Fillable Prerequisite Verification Form April2018 2009 Prerequisite Verification Form

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Prerequisite Verification Form April2018 2009 Prerequisite Verification Form

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OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Submit completed forms to: Diana.Rupprecht@slu.edu 314-977-8256
Great Plains OSHA Education Center
St. Louis University - College of Public Health & Social Justice
Center for Environmental Education & Training
3545 Lafayette Ave., Salus Center, St. Louis MO 63104
Approved:
Declined:
Approving Authority:
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 supporting documentation for prerequisite courses to the authorized OSHA Training Institute (OTI) Education Center
listed above prior to enrolling in the course. Registration is not permitted without prior OTI Education Center approval.
OSHA Trainer Course Prerequisites
• OSHA #500 Trainer Course in Occupational Safety and Health Standards for the Construction Industry - OSHA #510 Occupational Safety and
Health Standards for the Construction Industry course completed within the last seven years and five years of construction safety experience. A
bachelor or higher college degree in occupational safety and health or industrial hygiene by an accredited college or university, a Certified Safety
Professional (CSP) or Certified Industrial Hygienist (CIH) designation in the applicable training area may be substituted for two years of
experience.
• OSHA #501 Trainer Course in Occupational Safety and Health Standards for General Industry - OSHA #511 Occupational Safety and Health
Standards for General Industry course completed within the last seven years and five years of general industry safety experience. A bachelor or
higher college degree in occupational safety and health or industrial hygiene by an accredited college or university, a Certified Safety Professional
(CSP) or Certified Industrial Hygienist (CIH) designation in the applicable training area may be substituted for two years of experience.
• OSHA #5400 Trainer Course in Occupational Safety and Health Standards for the Maritime Industry – OSHA #5410 Occupational Safety and
Health Standards for the Maritime Industry Course completed within the last seven years and five years of maritime industry safety experience. A
bachelor or higher college degree in occupational safety and health or industrial hygiene by an accredited college or university, a Certified Marine
Chemist (CMC), Certified Safety Professional (CSP) or Certified Industrial Hygienist (CIH) designation in the applicable training area may be
substituted for two years of experience.
• OSHA #5600 Disaster Site Worker Trainer Course– Current OSHA authorization as a Construction, Maritime or General Industry Outreach
trainer, three years of safety training experience, and either completion of the 40-hour HAZWOPER course or possession of journey-level
credentials in a building trade union.
NOTE: Working safely does not meet the requirements of safety experience for any course.
Applicant Information – Please type or print. (Read instructions on pages 6-8 before completing this form)
1.
Applicant Legal
Name:
2. Job Title:
3. Company: 4. Email:
5.
Applicant Mailing Address:
City: State: ZIP:
Phone No.: ( ) Fax No.: ( )
6.
Indicate course applying for: OSHA #500 OSHA #501 OSHA #5400 OSHA #5600
OSHA #502 OSHA #503 OSHA #5402 OSHA #5602
If applying for OSHA #502, #503, #5402, or #5602, attach a copy of your current OSHA Outreach Training Program trainer card or an official
transcript of Outreach trainer course completion and skip to line 41.
7. Course Start Date:
Course End Date:
8. Course Location (City/State):
9.
Construction
General Industry
Maritime
Disaster Site Worker
OSHA #510
OSHA #511
OSHA #5410
OSHA #500, #501, or #5400
OSHA #500
OSHA #502
OSHA #501
OSHA #503
OSHA #5400
OSHA #5402
OSHA #5600
OSHA #5602
OSHA 4-50.13
Page 1 of 8
Submit 3 weeks
Prior to training
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
List work experience with most recent employer first
10.
Employer Name
and Job Title:
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
(mm/dd/yyyy):
16. End Date of Employment
(mm/dd/yyyy):
17. What percentage of this position
is safety related?
18. Describe Safety Responsibilities and Activities in this Position:
19. Describe Overall Job Duties in this Position:
Office Use Only Verified employment
Length of experience in this job (years/months):
OSHA 4-50.13
Page 2 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
List Work Experience with Next Most Recent Employer
20.
Employer Name
and Job Title:
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
(mm/dd/yyyy):
26. End Date of Employment
(mm/dd/yyyy):
27. What percentage of this
position is safety related?
28. Describe Safety Responsibilities and Activities in this position.
29. Describe Overall Job Duties in this Position:
Office Use Only Length of experience in this job (years/months):
OSHA 4-50.13
Page 3 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Note: Multiple Copies of Page 4 may be included to ensure all applicable experience is listed.
List Work Experience with Next Most Recent Employer
30.
Employer Name
and Job Title:
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
(mm/dd/yyyy):
36. End Date of Employment
(mm/dd/yyyy):
37. What percentage of this
position is safety related?
