Fillable Certified Safety & Health Official Certificate Request Form (OSHA Training Institute Education Center)

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Certified Safety & Health Official Certificate Request Form (OSHA Training Institute Education Center)

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Certified Safety & Health Official Certificate Request Form – General Industry
• Requires 10 OSHA courses - A minimum of 7 courses must have been taken with Chabot-Las
Positas Community College District – OSHA Training Institute Education Center.
• Only OSHA numbered courses taken at an OSHA Training Institute Education Center will be accepted.
• Copies of certificates must be provided with request; please do not submit until all courses are complete.
• Applicant is responsible for tracking their completion progress and submitting this application form when
all requirements have been met.
• All courses applied towards certificates must have been taken within the previous 5 years.
Name: Date Requested:
Street Address:
City: State: Zip:
Phone Number: Email:
Required Courses:
Elective Courses (choose 3):
OSHA 510: OSHA Standards for Construction
OSHA 5119: Cal/OSHA Standards for General Industry
OSHA 521: OSHA Guide to Industrial Hygiene
OSHA 5410: OSHA Standards for Maritime
OSHA 2225: Respiratory Protection
OSHA 6005: Collateral Duty Course for other Fed. Agencies
OSHA 2255: Principles of Ergonomics
40-Hour HAZWOPER (OTC 204)
OSHA 3115: Fall Protection
Safety Inspection Techniques (OTC 308)
A
dditional Electives – Short Courses
(3 short courses count as one (1) elective [maximum allowed is 6]):
O
SHA4you.com (866)
936
-OSHA (6742) otc@clpccd.org
OSHA 511: OSHA Standards for General Industry
OSHA 501: Trainer Course in OSHA for General Industry OR OSHA 503: Update for General Industry Trainers
OSHA 2015: Hazardous Materials
OSHA 2045: Machinery & Machine Guarding Standards
OSHA 2264: Permit-Required Confined Space Entry
OSHA 3095: Electrical Standards
OSHA 7505: Introduction to Incident (Accident) Investigation
OSHA 7100: Intro to Machinery & Machine Guarding
OSHA 7210: Pandemic Illness Preparedness
OSHA 7105: Intro to Evac. & Emergency Planning
OSHA 7215: Silica in Construction, Maritime, & General Industry
OSHA 7120: Intro to Combustible Dust Hazards
OSHA 7300: U. OSHA’s Permit-Required Confined Space Std.
OSHA 7115: Lockout/Tagout
OSHA 7400: Noise Hazards in Construction
OSHA 7200: Bloodborne Pathogen Exposure Control
OSHA 7500: Intro to Safety & Health Management
OSHA 7205: Health Hazard Awareness
OSHA 7845: Recordkeeping Rule Seminar
Payment Information:
Payment information must be included to complete the registration process. Certificate fee is $99.00.
Enclosed is a check payable to Chabot-Las Positas Community College District – OSHA Training
Institute Education Center
Please charge the credit card provided below (you may also call our office at (866) 936-6742 to make
credit card payment)
C
redit Card Number Name on Credit Card Exp. Date
Billing Address City State Zip Code
S
ignature of Credit Card Holder Date Card Type
(Visa/M
asterCard/AMEX accepted)
Completed registration forms and payment can be submitted by:
Email: otc@clpccd.org
Fax: (925) 460-0133
Mail: 5860 Owens Dr, 3
rd
Floor, Pleasanton, CA 94588
OSHA4you.com (866) 936-OSHA (6742) otc@clpccd.org
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Certified Safety & Health Official Certificate Request Form (OSHA Training Institute Education Center)

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Completed 17 July 2021

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