Form 182 Student Data Form

Student Data Form

U.S. DEPARTMENT OF LABOR

Occupational Safety and Health Administration
Public reporting burden for this collection of information is voluntary and is estimated to average 5 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the Office of Administration and Training Information, OSHA
Directorate of Training and Education, 2020 S. Arlington Heights Road, Arlington Heights, Illinois 60005. Persons are not required to
respond to the collection of information unless it displays a current valid OMB control number.

1. Course Number

FORM APPROVED
OMB NO. 1218-0172
Expires: 08-31-13

2. Course Dates (MM/DD/YY)

PERSONAL DATA
4. Job Title

3. Name

5. Local Lodging

EMPLOYER DATA
6. Name of Employer

7. Street Address

8. E-Mail Address

9. City

10. State

11. ZIP Code

EMERGENCY CONTACTS
13. Phone Number (Including Area Code)

12. Name of Supervisor

14. Name of Alternate Contact

15. Phone Number (Including Area Code)

STUDENT GROUPS
(Mark an “X” in the appropriate boxes. Complete only ONE of the following five sections #16 - #20.
(a)
16. FEDERAL OSHA

Region

National
Office

1

2

3

4

5

6

(2) Health

9

10

(3) Other __________________________________________

(a) State Program

18. OTHER GOVERNMENT
AGENCY

8

(b) Job Specialization
(1) Safety

17. STATE OSHA

7

(b) Job Specialization

(1) Compliance

(1) Safety

(2) Health

(2) Consultation

(3) Other___________________

a. Federal

c. City/County

b. State

d. Other___________________

a. Employer Representative

c. Government Contractor Employee

b. Employee Representative

d. Other___________________

19. PRIVATE SECTOR

20. INTERNATIONAL
STUDENT

Name of Country____________________________________________________________
(Previous editions are obsolete)

OSHA FORM 182 8/10 Edition