Request for Permission to Hold

OSHA Training with a Class Size over 40

Submit completed forms by “mail” to:
National Safety Education Center
Northern Illinois University
590 Garden Rd., EB 130
DeKalb IL 60115 /
PHONE:815-753-6904
TOLL FREE: 800-656-5317
WEB: / Submit completed forms by “email” to:
EMAIL:
Submit completed forms by “fax” to:
FAX: 815-753-4203

Outreach classes are limited to a maximum of 40 students. If a class is being planned which is expected to deviate from this, trainers must request an exception, however OSHA recommends that the class be divided. The request must be made at least 60 days prior to the start of the course. For further information, please see page 6 & 7 of the April 2011 Outreach Training Program Requirements.

This form must be completed in its entirety and submitted with a postmark, fax or email time stamp sixty days prior to the start date of the course. Failure to comply with the OSHA Outreach Training Program Requirements will result in automatic denial. Information contained in this form will be matched to the card request sent. Any discrepancies in student names, dates, etc. will be referred to OSHA before being processed.

The Trainer

Trainer Name
Work Phone / Cell Phone
Trainer Address / City, State, Zip
E-mail / NSEC Trainer Number
The Course
Start Date of Course / End Date of Course
Type of Training / 10-hour Construction / 10-hour General Industry / 30-hour Construction / 30-hour General Industry
Location of Training / Union Hall / Classroom / Breakroom / Hotel / Warehouse / Other
(Please specify)
Address where you will be providing the training (include city and state) / Is this a for-credit college course? / Yes
No
  1. Explain in detail why this course cannot be broken down into smaller sectionsto facilitate following the April 2011 Outreach Training Program Requirements? (For example, if multiple trainers are to be present, why do you feel it is not possibleto hold two concurrent sections of the course, with instructors rotating through the courses based on their expertise?)
  1. Provide a topic outline which indicates each topic, the length of time each topic will be taught, and what date and time the topic will be taught.

Topic / Length of Time Spent on Topic / Date Topic will be Covered / Time Topic Will Be Covered
  1. What materials will you be providing to the students? (At a minimum, trainers must provide students with a fact sheet on each topic covered.)
  1. What types of activities will the students be involved with? (Recall OSHA wants the training to be interactive and participatory.)
  1. How will students be able to ask questions when the class is not in session (for example e-mail, answering questions after class, and a Q&A session) so that class time is not spent on questions?
  1. How will you ensure participant attendance? At a minimum, you need to take attendance at the beginning and end of each class day. Only students who have signed in on ALL attendance sheets may receive cards. Trainers must retain these sign-in sheets in their class files.

  1. If more than one OSHA Authorized Outreach Trainer(s) will be assisting, please list their name, trainer ID number and expiration date of their trainer card?Please also list what percent of the class they will teach (Note: if there are multiple authorized trainers, the primary trainer must teach at least 20% of the course and must coordinate, document, and retain records of all training.)

AUTHORIZED Trainer Name
(List Primary Trainer first) / Trainer Number / Trainer Expiration / Percent of Time Training
(total must equal 100%)
  1. Please list anyadditional Guest Trainers used who are not authorized Outreach Trainers and their qualifications. (Note: If using a Guest Trainer, the Primary Trainer must teach a minimum of 50% of the course, be in attendance during the Guest Trainer’s presentation, and must coordinate, document, and retain records of all training.)

GUEST Trainer Name / Justification for use of this Guest Trainer (ie: their credentials) / Percent of Time Training
(total must equal 100%)
  1. Please include a brief description of any other relevant information that you feel will help us render a decision regarding permission for this extenuating circumstance.

10.Please list all student names that you anticipate completing the course.

Trainer Signature:______DateSUBMITTED:

If submitting this form by electronic means, by checking the box to the left or affixing signature, I attest that all information provided in this submission is true and accurate.

Note to Trainer: If approved, please submit a copy of the approval that you receive when you submit the card request for this class.

Office Use Only:
Date received______Date of course______Date within 60 days? Yes No

Approved? Yes NoDate Trainer Contacted______Approving Authority Initials______

If not approved, indicate reason: Outside 60 day requirementInadequate preplanning

Incomplete application Class size impractical Other ______

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