2016-2017 Course Locations and Supporting Organizations … Training... · 44 Woodrock Rd., Ste 1. • Weymouth, MA Assabet Valley Regional Technical High School. 21 Fitchburg

2016-2017 Course Locations and Supporting Organizations in New England:

Harold Brothers Training Institute, Inc. 44 Woodrock Rd., Ste 1. • Weymouth, MAAssabet Valley Regional Technical High School. 21 Fitchburg St.. • Marlborough, MAWeston & Sampson 225 New Boston St. • Woburn, MATNEC/UMASS Lowell Training Center Wannalancit Office & Technology Center 600 Suffolk St., 5th Floor. • Lowell, MASafety Council of Western N.E. 59 Interstate Dr. • West Springfield, MANortheast Public Power Association (NEPPA) Training Center 200 New Estate Rd. • Littleton, MA

Not pictured:

Associated General Contractors - MA 888 Worcester St. • Wellesley, MA

MASSACHUSETTS

Gould Construction Institute100 Unicorn Park, Suite 2 • Woburn, MA

ConnOSHA38 Wolcott Rd. • Wethersfield, CT

Mashantucket-Pequot Tribal Nation Public Safety Building

101 Pequot Trail • Mashantucket, CT

CONNECTICUT

CT Construction Industries Assoc. 912 Silas Deane Hwy. • Wethersfield, CT

Mohegan Tribe Public Safety Bldg 49 Sandy Desert Rd.• Uncasville, CT

RHODE ISLAND

New England Institute of Technology2480 Post Rd. • Warwick, RI

Hickok/Boardman346 Shelburne Rd. • Burlington, VT

VERMONT

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OTIEC Region 1 at the Ammon Center175 Ammon Dr. • Manchester NH

NEW HAMPSHIRE

Keene State College Technology, Design & Safety Center229 Main St. • Keene, NH

MAINE

SafetyWorks, Training Institute Maine Dept. of Labor

45 Commerce Dr. • Augusta, ME

CT Business & Industry Assn (CBIA) 350 Church St. • Hartford, CT

CONNECTICUT continued

FSU - Center for Professional Studies150B Main St. • Fitchburg, MA

Baystate Education Center (2nd Floor)361 Whitney Ave • Holyoke, MA

Richard Alden Training Center7 Nippnap Trail • Millbury, MASouthern Maine Community College 2 Fort Rd • South Portland, MEUnited Technologies Center 200 Hogan Rd. • Bangor, MESafety & Health Council of Northern NE 2 Whitney Rd., Ste 11 • Concord, NHWindjammer Conference Center 1076 Williston Rd. • So. Burlington, VT

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510 Occupational Safety and Health Standards for Construction

Course Description: This course is an excellent construction standards survey course for individuals seeking up to date knowledge of OSHA policies, procedures and standards, as well as construction safety and health principles. Topics include: the scope and application of the OSHA construction standards. Special emphasis is placed on those areas that are the most hazardous, using OSHA standards as a guide. Each student receives a current Code of Federal Regulations 1926 and materials related to the curriculum. Upon completion of the hourly and course requirements, the participant receives a certificate verifying course completion. OSHA 510 is also one of the prerequisite requirements for attendance at the OSHA 500 Construction Outreach Trainer Course.

500* Trainer Course in Occupational Safety and Health Standards for Construction Course Description: This course is designed for those interested in teaching the 10- and 30-hour construction safety and health outreach program to their employees and other interested groups. Special emphasis is placed on those topics that are required in the 10- and 30-hour programs as well as on those that are the most hazardous, using OSHA standards as a guide. Course participants are briefed on effective instructional approaches and the effective use of visual aids and hand-outs. This course allows the student to become a trainer in the Outreach Program and to conduct both a 10- and 30-hour construction safety and health course and to issue cards to participants verifying course completion.

NOTE: Students in Course 500 who wish to participate as authorized trainers in the Outreach Program must prepare a presentation on an assigned OSHA construction Outreach topic and successfully pass a closed book written examination. Authorized Outreach Trainers are required to attend Course 502 at least once every four years to maintain their trainer status.

