1218-0172_Student_Data_Form_with_Instructions omb 04_24_17

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 Training Programs and Administration, OSHA Directorate of Training and Education, 2020 S. Arlington Heights Road, Arlington Heights, Illinois 60005-4102. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number.

FORM APPROVED OMB NO. 1218-0172 Expires xx-xx-xxxx

C OURSE DATA

1. (a) Course Number and Title 2. Course Dates (MM/DD/YY)

(b) Scheduled Offering ID _______________________________ Start Date: ____ / ____ / ____ End Date: ____ / ____ / ____

PERSONAL DATA

3 . Student Legal Name 4. (a) Job Title

_________________________________

________________________ _____ ___________________________

First M.I. Last (b) Job Specialization

Safety Health Whistleblower Investigator Other________________

5. Work Phone 6. Mobile Phone

7. Work Email

ORGANIZATION DATA

8. Organization Name

9. Street Address

1 0. City 11. State 12. ZIP Code 13. Country

SUPERVISOR DATA

1 4. Supervisor Legal Name 15. Supervisor Mobile Phone

_______________________ ____ ______________________________

First M.I. Last

1 6. Work Email .

17. Hotel Name and Location

STUDENT GROUP

(Complete this section by making a single selection from only one of the following group sections #19 - #22)

18. FEDERAL OSHA	(a) Region	1 2 3 4 5 6 7 8 9 10
	(b) National Office	DOC DEP DSG DCSP DTSEM DEA DAP DWPP DTE OTHER
19. STATE OSHA PROGRAM	(1) Enforcement (2) Consultation
20. OTHER GOVERNMENT AGENCY	a. Federal b. State c. Local d. International
21. PRIVATE SECTOR	a. Employer Representative c. Government Contractor Employee b. Employee Representative d. International

(Previous editions are obsolete) OSHA FORM 182

Instructions for State OSHA Training Coordinators, Other Government Agency, and Private Sector Students

State OSHA Training Coordinators are required to use this form to register students in Learning Link. Complete the Student Data Form and submit it to the OSHA Training Institute (OT) Student Services at OTI.Registration@dol.gov. Other Government Agency (other than federal and state OSHA) and private sector students requesting enrollment in OTI courses, seminars, etc. must complete the Student Data form and submit it to OTI Student Services at OTI.Registration@dol.gov. PLEASE NOTE: State OSHA Training Coordinators do not need to complete Items 1 through 3.

Item 1a Course Number and Title

List the complete course number and full title.

Item 1b Scheduled Offering ID

Enter the Scheduled Offering ID which can be located in the online catalog.

Item 2 Course Dates

Enter the start and end dates of the course

Item 3 Student Legal Name

Enter the student’s legal first name, middle name or initial and last name as it appears on their birth certificate.

Item 4a Job Title

Enter the student’s official Job Title.

Item 4b Job Specialization

Place an “x” in the box to indicate the appropriate job specialization.

Item 5 Work Phone

Enter the student’s work phone number.

Item 6 Mobile Phone

Enter the student’s cell phone number.

Item 7 Work Email

Enter the student’s official work email address.

Item 8 Organization Name

Provide the name of the organization for which the student works. NOTE: State OSHA should type either (state name) Enforcement or (state name) Consultation.

Item 9 Street Address

Provide the street address where student works.

Item 10 City

Provide the name of the city where student works.

Item 11 State

Provide the state where student works.

Item 12 Zip Code

Provide the zip code where student works.

Item 13 Country

For international students, enter the country where the student works.

Item 14 Supervisor Legal Name

Enter the supervisor’s legal first name, middle name or initial and last name as it appears on their birth certificate.

Item 15 Supervisor’s Mobile Number

Enter the supervisor’s mobile number.

Item 16 Work Email

Enter the supervisor’s work email.

Item 17 Hotel Name and Location

Enter the name and location of your hotel.

Items 18 through 21 - Student Group

Select only one student group.

Item 18 Federal OSHA

If student works for federal OSHA, place an “x” in the box for the appropriate OSHA Region or National Office Directorates.

Item 19 State OSHA Program

If student works for a state OSHA program, place an “x” in the box for the appropriate program, either Enforcement or Consultation.

Item 20 Other Government Agency

If student works for another government agency, place an “x” in the appropriate box for either Federal, State, Local, or International agency.

Item 21 Private Sector

If student works for the private sector, place an “x” in the appropriate box for Employer Representative, Employee Representative, Government Contractor, or International Corporation.