CHP1 confirmation/certification
PRINT (1st READ CAREFULLY)
Check for accuracy and if necessary return to the form with your browser's "back" button and correct and re-submit.  PRINT, get signatures, copy (keep the original) and file copy/ies as directed by your group/department.
Last Name, First Name
 last, first		 date
 		 Department
dept 		Job title
jobtitle   
Workroom(s) --  include bldg(s)
workrooms 		email
email 		Staff Classification
staffclass 		Supervisor
supervisor
CompletedAndUnderstoodTrainingModule CompletedAndUnderstoodTrainingModule
InformedOfLabStandardContentsAndLocation InformedOfLabStandardContentsAndLocation
InformedOfCHPLocationAndAvailability InformedOfCHPLocationAndAvailability
InformedOfSafetyInfoLocationAndAvailability InformedOfSafetyInfoLocationAndAvailability
InformedOfExposureSignsAndSymptoms InformedOfExposureSignsAndSymptoms
InformedOfPELs InformedOfPELs
TrainedAboutMethodsAndObservationsToDetectRelease TrainedAboutMethodsAndObservationsToDetectRelease
TrainedAboutPhysicalAndHealthHazards TrainedAboutPhysicalAndHealthHazards
TrainedAboutProtectiveMeasures TrainedAboutProtectiveMeasures
TrainedAboutCHPDetails TrainedAboutCHPDetails
UnderstandWhomToAskQuestions UnderstandWhomToAskQuestions
CHP2 options CHP2options  

  
Signature

date _________________
Signature of person named here affirms that training material has been read completely, and that serious and careful effort will be made to remain abreast of all relevant safety and health rules which affect his/her work.

Not valid without all information requested above and below
Supervisor affirms that the person named above has demonstrated satisfactory competence and understanding of the principles and procedures of this training.  (Supervisor is not expected to guarantee that there will never be mistakes, and no liability is assumed by your signature that does not already exist.   Demonstration of understanding and competence is required by law.) 
Supervisor
(print name)		  
Supervisor
 signature

 

Supervisor must be Faculty, or Center/Laboratory/Facility Director, and in approved cases other technical or AP staff may sign for staff/students working in an area for which the technician/AP staff member has full responsibility, including firm control of funding and of who is approved to work in the area and who is not.  Faculty members and Directors may sign as their own supervisor.

     SUBMIT a signed copies to your dept/group as appropriate; requirements differ widely.  Contact your safety committee or safety committee representative. 
     It is a Federal and State requirement that all staff receive all necessary and appropriate training to help minimize all work place hazards.  The reading exercise certified here satisfies only a small part of OSHA requirements for safety training.  Work-area specific chemical safety training and other training is required.  REM offers a number of training classes to help with this, and sometimes it is only the work area supervisor( or someone else completely familiar with all of the local work area hazards) who can adequately provide training.  For more detail see the REM training page.