502 Update for Construction Industry Outreach Trainers

Course Description: This course is the update required every four (4) years for OSHA Authorized Construction Outreach Trainers in order to remain an outreach trainer. If your card has expired more than 90 days, you must retake the OSHA 500 course, examination and performance critique to be reauthorized. Restrictions on length of expiration apply. This trainer update provides professional development opportunity and education on new construction standards, Outreach Training Program Requirements and policies, provides a general overview of construction safety and best practices, training material resources, techniques used by other outreach trainers, and how to excel in conducting training on jobsite hazards. It is a training techniques focused program.

NOTE: Students registering for this course must provide a copy of their current OSHA Construction Outreach Trainer card (front and back copy) to be enrolled in this course.

Construction IndustryOSHA 510: 4 Days | 2.6 CEUs | $865Course Section Start Date End Date Location

NCOS-510-N2C Feb. 6, 2017NCOS-510-N3C March 6, 2017NCOS-510-N4C April 3, 2017NCOS-510-N5C May 1, 2017

Feb. 9, 2017 Warwick, RI March 9, 2017 Wellesley, MA April 6, 2017 Manchester, NH May 4, 2017 Mashantucket, CT June 2, 2017 Bangor, MENCOS-510-N5C May 30, 2017

4 Days | 2.6 CEUs | $895End Date Location

OSHA 500: Course Section Start Date

NCOS-500-N1C Jan. 23, 2017 NCOS-500-N2C Feb. 20, 2017

NCOS-500-N3C March 20, 2017NCOS-500-N4C April 17, 2017NCOS-500-N5C May 16, 2017NCOS-500-N6C June 19, 2017

Jan. 26, 2017 Manchester, NH Feb. 23, 2017 Warwick, RI

March 23, 2017 Wellesley, MA April 20, 2017 Manchester, NH May 19, 2017 Mashantucket, CT June 22, 2017 Bangor, ME

2.5 Days | 1.8 CEUs | $795End Date Location

OSHA 502:Course Section Start Date

NCOS-502-N1C Jan. 17, 2017 NCOS-502-N2C Feb. 15, 2017


Jan. 19, 2017 Manchester, NH Feb. 17, 2017 Wellesley, MA

March 17, 2017 Manchester, NH April 14, 2017 So. Portland, ME May 25, 2017 Wethers ield, CT June 16, 2017 Montpelier, VT

* Prerequisites: 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) or Certified Industrial Hygienist (CIH) designation in the applicable training area may be substituted for two years of experience with proper documentation. Registration is not permitted without approval.

Prerequisite: Course 500/502

NOTE: Update Course registrants MUST include a front/back copy of their current Authorized Outreach Trainer card with their registration.

OSHA Standards & Outreach Trainer Courses

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http://www.OSHAedcenter.com/coursecatalog.pdf

mailto:oshaed%40keene.edu?subject=

General Industry

Pre-registration required. Class hours are 8:00am-4:30pm daily unless otherwise specified on your course confirmation letter. Woburn, MA class hours are 7:30am-4:00pm. 3

*Registration information for Trainers: OSHA Outreach Trainer course registration must include a copy of the corresponding OSHA standardscertificate of completion and the Prerequisite Verification Form demonstrating knowledge of the discipline specific OSHA standards according to instructions. The documents will be reviewed and the applicant will be informed of the outcome prior to the course start date.

511 Occupational Safety and Health Standards for General Industry Prerequisite for the 501 Trainer Course Course Description: This four day occupational safety course is an excellent general industry standards program for individuals seeking up to date knowledge of OSHA policies, procedures and standards as well as general industry safety and health principles. Topics include the scope and application of the OSHA general industry standards with special emphasis on areas most hazardous using OSHA standards as a guide. Each student receives a current Code of Federal Regulations 29 CFR 1910 and materials related to the curriculum. At the conclusion of the course, there is a 50-question closed book knowledge inventory with a passing grade of 80%. 100% attendance is mandatory in order to complete the hourly and course requirements. Each participant receives a certificate verifying course attendance with associated CEUs (2.6).

