Fillable Prereq Verif Form - Single_Prereq_form_OSHA_format_WL FINAL revs 4-16-2012

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Prereq Verif Form - Single_Prereq_form_OSHA_format_WL FINAL revs 4-16-2012

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OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 1 of 7
Submit completed forms to:
It is the responsibility of the applicant to ensure all course prerequisites have been met prior to enrolling in the course. Please submit copies of this
completed and signed form and all necessary documentation for prerequisite courses to the authorized OTI Education Center listed above PRIOR
TO ENROLLING IN THE COURSE. Registration is not permitted without approval.
OSHA Trainer Course Prerequisites
OSHA #500 Construction - OSHA #510 Occupational Safety and Health Standards for the Construction Industry course and five years of construction
safety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP), Certified Industrial Hygienist (CIH),
Certified Safety & Health Technician (CSHT) or Certified Safety & Health Manager (CSHM) designation in the applicable training area may be
substituted for two years of experience with proper documentation.
OSHA #501 General Industry - OSHA #511 Occupational Safety and Health Standards for General Industry course and five years of general industry
safety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP), Certified Industrial Hygienist (CIH),
Occupational Safety & Health Technician (OSHT) or Certified Safety & Health Manager (CSHM) designation in the applicable training area may
be substituted for two years of experience with proper documentation.
OSHA #5400 Maritime – OSHA #5410 Occupational Safety and Health Standards for the Maritime Industry Course and three years of maritime safety
experience. Additional requirements include two years of occupational safety and health experience (with a broad focus) in any industry; a
college degree in occupational safety and health, from an accredited college or university; an Associate Safety Professional (ASP), Certified Safety
Professional (CSP), Certified Industrial Hygienist (CIH), Certified Marine Chemist (CMC), or Certified Safety & Health Manager (CSHM)
designation.
OSHA #5600 Disaster Site Worker – OSHA #500 Trainer Course in Occupational Safety and Health for the Construction Industry or OSHA #501 Trainer
Course in Occupational Safety and Health for General Industry, three years of safety training experience and completion of the 40-hour HAZWOPER
course.
If the expiration date on the trainer authorization card is less than ten (10) years old, proper documentation must be provided prior to being
allowed to register for the trainer course without having to take the corresponding OSHA prerequisite course. Documentation must be provided
to the OTI Education Center in order to verify the OSHA prerequisite course has been successfully completed including, at a minimum, the most
recent applicable trainer authorization card. If proper documentation is not available, completion of the OSHA prerequisite course is required.
In the event a previously authorized trainer wishes to register for a trainer course but the expiration date on the trainer authorization card is more
than ten (10) years old, all OTI Education Centers are required to enforce the current course prerequisites, which include completion of the OSHA
prerequisite course.
Outreach trainers are required to attend an Outreach Trainer Update course at least once every four years to maintain their trainer status.
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 No.: ( ) Fax No. ( )
6.
I am applying for the
OSHA #500 OSHA #501 OSHA #5400 OSHA #5600
NOTE: This form is not intended for use by trainers taking an update course. An authorized trainer who is interested in attending an update course
must submit an authentic copy of their trainer card to the OTI Education Center in advance of enrollment in the update course.
7. Course Dates: 8. Course Location:
9. I have completed the following prerequisite course(s) (Please attach a copy of your course completion card or certificate for each applicable
course):
Construction General Industry Maritime Disaster Site Worker
OSHA #500 OSHA #501 OSHA #5400 OSHA #500 or #501
OSHA #502 OSHA #503 OSHA #5402 OSHA #5600
OSHA #510 OSHA #511 OSHA #5410 OSHA #5602
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 2 of 7
List Work Experience with Most Recent Employer First
10. Employer Name:
11. Contact Person:
12. Contact Person’s Phone Number: 13. Contact Person’s Email Address:
14. Employer Address:
Company:
Address:
City: State: ZIP:
15. Start Date of Employment: 16. End Date of Employment:
17. Overall Job Duties in this Position:
18. Describe Safety Activities in This Position:
19. What Percentage of This Position is Safety Related?
Office Use Only Length of Experience in this Job:
List Work Experience with Next Most Recent Employer
20. Employer Name:
21. Contact Person:
22. Contact Person’s Phone Number: 23. Contact Person’s Email Address:
24. Employer Address
Company:
Address:
City: State: ZIP:
