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

Fill Online, Printable, Fillable, Blank O SHA Training Institute (OTI) Education Centers Program (OSHA Training Institute Education Center) Form

Use Fill to complete blank online OSHA TRAINING INSTITUTE EDUCATION CENTER pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 12 minutes to complete

The O SHA Training Institute (OTI) Education Centers Program (OSHA Training Institute Education Center) form is 2 pages long and contains:

  • 2 signatures
  • 26 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your OSHA Training Institute Education Center forms online.

BROWSE OSHA TRAINING INSTITUTE EDUCATION CENTER FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
O
SHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for General Industry
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 General Industry 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 #511
OSHA #521
OSHA #7200
OSHA #7500
OSHA #2255
OSHA #7205
OSHA #7505
OSHA #3095
OSHA #7210
OSHA #7300 or 2264
OSHA #7845
OSHA #7000
7
.
S
tatement 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:
click to sign
signature
click to edit
OSHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for General Industry
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.
click to sign
signature
click to edit
OSHA Training Institute (OTI) Education Centers Program
Public Sector Safety & Health Fundamentals for General Industry
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 #511 Occupational Safety and
Health Standards for General 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 #3095 Electrical Standards (26
hours)
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)
OR
OSHA #7300 Understanding OSHA’s
Permit-Required Confined Space
Standard (7 hours)
o OSHA #7000 OSHA Training Guidelines
for Safety Patient Handling (7.5 hours)
o OSHA #7005 Public Warehousing and
Storage (7 hours)
o OSHA #2045 Machinery and Machine
Guarding (26 hours)
OR
OSHA #7100 Introduction to
Machinery and Machine Safety
Guarding (4 hours)
o OSHA #7105 Introduction to
Evacuation and Emergency Planning (4
hours)
o OSHA #7115 Lockout/Tagout
[Controlling Hazardous Energy to
Prevent Workplace Injury] (7.5 hours)
o OSHA #7200 Bloodborne Pathogens
Exposure Control for Healthcare
Facilities (7 hours)
o OSHA #7205 Health Hazard Awareness
(6 hours)
o OSHA #7210 Pandemic Influenza and
Workplace Preparedness (5.5 hours)
o OSHA #7845 Recordkeeping Rule Seminar
(4 hours)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document