38. Describe Safety Responsibilities and Activities in this Position:
39. Describe Overall Job Duties in this Position:
Office Use Only Length of experience in this job (years/months):
OSHA 4-50.13
Page 4 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Complete this Section to Substitute Education or Professional Certification for Two (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
Certified Safety Professional (CSP)
Name of College or University from which degree was acquired
Certified Industrial Hygienist (CIH)
Academic Major
Certified Marine Chemist (CMC)
(Maritime applicants only)
Degree Level
Date of Graduation
Attach required copy of current professional certification as a CSP,
CIH, CMC
Attach required copy of official transcripts.
Name and address of Certifying Organization:
__________________________________________________________
__________________________________________________________
41. I have previously been subject to revocation, suspension, or probation by OSHA Yes No
42. If responded yes to #41, please attach all OSHA correspondence related to the investigation.
43. Statement of Certification
I certify that the information I have included herein and submitted to the OTI Education Center is true and accurate. I understand that I will be
subject to immediate dismissal from the OSHA Outreach Training Program if information provided herein is not true and correct. I further
understand that providing false information herein may subject me to civil and criminal penalties under Federal law, including 18 U.S.C. 1001
and section 17(g) of the Occupational Safety and Health Act, 29 U.S.C. 666 (g), which provides criminal penalties for making false statements or
representations in any document filed pursuant to that Act.
Applicant Signature:
Date:
OFFICE USE ONLY
Check one:
____________________________________
Approving Official Name:
____________________________________
Approving Official Title:
Approved
Not Approved
____________________________________
Approving Official Signature
Date:
If not approved, please indicate reason:
Applicant did not demonstrate completion of the prerequisite course
within the previous seven years
Applicant did not include transcripts
Applicant did not demonstrate the required years of experience Applicant did not sign form
Applicant did not submit proof of applicable certification or degree
Other (Please explain)
OSHA 4-50.13
Page 5 of 8
click to sign
signature
click to edit
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Privacy Act Statement and Paperwork Reduction Act Statement
Section 21 Training and Employer Education of the OSH Act, 29 USC 670 authorizes collection of this information. The purpose of this
information is to determine whether the applicant meets the prerequisite requirements of training and experience to enroll in the Outreach
Training Program trainer courses to become an authorized Outreach Training Program trainer. Completion of this form is required in order to
enroll in Outreach Training Program trainer courses and to become an authorized Outreach Training Program trainer.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average one hour per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Occupational Safety and Health Administration, Directorate
of Standards and Guidance, 200 Constitution Avenue, NW, Room N3718, Washington, DC 20210 and reference the OMB Control Number.
Note: Please do not return the completed OSHA Form 4-50.13 to this address.
Instructions for OSHA Trainer Course Applicants
It is the responsibility of the applicant to ensure all course prerequisites have been met prior to enrolling in the course. 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. Ensure all safety work experience is shown and complete.
Referring to a resume is not acceptable. Registration is not permitted without approval. Falsification of any items on this form
may result in revocation of trainer authorization.
OSHA Course Prerequisites
• OSHA #500 Trainer Course in Occupational Safety and Health Standards for the Construction Industry - OSHA #510
Occupational Safety and Health Standards for the Construction Industry course completed within the last seven years and five
years of construction safety experience. A bachelor or higher college degree in occupational safety and health or
industrial hygiene by an accredited college or university, a Certified Safety Professional (CSP) or Certified Industrial
Hygienist (CIH) designation in the applicable training area may be substituted for two years of experience. Applicant
must provide official college transcript or proof of professional certification with proper documentation.
• OSHA #501 Trainer Course in Occupational Safety and Health Standards for General Industry - OSHA #511
Occupational Safety and Health Standards for General Industry course completed within the last seven years and five years of
general industry safety experience. A bachelor or higher college degree in occupational safety and health or industrial
hygiene by an accredited college or university, a Certified Safety Professional (CSP) or Certified Industrial Hygienist
(CIH) designation in the applicable training area may be substituted for two (2) years of experience. Applicant must
provide official college transcript or proof of professional certification with proper documentation.
• OSHA #5400 Trainer Course in Occupational Safety and Health Standards for the Maritime Industry – OSHA #5410
Occupational Safety and Health Standards for the Maritime Industry Course completed within the last seven years and five years
of maritime industry safety experience. A bachelor or higher college degree in occupational safety and health or industrial
hygiene by an accredited college or university, a Certified Marine Chemist (CMC), Certified Safety Professional (CSP) or
Certified Industrial Hygienist (CIH) designation in the applicable training area may be substituted for two years of
experience. Applicant must provide official college transcript or proof of professional certification with proper
documentation.