501* Trainer Course in Occupational Safety and Health Standards for General Industry

Course Description: This course is designed for those interested in teach-ing the 10-hour and 30-hour general industry safety and health outreach programs to their employees and other interested groups. Special emphasis is placed on those topics required in the 10-hour and 30-hour programs, as well as on those that are the most hazardous, using OSHA standards as a guide. Course participants are briefed on effective instructional approach-es and use of visual aids and handouts. This course allows the student to become a trainer in the Outreach Training Program and to conduct both 10-hour and 30-hour general industry safety and health outreach courses and to issue cards to participants verifying course completion.

NOTE: Students in Course 501 who wish to participate as authorized trainers in the OSHA Outreach Training Program must prepare a presentation on an assigned OSHA General Industry topic and pass a closed book examination. Authorized OSHA Outreach Trainers are required to attend Course 503 at least once every four (4) years to maintain their outreach program trainer status.

503 Update for General Industry Outreach Trainers

Course Description: This course is the update required every four (4) years for OSHA Authorized General Industry Outreach Trainers in order to remain an outreach trainer. If your card has expired more than 90 days, you must retake the OSHA 501 course, examination and performance critique to be reauthorized. Restrictions on length of expiration apply.

This training update provides professional development opportunity and education on new general industry standards, Outreach Training Program Requirements and policies, provides a general overview of safety and best work practices, training material resources, techniques used by other outreach trainers, and how to excel in conducting training on job site hazards. It is a training techniques focused program.

NOTE: Students registering for this course must provide a copy of their current OSHA General Industry Outreach Trainer card (front and back copy) to be enrolled in this course.

OSHA 511: 4 Days | 2.6 CEUs | $865Course Section Start Date End Date LocationNCOS-511-N1C Jan. 30, 2017 NCOS-511-N2C Feb. 20, 2017


Feb. 2, 2017 Weymouth, MA Feb. 23, 2017 Manchester, NH

March 23, 2017 Hartford, CT April 13, 2017 Lowell, MA May 25, 2017 Manchester, NH June 29, 2017 So. Portland, ME

OSHA 501: 4 Days | 2.6 CEUs | $895Course Section Start Date End Date LocationNCOS-501-N2C Feb. 6, 2017 NCOS-501-N3C March 6, 2017 NCOS-501-N4C April 24, 2017 NCOS-501-N6C June 5, 2017

Feb. 9, 2017 Warwick, RI March 9, 2017 Manchester, NH April 27, 2017 Lowell, MA June 8, 2017 So. Burlington, VT

OSHA 503: 2.5 Days | 1.8 CEUs | $795Course Section Start Date End Date Location NCOS-503-N1C Jan. 17, 2017

NCOS-503-N3C March 13, 2017NCOS-503-N4C April 10, 2017 NCOS-503-N5C May 16, 2017

Jan. 19, 2017 W. Springfield, MA

March 15, 2017 Manchester, NH April 12, 2017 So. Portland, ME May 18, 2017 Uncasville, CT

* Prerequisites: OSHA #511 OSHA 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) or Certified Industrial Hygienist (CIH) designation in the applicable training area may be substituted for two years of experience with proper documen-tation. Registration is not permitted without approval.

*Prerequisites: Course 501/503.

NOTE: Update Course registrants MUST include a front/back copy of

their current Authorized Outreach Trainer card with their registration.

Construction General Industry

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GI

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How to become an OSHA Outreach Trainer

Current trainers! Be aware of your expiration date. To remain an authorized outreach trainer, every 4 years you must complete the appropriate update course prior to expiration!

* Five years of safety experience: Person has knowledge of the OSHA standards gained by using them in their job for at least fiveyears. They do not need to have devoted all of their time to safety and health, but safety and health was a part of their responsibilities.

Step 1:OSHA Standards CourseThe first step is to successfully complete the OSHA Standards course for the appropriate discipline (Construction 510, General Industry 511).

Standards courses survey OSHA policies, procedures and standards, as well as safety and health principles. Special emphasis is placed on those areas that are the most hazardous, using OSHA standards as a guide. Each student receives a Code of Federal Regulations and materials related to the curriculum.