25. Start Date of Employment: 26. End Date of Employment:
27. Overall Job Duties in this Position:
28. Describe Safety Activities in This Position:
29. What Percentage of This Position is Safety Related?
Office Use Only Length of Experience in this Job:
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 3 of 7
List Work Experience with Next Most Recent Employer
30. Employer Name:
31. Contact Person:
32. Contact Person’s Phone Number: 33. Contact Person’s Email Address:
34. Employer Address
Company:
Address:
City: State: ZIP:
35. Start Date of Employment: 36. End Date of Employment:
37. Overall Job Duties in this Position:
38. Describe Safety Activities in This Position:
39. What Percentage of This Position is Safety Related?
Office Use Only Length of Experience in this Job:
Complete This Section To Substitute Education or Professional Certification for 2 Years Work Experience
40a. COLLEGE DEGREE – PROOF REQUIRED 40b. PROFESSIONAL CERTIFICATION – PROOF REQUIRED
I have a degree in occupational safety and health from an accredited
college or university
I am a Certified Safety Professional (CSP)
Name of College or University from which degree was acquired
I am a Certified Safety & Health Technician (CSHT) (construction
applicants only)
Date of Graduation
I am a Certified Industrial Hygienist (CIH)
Name of Degree
I am a Certified Safety & Health Manager (CSHM)
I am an Occupational Safety and Health Technician (OHST)
(general industry applicants only)
I have the associate safety professional certification (ASP)
(maritime applicants only)
I am a Certified Marine Chemist (CMC) (maritime applicants only)
I have attached the required copy of my transcripts (Required).
Unofficial transcript is acceptable.
I have attached the required copy of my current professional
certification as a CSP, CIH, CSHT or CSHM (Required).
41. 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:
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 4 of 7
THIS PAGE IS USED FOR INTERNAL PURPOSES ONLY
OFFICE USE ONLY
Check One:
Approving Authority Signature
Approved Not Approved
Please print name
If not approved, please indicate reason
Applicant did not take the prerequisite course Applicant’s trainer card expired over 10 years ago
Applicant did not meet the required years of experience Applicant did not include transcripts
Applicant did not submit proof of applicable certification Applicant did not sign form
Other (Please explain)
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 5 of 7
Instructions for OSHA Outreach Trainer Course Applicants
It is the responsibility of the applicant to ensure all course prerequisites have been met prior to enrolling in the course. Please
submit copies of this completed and signed form and all necessary documentation for prerequisite courses to (Name & Contact
info for approving OTI Education Center) PRIOR TO ENROLLING IN THE COURSE. Registration is not permitted without
approval.
OSHA Course Prerequisites
Construction - OSHA #510 Occupational Safety and Health Standards for the Construction Industry course and five years of
construction safety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP),
Certified Industrial Hygienist (CIH), Certified Safety & Health Technician (CSHT) or Certified Safety & Health Manager
(CSHM) designation in the applicable training area may be substituted for two years of experience with proper
documentation.
General Industry - OSHA #511 Occupational Safety and Health Standards for General Industry course and five years of
general industry safety experience. A college degree in occupational safety and health, a Certified Safety Professional
(CSP), Certified Industrial Hygienist (CIH), Occupational Safety & Health Technician (OSHT) or Certified Safety &
Health Manager (CSHM) designation in the applicable training area may be substituted for two years of experience with
proper documentation.
Maritime – OSHA #5410 Occupational Safety and Health Standards for the Maritime Industry Course and three years of
maritime safety experience. Additional requirements include two years of occupational safety and health experience
(with a broad focus) in any industry; a college degree in occupational safety and health from an accredited college or
university; an Associate Safety Professional (ASP), Certified Safety Professional (CSP), Certified Industrial Hygienist
(CIH), Certified Marine Chemist (CMC), or Certified Safety & Health Manager (CSHM) designation.
Disaster Site Worker – OSHA #500 Trainer Course in Occupational Safety and Health for the Construction Industry or OSHA
#501 Trainer Course in Occupational Safety and Health for General Industry, three years of safety training experience and
completion of the 40-hour HAZWOPER course.
If the expiration date on the trainer card is less than ten (10) years old, proper documentation must be provided prior to
being allowed to register for the trainer course without having to take the corresponding OSHA prerequisite
course. Documentation must be provided to the OTI Education Center in order to verify the OSHA prerequisite course
has been successfully completed including, at a minimum, the most recent applicable trainer card. If proper
documentation is not available, completion of the OSHA prerequisite course is required.