• OSHA #5600 Disaster Site Worker Trainer Course– Current OSHA authorization as a Construction or General Industry
Outreach trainer, three years of safety training experience, and either completion of the 40-hour HAZWOPER course or
possession of journey-level credentials in a building trade union.
OSHA 4-50.13
Page 6 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Submit completed forms to: Address will be provided by the OTI Education Center and used to note approval or disapproval of applicant.
Item 1 Applicant Name
Provide full legal name.
Item 2 Title
Provide current job title. If currently not
working, leave field blank.
Item 3 Company
Provide current employer. If currently not
working, leave this field blank.
Item 4 E-Mail
Provide current e-mail address.
Item 5 Applicant Mailing Address
Provide current mailing address, phone and
fax number.
Item 6 Course
Check the box indicating which course you
are interested in attending.
Item 7 Course Dates
List dates during which you wish to take the
course from the OTI Education Center’s
course schedule. If unsure, leave this field
blank.
Item 8 Course Location
List the location of the specific course in
which you would like to enroll. If unsure,
leave this field blank.
Item 9 Prerequisite Course
Check the box which corresponds to the
applicable prerequisite OSHA course(s)
completed:
• For the OSHA #500, the prerequisite
course(s) are the OSHA #510, or a
current OSHA #500 or OSHA #502.
• For the OSHA #502, the prerequisite
course(s) are a current OSHA #500 or
OSHA #502.
• For the OSHA #501, the prerequisite
course(s) are the OSHA #511, or a
current OSHA #501 or OSHA #503.
• For the OSHA #503, the prerequisite
course(s) are a current OSHA #501 or
OSHA #503
• For the OSHA #5400, the prerequisite
course(s) are the OSHA #5410, or a
current OSHA #5400 or OSHA #5402.
• For the OSHA #5402, the prerequisite
course(s) are the OSHA #5400 or
OSHA #5402.
• For the OSHA #5600, the prerequisite
course(s) are the OSHA #5600,
OSHA #500, or OSHA #501.
• For the OSHA #5602, the prerequisite
course(s) are the OSHA #5600 or
OSHA #5602.
Item 10 Employer Name and Job Title
Provide job title and current employer name.
Item 11 Contact Person
Provide name of supervisor or Human
Resources at this employer who can verify
employment and role for this employee.
Item 12 Contact Person’s Phone Number
Provide current contact phone number for
person identified in Item 11.
Item 13 Contact Person’s Email Address
Provide valid email address for person
identified in Item 11.
Item 14 Employer Address
Provide current mailing address for
employer.
Item 15 Start Date of Employment
Provide start date with this employer.
Item 16 End Date of Employment
Provide end date with this employer. If this is
current employer, write “present”.
Item 17 What Percentage of this Position is Safety
Related?
Indicate the percentage of time devoted to
safety-related tasks in this position.
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
used to determine whether eligibility requirements
have been met.
OSHA 4-50.13
Page 7 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Item 19 Overall Job Duties in this Position
Indicate duties performed in this position,
focusing on those that are safety-related.
Item Second Employer
20-29 If applicable, list the information as directed
from the corresponding items 10-19 as applies
to second most recent position.
Item Third Employer
30-39 If applicable, list the information as directed
from the corresponding items 10-19 as applies
to next most recent position.
Additional Employers
Attach additional pages as needed, following
the same format.
Item 40a College Degree
Complete this section only if substituting a
bachelor or higher college degree for two (2)
years of work experience. If applicable, place
an “x” in the box indicating a college degree
in safety or industrial hygiene from an
accredited university, the name of the college
or university from which degree was
received date of graduation, and title of
degree earned. Place an “x” in the box
indicating transcripts are attached. The
official college transcript must be provided
for the degree to be considered as a substitute
for work experience.
Item 40b Professional Certification
Complete this section only if substituting
professional certification for two (2) years of
work experience. If applicable, place an “x”
in the box that corresponds to the
professional certification currently held.
Place an “x” in the box indicating a copy of
the professional certification is attached.
Provide the name and address of the
certifying organization. A copy of the
professional certification must be provided to
be considered as a substitute for work
experience.
Item 41. Revocation, Suspension, or Probation
Indicate if you have ever been subject to
revocation, suspension, or probation by
OSHA.
Item 42. Investigation Correspondence
If you have ever been subject to revocation,
suspension, or probation by OSHA; you must
provide all correspondence between you and
OSHA related to the investigation.
Item 43. Statement of Certification
This statement must be signed by the
applicant to certify that the information
provided on the Prerequisite Verification
Form is true and correct. Neglecting to sign
the Statement of Certification will result in the
application being declined.
Page 8 of 8
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Prerequisite Verification Form April2018 2009 Prerequisite Verification Form

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Completed 19 March 2020

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