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HONOLULU COMMUNITY COLLEGE

REQUEST FOR OESM 193V EXEMPTION

An Occupational and Environmental Safety Management (OESM) major whose employment

during the past twelve months includes at least 50% occupational/environmental health and

safety functions may seek exemption from the OESM 193V requirement. The request form

below must be completed and submitted to the Cooperative Education Coordinator at least one

semester prior to the expected graduation date.

I. STUDENT INFORMATION

Name: ______________________________ Student ID: ______________________________

Phone number: _______________________ E-mail address: ___________________________

Date started OESM major: _________________

Date expected to graduate: _________________

II. EMPLOYMENT INFORMATION

Employer’s name and address: ___________________________________________________

____________________________________________________________________________

Supervisor’s name and position title: ______________________________________________

____________________________________________________________________________

Supervisor’s phone number: ____________________________________________________

E-mail address: _____________________________________________________

Date started: _________________________________________________________________

Your position title: ____________________________________________________________

Position description: __________________________________________________________

____________________________________________________________________________

III. JOB FUNCTIONS

Check all that apply to your current health and safety responsibilities. For each job function,

provide details of the work you have performed. Attach, if necessary, additional information.

Development of written occupational/environmental health and safety plans

List plans you developed and explain your role in the development of these plans.

______________________________________________________________________

Hazard identification and evaluation

_______________________________________________________________________

______________________________________________________________________

_______________________________________________________________________

Hazard control

_______________________________________________________________________

________________________________________________________________________

III. JOB FUNCTIONS (continued)

OSHA/EPA/DOT Regulatory application

______________________________________________________________________

Accident investigation

______________________________________________________________________

Communication and training

______________________________________________________________________

Other: _________________________________________________________________

______________________________________________________________________

IV. DOCUMENTATION

Attach a copy of your resume.

V. CERTIFICATIONS

I certify that, to the best of my knowledge and belief, all of the information on and attached to

this Request for OESM Exemption is true, correct, complete and made in good faith. I

understand that false and fraudulent information on or attached to this request form may be

grounds for denial of my request. I understand that any information I give may be

investigated. I consent to the release of information about my current employment by

employers and other individuals and organizations to Cooperative Education Coordinator and

OESM Program Liaison of Honolulu Community College. I understand that I am required to

enroll in OESM 193V and will receive a credit (CR) grade upon approval of my request.

Student’s Signature: _______________________________________ Date ______________

As the supervisor of _______________________________________, I certify

that, for the past

twelve months, at least 50% of his/her current responsibilities include occupational/

environmental health and safety functions and that the information above regarding his/her

health and safety functions is accurate.

Supervisor’s Signature: ___________________________________ Date _______________

COOPERATIVE EDUCATION OFFICE

Approved

Disapproved

Reason(s) _______________________________________________________________

_______________________________________________________________________

_________________________________________________ _____________________

Signature, Cooperative Education Coordinator Date

__________________________________________________ _____________________

Signature, OESM Program Liaison Date

Spring 2007 Revision

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HONOLULU COMMUNITY COLLEGE REQUEST FOR OESM 193V EXEMPTION (Honolulu Community College)

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