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O SHA Training Institute (OTI) Education Centers Program (OSHA Training Institute Education Center)

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O
SHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for Construction
Application for Certificate Program
Read instructions before completing this form.
Page 1 of 3
05.20.2019
Submit completed forms to:
Chabot-Las Positas Community College District – OSHA Training Institute Education Center
Email: otc@clpccd.org
Fax: (925) 460-0133
Questions: (866) 936-6742
It is the responsibility of the applicant to ensure all required and elective courses have been completed prior
to submitting this application. An application processing fee of $95 is due at the time of application. Please
submit copies of this completed and signed Application for Certificate Program and all necessary
documentation that verifies successful completion for each course to the authorized OTI Education Center
listed above.
Requirements to complete the certificate program:
Participants must complete a minimum of seven (7) courses, comprised of required and elective
courses that include a minimum of 68 contact hours of training through the OTI Education Centers
Program to complete the Public Sector Safety & Health Fundamentals for Construction certificate
program.
Participants must have completed the three (3) required courses listed below in Item #6 for a
minimum of 39 contact hours of training.
Participants must have completed a minimum of four (4) elective courses that include a
minimum of 29 contact hours of training from the list below in Item #6.
Applicant Information – Please type or print
1. Applicant Name: 2. Title:
3. Company: 4. E-Mail:
5.
Applicant Address
Company:
Address:
City: State: ZIP:
Phone: Fax:
6.
I have completed the following course(s) (Please attach a copy of your course completion certificate for each applicable course):
Required Courses
Elective Courses
OSHA #510
OSHA #521
OSHA #7205
OSHA #7500
OSHA #2255
OSHA #7400
OSHA #7505
OSHA #2264
OSHA #7845
OSHA #3095
7. Statement of Certification
The information I have included herein and submitted to the OTI Education Center (or its designee) is true and accurate.
Applicant Signature:
Date:
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OSHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for Construction
Application for Certificate Program
Read instructions before completing this form.
Page 2 of 3
05.20.2019
THIS PAGE IS USED FOR INTERNAL PURPOSES ONLY
OFFICE USE ONLY
Check One:
Approving Authority Signature
Approved Not Approved Date
1. Approving Authority Name: 2. Title:
3. OTI Education Center: 4. E-Mail:
5. Approving Authority Address
Address:
City: State: ZIP:
Phone: ( ) Fax: ( )
If not approved, please indicate reason:
Applicant did not complete the required courses Applicant did not complete four of the elective courses
Applicant did not submit documentation of completion for all
courses
Applicant did not complete a minimum of 29 contact hours
of elective courses
Applicant did not sign form Applicant did not complete the minimum 68 contact hours
Application processing fee was not paid Other (please explain):
Process for review and approval:
The OTI Education Center will review this form for accuracy and ensure that appropriate supporting
documentation is attached.
If this form is not approved, the OTI Education Center will notify the applicant in writing with the reason.
If the form is approved, the OTI Education Center will send the completed form and all supporting
documentation to the Directorate of Training and Education (DTE) at the following address:
Director
Office of Training Program and Administration
OSHA Directorate of Training and Education
2020 S. Arlington Heights Road
Arlington Heights, IL 60005-4102
Upon receipt, DTE will process the program certificate, to include the applicant’s name and issue date, and will
mail the program certificate to the OTI Education Center. DTE will contact the OTI Education Center with any
questions or concerns.
The authorized OTI Education Center is responsible for issuing the program certificate to the student.
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signature
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OSHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for Construction
Application for Certificate Program
Read instructions before completing this form.
Page 3 of 3
05.20.2019
Instructions for Applicants
It is the responsibility of the applicant to ensure all required and elective courses have been completed prior to
submitting this application for the Public Sector Safety &Health Fundamentals for Construction certificate program. Submit
copies of this completed and signed application and all required documentation of successful course completion for all
courses to Chabot-Las Positas Community College District – OSHA Training Institute Education Center along with a check or
money order made out to CLPCCD – OTI Education Center, or credit card for $95 (if paying by credit card, please contact our
office at 866-936-6742). Required documentation is either a course completion certificate or official transcript from the
OTI Education Center where the course was completed.
Item 1 Applicant Name
List full legal name.
Item 2 Title
List current job title. If currently not working,
leave this field blank.
Item 3 Company
List current employer. If currently not
working, leave this field blank.
Item 4 E-Mail
List a current email where you may be
contacted.
Item 5 Applicant Address
Provide a current address, phone, and fax
number where you may be contacted.
Item 6 Completed Course(s)
Check the box which corresponds to the
applicable OSHA course(s) completed.
OSHA Course Prerequisites
Must have complete the three (3) required
courses:
o OSHA #510 Occupational Safety and
Health Standards for the Construction
Industry
o OSHA #7500 Introduction to Safety and
Health Management
o OSHA #7505 Introduction to Accident
[Incident] Investigation
Must have complete a minimum of four (4)
of the following elective courses that
include a minimum of 29 contact hours of
training:
o OSHA #521 OSHA Guide to Industrial
Hygiene (26 hours)
o OSHA #2255 Principles of Ergonomics (18
hours)
o OSHA #2264 Permit-Required Confined
Space Entry (20 hours)
o OSHA #3015 Excavation, Trenching, and
Soil Mechanics (20 hours)
OR
OSHA #7410 Managing Excavation
Hazards (6.5 hours)
o OSHA #3095 Electrical Standards (26
hours)
o OSHA #3115 Fall Protection (18 hours)
OR
OSHA #7405 Fall Hazard Awareness
for the Construction Industry (5 hours)
o OSHA #7105 Introduction to
Evacuation and Emergency Planning (4
hours)
o OSHA #7110 Introduction to Bolting
Safety (7 hours)
o OSHA #7205 Health Hazard Awareness
(6 hours)
o OSHA #7400 Noise in the Construction
Industry (5.5 hours)
o OSHA #7845 Recordkeeping Rule Seminar
(4 hours)
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Completed 17 July 2021

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