LEVEL ONE & LEVEL TWO CERTIFICATES Progress Log / Application Form

MIOSHA Training Institute certificates will be awarded upon successful completion of the required + elective courses listed for each program. There is no expiration or renewal for these programs. The intent of this form is for you to track the courses you complete and then submit this same form as application. Please retain a copy of this application for your own records. All MTI classes statewide will be transcripted at MacombCC, and you may view your progress online with WebAdvisor: https://webadvisor.macomb.edu/.

WebAdvisor most effective for transcripts if you provide full SocSec# on MTI registration forms, or birthdate may be alternate unique identifier for your records.

MTI_1617_ProgressLogApp / Rev.07-15-2016

Level One – Safety & Health General Industry Certificate Timeline to complete Level One is 3 years from date of first course attended in this track.

2 COURSES REQUIRED:

Date-s Attended Location Attended

MIOSHA General Industry 10-Hour + (3-day course)

Elements of a Safety & Health Management System (2-day) (formerly titled Blueprint S&H Mgmt System)

SELECT 2 ELECTIVE COURSES FOR TOTAL 4 COURSES:

*Asterisk notates course eligible toward multiple MTI certificate programs.

* Supervisor’s Role in Safety & Health

* When MIOSHA Enforcement Visits

Machine Guarding & Hazard Identification

* Human Factors Engineering (formerly titled Ergonomic Principles)

Job Safety Analysis, Made Easy (Effective March’2014, eligible elective for L1GI Certificate) Fact (this course also meets requirements for Level Two Health Certificate)(or if you successfully completed MIOSHA Recordkeeping & Cost of Injuries before 10/2016, still eligible elective for L1GI Certificate)

Level One - Safety & Health Construction Certificate Timeline to complete Level One is 3 years from date of first course attended in this track.

3 REQUIRED COURSES:

Date-s Attended Location Attended

MIOSHA Construction 10-Hour Course

MIOSHA Construction – Part 45 Fall Protection (Required effective 4/26/13, previously elective)

Health Hazards in Construction (Required effective 7/9/12, previously elective)

SELECT 4 ELECTIVE COURSES, TOTAL 7 COURSES:Asterisks notate course meets requirements also for other *Level One or **Level Two Certificate tracks.

** MIOSHA Recordkeeping & Cost of Injuries

* Supervisor’s Role in Safety & Health

* When MIOSHA Enforcement Visits

Asbestos & Lead Awareness

Electricity: The Invisible Killer

Excavations: The Grave Danger

Part 2 (CS) – Masonry Wall Bracing

Part 10 (CS) – Cranes and Derricks

Part 12 (GI) – Scaffolds & Scaffold Platforms

Part 13 (CS) – Mobile Equipment & Work Zone Safety

Part 32 (CS) – Aerial Work Platforms

**Part 451 (OH) – Respiratory Protection

**Parts 6 (CS), 33 & 433 (GI) – Personal Protective Equipment Standards for GI & CS

**Parts 17 (CS), 39 & 40 (GI) – Electrical Standards for General Industry & Construction

**Parts 92 & 430 (GI), 42 (CS) – Hazard Communication & Right to Know Requirements

(GI) = General Industry Safety Standards, (CS) = Construction Safety Standards, (OH) = Occupational Health Standards.

Occupational Health CertificateAsterisks notate course eligible also toward other *Level One or **Level Two Certificate.

TOTAL 5 COURSES REQUIRED:

Date-s Attended Location Attended

**Parts 92 & 430 (GI), 42 (CS) – Hazard Communication & Right to Know Requirements

**Part 380 (OH) –Occupational Noise Exposure & Hearing Conservation

**Part 451 (OH) – Respiratory Protection

**Part 472 (OH)– Medical Services, First Aid & Part 554 (OH)–Blood Borne Infectious Diseases

*Human Factors Engineering (formerly titled Ergonomic Principles)

Or

**Parts 90 (GI) & 490 (OH) – Permit Required Confined Spaces

Level Two - Safety & Health Management Systems Certificate TOTAL 6 COURSES REQUIRED: (Note- Job Safety Analysis class eligible only if attended prior to March’2014)

Date-s Attended Location Attended

Advanced Accident Investigation

Behavior-Based Safety: Fundamentals & Implementation (New Mar’2014, previously required JSA)

Continuous Safety & Health Improvement

Creating a Positive Safety Culture

Effective Safety & Health Training

*MIOSHA Recordkeeping & Cost of Injuries (or if completed Workplace Inspection before 10/2016, still eligible)

Level Two – MIOSHA Compliance – General Industry Certificate ** Double-asterisk notates courses meeting requirements also for other Level Two Certificate tracks.

4 COURSES REQUIRED:

Date-s Attended Location Attended

Part 7 (GI) – Guards for Power Transmission

Part 85 (GI) – Control of Hazardous Energy Sources

**Parts 17 (CS), 39 & 40 (GI) – Electrical Standards for General Industry & Construction

**Parts 92 & 430 (GI), 42 (CS) – Hazard Communication & Right to Know Requirements

SELECT 5 ELECTIVE COURSES FOR TOTAL 9 COURSES:

Industrial Laser Safety

Industrial Robot Safety

Part 1 (GI) – General Provisions

Parts 2, 3 & 4 (GI)– Floor/Wall Openings, Stairways and Skylights, Ladders

Part 14 (GI) – Conveyors

Part 21 (GI) – Powered Industrial Trucks: What Every Trainer & Operator Should Know

Part 24 (GI) – Mechanical Power Presses

**Parts 6 (CS), 33 & 433 (GI) – Personal Protective Equipment Standards for GI & CS

**Parts 90 (GI) & 490 (OH) – Permit Required Confined Spaces

**Part 380 (OH) –Occupational Noise Exposure & Hearing Conservation

**Part 451 (OH) – Respiratory Protection

**Part 472 & 554 (OH)– Medical Services and First Aid, Bloodborne Infectious Diseases

(GI) = General Industry Safety Standards, (CS) = Construction Safety Standards, (OH) = Occupational Health Standards.

Level Two – MIOSHA Compliance –Construction Certificate

TOTAL 8 COURSES not previously attended for Level One Construction Certificate:

(All Construction courses are listed on previous page, see Level One Construction) Date-s Attended Location Attended

Name (exactly as you would like it printed on your certificate) _________________________________________________

Birthdate or SocSec# ____________________ Phone ____________________ Email ___________________________ Mailing Address preferred to receive your certificate:

Home Employer - Company Name: _________________________________________________________________

Address: __________________________________________________________________________________________________

City, State Zip: ____________________________________________________________________________________________

Applications are processed in the order received. Verified applications will have certificate printing occur on the 10th of each month. Allow 6-8 weeks processing to receive your certificate. Applications are required by postal mail, email or fax: Yvonne Grant/office – 586-498-4106

Macomb Community College Attention: Yvonne Grant / MTI 21901 Dunham, ClintonTownship MI 48036 or email to: mti@macomb.edu or fax to: 586-498-4058

www.michigan.gov/mti • www.macomb.edu/mti