Advanced Safety & Health Certificate Application | CSUDH CCPE

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Advanced Safety & Health Certificate
Application Form

Requirements for Certificate of Completion

To receive the CSUDH Advanced Safety & Health Certificate participants must complete at least three (3) courses through the CSUDH OTI Education Center.
The two final Advanced Safety & Health Certificate courses must be taken through the CSUDH OTI Education Center.
All coursework must be completed within three years after the official “certificate enrollment date.” The official “certificate enrollment date” is the first day of the first CSUDH OTI Education Center Certificate class the participant wishes to count towards the Certificate.

Requirements for Courses from Other OTIECs

Courses taken through other official OSHA Training Institute Education Centers can be used to fulfill up to four (4) courses required for the certificate of completion if these courses were completed within two (2) years prior to the participant’s official certificate begin date at CSUDH OTIEC.
Proof (certificate/transcript) for any course taken at another center should be emailed to osha@csudh.edu titled "Certificate Request {student name}" when submitting a Certificate Request.

Student Information
*Full Name:	[Name as it should appear on the printed Certificate]
*Full Mailing Address:	[Include Street Address, City, State and Zip Code]
*Student ID:
*E-mail Address:
Contact Phone:
*Certificate Track:	Construction Track General Industry Track

Required Courses (check all that apply)
Construction Track — (4 Required Courses) OSX 910 • OSHA 510 – OSHA Standards for the Construction Industry OSX 921 • OSHA 521 – OSHA Guide to Industrial Hygiene OSX 961 • OSHA 3095 – Electrical Standards OSX 905 • OSHA 3115 – Fall Protection — OR — General Industry Track — (4 Required Courses) OSX 911 • OSHA 511 – Occupational Safety and Health Standards for General Industry OSX 921 • OSHA 521 – OSHA Guide to Industrial Hygiene OSX 957 • OSHA 2225 – Respiratory Protection OSX 959 • OSHA 2264 – Permit-Required Confined Space Entry Electives for all Tracks — (3 Elective Courses) OSX 910 • OSHA 510 – OSHA Standards for the Construction Industry OSX 911 • OSHA 511 – Occupational Safety and Health Standards for General Industry OSX 950 • OSHA 500 – Trainer Course in OSHA for the Construction Industry OSX 951 • OSHA 501 – Trainer Course in OSHA for General Industry OSX 955 • OSHA 2015 – Hazardous Materials OSX 956 • OSHA 2045 – Machinery and Machine Guarding Standards OSX 995 • OSHA 2055 – Cranes in Construction OSX 957 • OSHA 2225 – Respiratory Protection OSX 958 • OSHA 2255 – Principles of Ergonomics OSX 959 • OSHA 2264 – Permit-Required Confined Space Entry OSX 960 • OSHA 3015 – Excavation, Trenching and Soil Mechanics OSX 961 • OSHA 3095 – Electrical Standards OSX 905 • OSHA 3115 – Fall Protection OSX 940 • OSHA 5119 – Cal/OSHA Standards for General Industry OSX 939 • OSHA 5109 – Cal/OSHA Standards for the Construction Industry OSX 918 • OSHA 5410 – OSHA for the Maritime Industry OSX 965 • OSHA 5400 – Trainer Course in OSHA for the Maritime Industry OSX 963 • OSHA 5600 – Disaster Site Worker Trainer Course OSX 964 • OSHA 6000 – Collateral Duty Course for Other Federal Employees OSX 971 • OSHA 7505 – Introduction to Incident (Accident) Investigation OSX 993 • 40 Hour HAZWOPER OSX 941 • EM 385-1-1 OSX 995 • Safety Audits and Inspections OSX 914 • Cal/OSHA Legal Processes OSX 949d • Trainer Course – Aerial Lifts OSX 949b • Trainer Course – Fall Protection OSX 949 • Trainer Course – Forklift Safety OSX 995 • Trainer Course – Rigging Safety

Required Courses (check all that apply)

Construction Track — (4 Required Courses)

OSX 910 • OSHA 510 – OSHA Standards for the Construction Industry
OSX 921 • OSHA 521 – OSHA Guide to Industrial Hygiene
OSX 961 • OSHA 3095 – Electrical Standards
OSX 905 • OSHA 3115 – Fall Protection

— OR —

General Industry Track — (4 Required Courses)

OSX 911 • OSHA 511 – Occupational Safety and Health Standards for General Industry
OSX 921 • OSHA 521 – OSHA Guide to Industrial Hygiene
OSX 957 • OSHA 2225 – Respiratory Protection
OSX 959 • OSHA 2264 – Permit-Required Confined Space Entry

Electives for all Tracks — (3 Elective Courses)

OSX 910 • OSHA 510 – OSHA Standards for the Construction Industry
OSX 911 • OSHA 511 – Occupational Safety and Health Standards for General Industry
OSX 950 • OSHA 500 – Trainer Course in OSHA for the Construction Industry
OSX 951 • OSHA 501 – Trainer Course in OSHA for General Industry
OSX 955 • OSHA 2015 – Hazardous Materials
OSX 956 • OSHA 2045 – Machinery and Machine Guarding Standards
OSX 995 • OSHA 2055 – Cranes in Construction
OSX 957 • OSHA 2225 – Respiratory Protection
OSX 958 • OSHA 2255 – Principles of Ergonomics
OSX 959 • OSHA 2264 – Permit-Required Confined Space Entry
OSX 960 • OSHA 3015 – Excavation, Trenching and Soil Mechanics
OSX 961 • OSHA 3095 – Electrical Standards
OSX 905 • OSHA 3115 – Fall Protection
OSX 940 • OSHA 5119 – Cal/OSHA Standards for General Industry
OSX 939 • OSHA 5109 – Cal/OSHA Standards for the Construction Industry
OSX 918 • OSHA 5410 – OSHA for the Maritime Industry
OSX 965 • OSHA 5400 – Trainer Course in OSHA for the Maritime Industry
OSX 963 • OSHA 5600 – Disaster Site Worker Trainer Course
OSX 964 • OSHA 6000 – Collateral Duty Course for Other Federal Employees
OSX 971 • OSHA 7505 – Introduction to Incident (Accident) Investigation
OSX 993 • 40 Hour HAZWOPER
OSX 941 • EM 385-1-1
OSX 995 • Safety Audits and Inspections
OSX 914 • Cal/OSHA Legal Processes
OSX 949d • Trainer Course – Aerial Lifts
OSX 949b • Trainer Course – Fall Protection
OSX 949 • Trainer Course – Forklift Safety
OSX 995 • Trainer Course – Rigging Safety

Student Signature
Initials
Date
I would like to be contacted to provide a review/testimonial about my experience in the program.

Advance Safety and Health Certificate

Advanced Safety & Health CertificateApplication Form