
________	Hazard Awareness (Traumatic Stress)
________	Tool/Equipment Safety
________	Risk Assessment
________	Incident Command System
________	Hierarchy of Controls
________	Personal Protective Equipment
________	Exercise/Workshop
________	TOTAL HOURS

15-Hour Topics *Indicate the amount of time spent on each topic in the class.
Required
Hours *
________	Characteristics of a Disaster
________	Hazard Awareness (Physical)
________	Hazard Awareness (Health)
________	Hazard Awareness (Traumatic Stress)
________	Tool/Equipment Safety
________	Risk Assessment
________	Incident Command System
________	Hierarchy of Controls
________	Personal Protective Equipment
________	Exercise/Workshop
________	TOTAL HOURS

16. Student Names
(Names must be legible)
1.		21.
2.		22.
3.		23.
4.		24.
5.		25.
6.		26.
7.		27.
8.		28.
9.		29.
10.		30.
11.		31.
12.		32.
13.		33.
14.		34.
15.		35.
16.		36.
17.		37.
18.		38.
19.		39.
20.		40.

Instructions for Outreach Training Program Trainer

The Occupational Safety and Health Administration (OSHA) Outreach Training Program is a voluntary orientation training program aimed at workers. It provides workers with information about OSHA and an overview of job hazards. Trainers authorized through the OSHA Outreach Training Program must conduct Outreach Training Program classes in accordance with the current Outreach Training Program Requirements and Industry-Specific Procedures issued by the Office of Training and Education (OTE). The Outreach Training Program Requirements and Industry-Specific Procedures can be found online at the OSHA.gov website under Training, OSHA Outreach Training Program.

Item 1	Trainer Name
	List the trainer’s full name. When completing student course completion cards, print or type the trainer’s name on each card. Names must be legible.
Item 2	ID Number
	This applies only to trainers who have already received student cards. New trainers do not have an ID number. ID numbers are issued to trainers after their initial course is documented. If this is the trainers first class, or if the trainer has an updated trainer status, include a cop of the trainer card.
Item 3	Most Recent Trainer Course
	Indicate the most recent applicable course number you have completed.
Item 4	Expiration Date
	Enter the trainer authorization expiration date listed on the bottom right OSHA-authorized trainer card.
Item 5	Authorizing Training Organization (ATO)
	The trainer’s ATO is the OTI Education Center that conducted the trainer’s most recent trainer or update course.
Item 6	Trainer Address
	Provide an address of where to send the student cards. The cards must be sent directly to the trainer.
Item 7	Course Conducted
	Place an “x” in the appropriate box. A separate report must be completed for each course completed.
Item 8	Course Emphasis (check all that apply)
	Place an “x” net to all the information that applies to the majority of this course. If the course included special-emphasis such as (CalOSHA, ET&D, etc) place an “x” next to Other and denote the specific type on the line below.
Item 9	Number of Students
	Indicate the number of students who completed the course.
Item 10	Training Site Address
	Provide the address, city, state, and country where the course was conducted.
Item 11	Type of Training Site
	Place an “x” next to the type of site where the training was held. If none of the choices apply, specify the type of training site.
Item 12	Course Duration
	Enter the date, start time, and end time of each day the course was held. Trainers
Item 13	Sponsoring Organization
	Place an “x” in the box to indicate the sponsor of the training. If the category is not listed check other and specify.
Item 14	Statement of Certification
	The trainer must sign the Statement of Certification to attest to the accuracy of the document and that the class was conducted in accordance with OSHA Outreach Training Program Requirements and Procedures. If requesting cards electronically, the trainer must place an “x” in the box or affix a signature.
Item 15	Topic Outline
	Complete the applicable 10- or 30-hour topic outline. The trainer must complete this part of the form.
Item 16	Student Names
	List the first and last name of each student that completed the entire course. Ensure the names are legible and spelled correctly.

Privacy Act Statement: The Privacy Act of 1974 as amended (5 U.S.C. 552a), section 901 of Title 30 to the US Code and 20 CFR 725.504 - 513 authorize collection of this information. The purpose of this information is to determine whether the trainer is authorized and whether the training was properly completed.  Completion of the information on the form is required to obtain the OSHA student course completion cards.  Additional disclosures of this information are not required. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.

Paperwork Reduction Act Statement: Public reporting burden for this collection of information is estimated to average 15 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.  The obligation to respond to this collection is required to obtain OSHA student course completion cards as stated in OSHA’s Outreach Training Program Requirements and Industry-Specific Procedures. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Occupational Safety and Health Administration, Directorate of Standards and Guidance, 200 Constitution Avenue, NW, Room N3718, Washington, DC 20210 and reference the OMB Control Number 1218-0262. Note: Please do not return the completed OSHA Form 4-50.1 to this address.