Fillable Safety Associate Certificate Request Form General Industry (OSHA Training Institute Education Center)

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Safety Associate Certificate Request Form General Industry (OSHA Training Institute Education Center)

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Safety Associate Certificate Request Form – General Industry
• Requires 6 OSHA courses - A minimum of 4 courses must have been taken with Chabot-Las Positas
Community College District – OSHA Training Institute Education Center.
• Only OSHA numbered courses taken at an OSHA Training Institute Education Center will be accepted.
• Copies of certificates must be provided with request; please do not submit until all courses are complete.
• Applicant is responsible for tracking their completion progress and submitting this application form when
all requirements have been met.
• All courses applied towards certificates must have been taken within the previous 5 years.
Name: Date Requested:
Street Address:
City: State: Zip:
Phone Number: Email:
Required Courses:
Elect
ive Courses (choose 3):
OSHA 521: OSHA Guide to Industrial Hygiene
OSHA 2255: Principles of Ergonomics
OSHA 2015: Hazardous Materials
OSHA 5119: Cal/OSHA Standards for General Industry
OSHA 2045: Machinery & Machine Guarding
Safety Inspection Techniques
OSHA 2225: Respiratory Protection
Additi
onal Electives – Short Courses
(3 short courses count as one (1) elective [maximum allowed is 6]):
OSHA4you.com
(866) 936-OSHA (6742)
OSHA 511: OSHA Standards for General Industry
OSHA 7505: Intro to Incident (Accident) Investigation
OSHA 7845: Recordkeeping Rule Seminar
OSHA 7100: Intro to Machinery & Machine Guarding
OSHA 7205: Health Hazard Awareness
OSHA 7105: Intro to Evac. & Emergency Planning
OSHA 7210: Pandemic Illness Preparedness
OSHA 7120: Intro to Combustible Dust Hazards
OSHA 7215: Silica in Construction, Maritime, & General Industry
OSHA 7115: Lockout/Tagout
OSHA 7300: U. OSHA’s Permit-Required Confined Space Std.
OSHA 7200: Bloodborne Pathogen Exposure Control
OSHA 7400: Noise Hazards in Construction
OSHA 7500: Intro to Safety & Health Management
otc@clpccd.org
(OTC 308)
Payment Information:
Payment information must be included to complete the registration process. Certificate fee is $99.00.
Enclosed is a check payable to Chabot-Las Positas Community College District – OSHA Training
Institute Education Center
Please charge the credit card provided below (you may also call our office at (866) 936-6742 to make
credit card payment)
Cred
it Card Number Name on Credit Card Exp. Date
Billing Address City State Zip Code
Sign
ature of Credit Card Holder Date Card Type
(Visa/MasterCard/AMEX acc
epted)
Completed registration forms and payment can be submitted by:
Email: otc@clpccd.org
Fax: (925) 460-0133
Mail: 5860 Owens Dr, 3
rd
Floor, Pleasanton, CA 94588
OSHA4you.com (866) 936-OSHA (6742)
otc@clpccd.org
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Safety Associate Certificate Request Form General Industry (OSHA Training Institute Education Center)

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Completed 17 July 2021

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