Step 2:5 years of safety & health experienceComplete the Prerequisite Verification Form documenting 5 years of safety and health experience* in the selected occupational safety and health discipline. Send the completed form, demonstrating working knowledge of the OSHA standards

NOTE: A college degree in occupational safety and health, a Certified Safety Professional (CSP), or Certified Industrial Hygienist (CIH) designation may be substituted for two years of experience.

Your registration and associated documen-tation will be reviewed, and you will receive notice if your experience and knowledge of OSHA standards satisfy the Directorate of Training and Education /OSHA criteria to be approved to attend the Outreach Trainer course of your choice.

Step 3:OSHA Outreach Trainer CourseSuccessfully complete the OSHA Trainer Course in Occupational Safety and Health Standards for appropriate discipline (Construction 500, General Industry 501).

Students in a trainer course must prepare a presentation on an assigned OSHA Outreach topic and successfully pass a closed book written examination.

The additional step for those who successfully become Outreach Trainer is a Trainer update every four years (Construction 502, General Industry 503). When registering for an update course, include a front and back copy of your current trainer card with the registration form.

NOTE: A trainer who fails to take an update prior to expiration has 90 days during which to still take the update course. During this time an expired trainer will be unable to teach. If the 90 day grace period from the expiration date has passed, an expired trainer must retake the appropriate full outreach trainer course.

OSHA Introduces NEW 10 & 30 Hour Outreach Cards More durable. More secure.

As of March 1, 2016, in order to reduce fraud, improve efficiency and benefit workers, OSHA introduced more durable and secure Outreach Training Program trainer and student course completion cards for construction , general industry, maritime, and disaster site worker at all OSHA Training Institute Education Centers in the U.S.

Completion cards are made of a more durable card stock, like a credit card, with authorizing logos, a watermark when copied, and a QR code for authentication.

Card fees are $8 per card, and complementary card duplication and replacement is discontinued.

Open enrollment class hours:8:00am-4:30pm daily unless otherwise specified on your course confirmation letter. Woburn, MA class hours are 7:30am-4:00pm.

http://www.oshaedne.com

mailto:oshaed%40keene.edu?subject=

http://www.oshaedne.com/classroom

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Registration and Tuition:

In New England, we have occasional inclement weather, and courses may be postponed or rescheduled. Keene State College reserves the right to cancel or reschedule courses due to unforeseen circumstances. Safety of our students is important to us. If a course is cancelled by Keene State College, students have the option to transfer to another course, have their tuition held in escrow, or receive a refund.

Keene State College is not responsible for travel related expenses incurred by the student in the event of unforeseen delays, postponement and/or necessary cancellation or rescheduling. “Open enrollment” courses may be cancelled or rescheduled due to low enrollment within five business days. If you are registered, you will be notified should a course be delayed, rescheduled, postponed or removed from the master calendar.

Directions and AccommodationsUpon registration, course confirmation, directions, and local area accom-modation information will be sent to you by mail, fax, or e-mail. Please tell our registration specialist if you will be traveling a distance to one of our facilities and require additional information.

Special needs: If you have a disability requiring a specific academic accommodation, please call the OSHA Training Institute Education Center (800-449-6742) before your course starts.

Dietary Limitations: Attendees with special dietary needs (diabetic, allergies, gluten-free, religious, vegetarian, etc.) should plan to bring their own suitable food and drink to OTIEC courses.

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http://www.OSHAedNE.com

mailto:OSHAed%40keene.edu?subject=

OTIEC/KSC REGISTRATION FORM OSHA SGE

END DATESTART DATECOURSE TITLE

BIRTH DATE: TODAY’S DATE:

FORMAL NAME:

COMPANY NAME:

JOB TITLE:

STREET/RFD/BOX

STREET/RFD/BOX

CITY/TOWN STATE ZIP

LAST FIRST MI SUFFIX

MO DAY YR MO DAY YR

–

CITY/TOWN STATE ZIP

–

Check Appropriate Boxes

GENDER: ❏ Male ❏ Female

U.S. CITIZEN: ❏ Yes ❏ No

If “No”, currently a citizen of: _________________

ETHNICITY:

What is your racial background?