In the event a previously authorized trainer wishes to register for a trainer course but the expiration date on the trainer
course card is more than ten (10) years old, all OTI Education Centers are required to enforce the current course
prerequisites, which include completion of the OSHA prerequisite course.
Outreach trainers are required to attend an Outreach Trainer Update course at least once every four years to maintain
their trainer status.
Item 1 Applicant Name
List your full, legal name.
Item 2 Title
List your current job title. If you are currently
not working, please leave this field blank.
Item 3 Company
List your current employer. If you are
currently not working, please leave this field
blank.
Item 4 E-Mail
List a current, working email where you can
be contacted.
Item 5 Applicant Address
Provide a current, work address, phone and
fax number where you can be contacted.
Item 6 Course
Check the box indicating which course you
are interested in attending.
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 6 of 7
Item 7 Course Dates
List dates you wish to take course from the
OTI Education Center’s course schedule. If
you are unsure, leave this field blank.
Item 8 Course Location
List the location of the specific course in
which you would like to enroll. If you are
unsure, leave this field blank.
Item 9 Prerequisite Course
Check the box which corresponds to the
applicable prerequisite OSHA course(s) you
have completed:
For the OSHA #500, the prerequisite
course(s) are the OSHA #510 or
OSHA #500 course, for the OSHA
#502, the prerequisites are the OSHA
#500 or OSHA #502 course.
For the OSHA #501, the prerequisite
course(s) are the OSHA #511 or
OSHA #501 course, for the OSHA
#503, the prerequisites are the OSHA
#501 or OSHA #503 course.
For the OSHA #5400, the prerequisites
are the OSHA #5410 or OSHA #5400,
for the OSHA #5402 the prerequisites
are the OSHA #5400 or OSHA #5402.
For the OSHA #5600, the prerequisites
are the OSHA #5600, for the OSHA
#5602 the prerequisites are the OSHA
#5600 or OSHA #5602.
Item 10 Employer Name
List your current or most recent employer.
Item 11 Contact Person
List the name of your supervisor or someone
in Human Resources at that employer who
can verify your employment and role for that
employer.
Item12 Contact Person’s Phone Number
List a current contact phone number for the
person identified in Item 15.
Item 13 Contact Person’s Email Address
List a valid email address for the person
identified in Item 15.
Item 14 Employer Address
List the current mailing address for the
employer.
Item 15 Start Date of Employment
List the date you began working for this
employer.
Item 16 End Date of Employment
List the date you stopped working for this
employer. If this is your current employer,
list “present”.
Item 17 Overall Job Duties in this Position
List the duties that you performed in this
position, focusing on those that are safety-
related.
Item 18 Describe Safety Activities in This Position
List safety related tasks performed on the
job, including the responsibility for the
safety of others.
Indicate the percentage of time devoted to
each area listed below.
Note: Related experience must be detailed
since this document is a record of safety
experience and will be carefully reviewed
to determine whether eligibility
requirements have been met.
Item 19 What Percentage of This Position is Safety
Related?
Indicate the percentage of time devoted to
safety related tasks in this position.
Item Second Employer
20-29 If needed, list the information as directed from
the corresponding items 10-19 as applies to
your second most recent position.
OSHA Training Institute Education Centers Program
OSHA Outreach Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions before completing this form.
OSHA Form 4-50-10
April 2012
Page 7 of 7
Item Third Employer
30-39 If needed, list the information as directed from
the corresponding items 10-19 as applies to
your next most recent position. Attach
additional sheets as needed, following the
same format.
Item 40a College Degree
Skip this step if you do not wish to substitute
a college degree from an accredited
university for 2 years work experience. If
applicable, place an “x” in the box indicating
you have a college degree in safety from an
accredited university, the name of the college
or university from which you received the
degree, the date you graduated, and the
name of the degree earned. Place an “x” in
the box indicating that you have attached
your transcripts. If you do not include a copy
of your transcripts, the degree will not be
counted.
Item 40b Professional Certification
Skip this step if you do not if you do not wish
to substitute a professional certification for
work experience. If applicable, place an “x”
in the box that corresponds to the
professional certification you currently hold.
Place an “x” in the box indicating that you
have attached a copy of your professional
certification. If you do not include proof of
your professional certification, it will not be
counted.
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Prereq Verif Form - Single_Prereq_form_OSHA_format_WL FINAL revs 4-16-2012

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