OSHA Outreach Request

If this is your first request, please download the following and submit a copy of your your trainer card or certificate to outreach@rrcc.edu for processsing prior to submitting the OSHA Outreach Request form:

Training Report
PDF (Adobe Acrobat Reader Required)
Microsoft Word

Your Information
*First Name:	A value is required.	*MI	A value is required.	*Last Name	A value is required.
Company Name
*Address	A value is required.

*City	A value is required.	*State		*Zip	Invalid format.A value is required.
*Phone	A value is required.	Ext
*Email	Invalid format.A value is required.
Address Change	Check this box if your card needs to be updated to this address.
Trainer Details
Trainer ID# Must have RMEC#	A value is required.*required
Course taught	(Please indicate Construction/GI – 10 or 30 hour)
Course End Date:	A value is required.Invalid format. mm/dd/yyyy*required
Number of Students:	A value is required.*required
Check all that apply	English Spanish Language other than English or Spanish Youth (18 & under) OSHA Alliance or partnership related
State where training was held or country if outside of U.S.
Required	This is required! Statement of Certification. I certify that I have conducted this outreach training class 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 if information provided herein is not true and correct. I further understand that providing false information herein may subject me to civil and criminal penalties under Federal law, including 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.
Trainer Signature
Trainer Signature	A value is required.required (By typing your name in here, you are attesting that all information provided in this submission is true and accurate.)*
Date	A value is required.Invalid format.*required

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Student Names:

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