❏ American Indian/Alaskan Native❏ Black, Non-Hispanic Origin❏ Asian/Pacific Island❏ Hispanic❏ White, Non-Hispanic Origin❏ Other _________________________

WORK PHONE CELL PHONE FAX NUMBER HOME PHONE

COURSE NUMBER

NO

N-C

RE

DIT

CO

UR

SE

S

BUSINESS ADDRESS:

PERMANENT(HOME) ADDRESS:

XStudent’s Signature

rev

March

2016

LOCATION

Payment will be handled by the Maine Department of Education-CTE Safety Grant 2017. Once payment is received, a letter and registration packet will be sent to your home address or emailed upon request.

EMAIL ADDRESS

I certify that to the best of my knowledge the information I have given is correct and complete.

My signature on this form confirms that, should my employer default on this agreement, I am responsible for any and all charges incurred by Keene State College, including any additional collection costs associated with the satisfactory conclusion of this debt.

Payment Information:

Terms and Conditions of registration can be found at oshaednecom (located with the Registration Forms).

FAX to: 207-624-6821 Atten: Elaine BriggsScan & email to: [email protected]: [email protected]

I wish to further restrict information Initial here:

Note to OTIEC Region 1 / Keene State College Safety Education Center course registrants: Provision of email and telephone contact information implies consent to be contacted for registration, attendance and transcript records use, and future communication for announcements and updates. Data collected for registration is confidential and is not publically released, rented or sold.

Group: Maine CTE Safety Grant 2017

❏ Resident of N.H. ❏ Not a resident of N.H.

OSHA Training Institute Education Centers Program OSHA Outreach Trainer Course

PREREQUISITE VERIFICATION FORM Read instructions before completing this form.

OSHA Form 4-50-10 May 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 constructionsafety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP) or Certified Industrial Hygienist (CIH) 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 industrysafety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP) or Certified Industrial Hygienist (CIH) 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 safetyexperience. Additional requirements include two years of occupational safety and health experience (with a broad focus) in any industry; acollege degree in occupational safety and health, from an accredited college or university; an Associate Safety Professional (ASP), Certified SafetyProfessional (CSP), Certified Industrial Hygienist (CIH) or Certified Marine Chemist (CMC) designation.

OSHA #5600 Disaster Site Worker – OSHA #500 Trainer Course in Occupational Safety and Health for the Construction Industry or OSHA #501 TrainerCourse 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 mostrecent 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 morethan 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

Elaine Briggs ([email protected])

or fax: 207-624-6821




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



24. Employer Address

Company:

Address:

City: State: ZIP:









Page 3 of 7

List Work Experience with Next Most Recent Employer



34. Employer Address

Company:

Address:

City: State: ZIP:






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 Industrial Hygienist (CIH)

Date of Graduation I am a Certified Safety & Health Manager (CSHM) (maritime applicants only)

Name of Degree 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:




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)




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) or Certified Industrial Hygienist (CIH) 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 ofgeneral industry safety experience. A college degree in occupational safety and health, a Certified Safety Professional (CSP) or Certified Industrial Hygienist (CIH) 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 ofmaritime 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) or Certified Marine Chemist (CMC) 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 tobeing 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 trainercourse 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 maintaintheir 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.

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.




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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 prerequisitecourse(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 prerequisitecourse(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 prerequisitesare the OSHA #5410 or OSHA #5400, for the OSHA #5402 the prerequisites are the OSHA #5400 or OSHA #5402.

For the OSHA #5600, the prerequisitesare 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 thesafety of others.Indicate the percentage of time devoted toeach area listed below.

Note: Related experience must be detailedsince this document is a record of safetyexperience and will be carefully reviewedto determine whether eligibilityrequirements 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.

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.




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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.

Documents

2016-2017 Course Locations and Supporting Organizations … Training... · 44 Woodrock Rd., Ste 1. • Weymouth, MA Assabet Valley Regional Technical High School. 21 Fitchburg