Fillable Specialist in Safety and Health Certificate Request Form (OSHA Training Institute Education Center)

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Specialist in Safety and Health Certificate Request Form (OSHA Training Institute Education Center)

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Specialist in Safety and Health Certificate Request Form – Construction Industry
• Requires 8 OSHA courses - A minimum of 5 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:
Elective Courses (choose 4):
OSHA 2015: Hazardous Materials
OSHA 3095: Electrical Standards
OSHA 2264: Permit-Required Confined Space Entry
OSHA 3115: Fall Protection
OSHA 3015: Excavation, Trenching, & Soil Mechanics
OSHA 5109: Cal/OSHA Standards for Construction
OSHA 3085: Principles of Scaffolding
Safety Inspection Techniques (OTC 308)
A
dditional Electives – Short Courses
(3 short courses count as one (1) elective [maximum allowed is 6]):
O
SHA4you.com (866)
936
-OSHA (6742) otc@clpccd.org
OSHA 510: OSHA Standards for the Construction Industry
OSHA 500: Trainer Course in OSHA for Construction Industry OR OSHA 502: Update for Construction Industry Trainers
OSHA 7505: Intro to Incident (Accident) Investigation
OSHA 7845: Recordkeeping Rule Seminar
OSHA 7100: Intro to Machinery & Machine Guarding
OSHA 7210: Pandemic Illness Preparedness
OSHA 7105: Intro to Evac. & Emergency Planning
OSHA 7215: Silica in Construction, Maritime, & General Industry
OSHA 7120: Intro to Combustible Dust Hazards
OSHA 7300: U. OSHA’s Permit-Required Confined Space Std.
OSHA 7115: Lockout/Tagout
OSHA 7400: Noise Hazards in Construction
OSHA 7205: Health Hazard Awareness
OSHA 7410: Managing Excavation Hazards
OSHA 7500: Intro to Safety & Health Management
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)
Cre
dit Card Number Name on Credit Card Exp. Date
Billing Address City State Zip Code
Si
gnature of Credit Card Holder Date Card Type
(Visa/MasterCard/AMEX ac
cepted)
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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Specialist in Safety and Health Certificate Request Form (OSHA Training Institute Education Center)

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Completed 17 July 2021

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