Outreach Program Report Form

Pacific Northwest OSHA Education Center
Electronic Card Request Form
Outreach Training Program Reports
--To view NEW requirements for Construction, click here
--To view NEW requirements for General Industry, click here
--To view requirements for Disaster Site Worker, click here
--To view requirements for Maritime, click here
--(please fax or mail maritime requests)

First name	Last name

Organization

Address

City	State	Zip code

Phone

E-mail

Trainer ID #:
Your Completed Trainer Course(s):
500 502 501 503 5600
Your Trainer Card Expiration Date:
Statement of Certification (updated 2/6/2009) I certify that I have conducted this outreach training class and have read the statement below:
10 hour Construction 30 Hour Construction 10 Hour General Industry 30 Hour General Industry 16 Hour Disaster Site Worker In accordance with the OSHA Outreach Training Program guidelines. I have maintained the training records as required by these guidelines and I will provide these records to the OSHA Directorate of Training and Education (or their designee) upon request. I understand that I will be subject to immediate dismissal from the OSHA Outreach Training Program is information provided herein is not true and correct. I further understand that providing false information herin 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. I hereby attest that the information on this form is true and correct.
Course Information: (Check All that Apply)
Spanish Language other than Spanish or English Youth (age 18 or less) Training conducted outside the US OSHA Alliance or Partnership related - please specify:
Ending date of course: *Please do not submit card request before the course is completed
Number of students:
Student names (May copy & paste)

List topics covered and hours spent on each for example: Intro to OSHA - 1 hr, Electrical - 1 hr, and so on... (you can copy and paste from a text file) *Please make sure your submissions total 10 or 30 hours --To view requirements for Construction, click here --To view requirements for General Industry, click here

* If this is your first request, please fax (206-685-3872) or mail a copy of your certificate or trainer card to:

Pacific Northwest OSHA Education Center
ATTN: Outreach Administration
4225 Roosevelt Way NE, Suite 100
Seattle, WA 98105

For questions or concerns, please contact:
Pacific Northwest OSHA Education Center: (206) 685-3089 or (800) 326-7568, Fax: (206) 685-3872, e-mail:ce@u.washington.edu
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