Fillable Appendix A Statement of Compliance Statement of Compliance (OSHA Training Institute Education Center)

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Appendix A Statement of Compliance Statement of Compliance (OSHA Training Institute Education Center)

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Appendix A – Statement of Compliance
Statement of Compliance with OSHA Outreach Training Program Requirements
I certify that I will conduct all OSHA Outreach Training Program training classes in accordance
with OSHA Outreach Training Program requirements. 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 industry-specific Procedures. I will maintain the training
records as required by the 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 OSHA 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
Type or Print Legal Name (middle name not requir
ed) Authorized Trainer Expiration Date
Name of Course & Course Dates (To be completed by OTI Education Center)
Chabot-Las Positas Community College District - OTIEC
Name of OTI Education Center (To be completed by OTI Education Center)
The OSHA authorized Outreach trainer is responsible for listing all additional or concurrent
Authorizing Training Organizations (ATOs) through which the Outreach Trainer is authorized
to deliver OSHA Outreach Training Program Classes. You need to complete this section only if
you are authorized through a different ATO for an additional industry.
Failure or refusal to list concurrent authorizations may result in corrective action, up to and
including revocation of authorized trainer status, or immediate dismissal from the OSHA
Outreach Training Program:
Authorizing Training
Organization (ATO) Name
OSHA Outreach Trainer or
Trainer Update Course Name
Expiration date of
Authorization
Please mail my certificate and trainer card to:
Street:
City, State, Zip:
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signature
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OSHA Outreach Training Program Searchable Trainer List
OSHA has published a list of OSHA-authorized trainers who conduct 10- and 30-hour
Outreach Training classes in construction, general industry, maritime, or disaster site
work. The Department of Labor/Occupational Safety and Health Administration lists
only those trainers who request that their contact information be public. This list
serves as a resource that allows members of the general public to find Outreach
trainers in their area. The list includes the trainer’s name, city, state, email address and
phone number
Would you like to be added to this list? Yes No
Desired listed phone number:
Desired listed email address:
If applicable, please indicate any language(s) other than English you are fluent in:
If applicable, please indicate your website:
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Appendix A Statement of Compliance Statement of Compliance (OSHA Training Institute Education Center)

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Completed 17 July 2021

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