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Exp Shts

The document is a prerequisite verification form for the OSHA Trainer Course under the OSHA Training Institute Education Centers Program. It requires detailed work experience information, including employer details, job responsibilities, and safety-related activities. The form is structured to capture multiple employers' information and is intended for use in verifying qualifications for the training course.

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Mago_88
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10 views3 pages

Exp Shts

The document is a prerequisite verification form for the OSHA Trainer Course under the OSHA Training Institute Education Centers Program. It requires detailed work experience information, including employer details, job responsibilities, and safety-related activities. The form is structured to capture multiple employers' information and is intended for use in verifying qualifications for the training course.

Uploaded by

Mago_88
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

OMB Control Number – 1218-0

Expiration Date XXXX


OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.

List work experience with most recent employer first


Employer Name
10. Contact Person:
and Job Title: 11.

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. What percentage of this position 0%
(mm/dd/yyyy): (mm/dd/yyyy): is safety related?
18. Describe Safety Responsibilities and Activities in this Position:

19. Describe Overall Job Duties in this Position:

Office Use Only Length of experience in this job (years/months):

OSHA 4-50.13
Page 2 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.

List Work Experience with Next Most Recent Employer

Employer Name
20. 21. Contact Person:
and Job Title:

22. Contact Person’s Phone Number: 23. Contact Person’s Email Address:

24. Employer Address:

Company:

Address:

City: State: ZIP:


25. Start Date of Employment 26. End Date of Employment 27. What percentage of this
(mm/dd/yyyy): (mm/dd/yyyy): position is safety related? 0%
28. Describe Safety Responsibilities and Activities in this position.

29. Describe Overall Job Duties in this Position:

Office Use Only Length of experience in this job (years/months):

OSHA 4-50.13
Page 3 of 8
OMB Control Number – 1218-0
Expiration Date XXXX
OSHA Training Institute Education Centers Program
OSHA Trainer Course
PREREQUISITE VERIFICATION FORM
Read instructions on pages 6-8 before completing this form.
Note: Multiple Copies of Page 4 may be included to ensure all applicable experience is listed.

List Work Experience with Next Most Recent Employer

Employer Name
30. 31. Contact Person:
and Job Title:

32. Contact Person’s Phone Number: 33. Contact Person’s Email Address:

34. Employer Address:

Company:

Address:

City: State: ZIP:


35. Start Date of Employment 36. End Date of Employment 37. What percentage of this
(mm/dd/yyyy): (mm/dd/yyyy): position is safety related? 0%
38. Describe Safety Responsibilities and Activities in this Position:

39. Describe Overall Job Duties in this Position:

Office Use Only Length of experience in this job (years/months):

OSHA 4-50.13
Page 4 of 8

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