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This is the application to be completed to apply for our instructor training program to be an OSSA instructor.
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MISAFETY | Box 1231 | Nisku AB | T9E 8A8 | P 780 987 3465 | F 866 695 3655 | [email protected]
Instructor applica on and agreement
OSSA CSEM
2013
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MISAFETY | Box 1231 | Nisku AB | T9E 8A8 | P 780 987 3465 | F 866 695 3655 | [email protected]
REQUIREMENTS AND PROCESS FOR CERTIFICATION
1. Have a minimum of two years field experience in CSEM equivalencies will be considered.
2. Complete and forward the Instructor Applica on Form to MISAFETY for review.
3. Applicants must complete the MISAFETY OSSA CSEM Instructor Training course.
PROCESS:
1. Once we at MISAFETY receive the completed CSEM Instructor Applica on Form which details related pre-
requisite experience, training and employment references, the official process begins.
2. The applicant will then complete the End User OSSA CSEM course with a minimum grade of 90%.
3. Once the prerequisite course has been completed, the applicant will a end and successfully complete a
one day course on administra ve processes, program standards and instruc on techniques.
4. The successful applicant will then complete two co teach courses with a cer fied MISAFETY Instructor. The
first course will be 25% taught by the candidate and the second course will be 75% taught by the candidate.
If the instructor is given a 80% score on the course audit by his co teach instructor, then will then be cer fied
to teach.
Instructor Agreement
1. MISAFETY reserves the right to remove instructors cer fica on if an inves ga on
reveals courses were taught by the instructor not in accordance with the program standards.
2. Cer fica on is valid for two years.
3.All instructors must have an in class audit within 6 months of being approved and at least once every two
years a er that to maintain their approval to instruct the accredited course.
4. A minimum of three CSEM courses must be taught per year to maintain instructor cer fica on.
5. The agreement requires that the instructor has on hand all the necessary approved equipment and materi-
als for each course.
6. Instructor must have all required course equipment in class during the course and
must have a minimum of 8hrs instruc onal me.
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MISAFETY | Box 1231 | Nisku AB | T9E 8A8 | P 780 987 3465 | F 866 695 3655 | [email protected]
Instructor Program Applica on Form
Personal Informa on
Name _________________________________________
Address _______________________________________
City/Province ________________ Postal Code _________
Phone ________________ Fax _____________________
Cell __________________Email ____________________
Employer Informa on (Same as Above )
Supervisor Name _______________________________
Address _______________________________________
City/Province ________________ Postal Code _________
Phone ________________ Fax _____________________
Cell __________________Email ____________________
For what applica on or industry will you be using this training?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
What are your professional aspira ons for becoming an instructor?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
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MISAFETY | Box 1231 | Nisku AB | T9E 8A8 | P 780 987 3465 | F 866 695 3655 | [email protected]
D) WORK HISTORY
For this sec on, we would ask that you a ach a copy of your resume with special emphasis on employment
related to the Industrial CSEM field. Please be sure to include the following relevant informa on:
- Provide a minimum of 3 previous/current employment opportuni es related
to CSEM
- Previous/Current Employer/Company contact informa on
- The me period of employment
- Your Posi on and Descrip on of Du es
- Your Supervisor (s) and/or Manager (s) contact informa on
- Special Training and Courses
- Other Per nent Work experience/informa on
I hereby submit my applica on to become a MISAFETY OSSA Cer fied CSEM Instructor. I understand that the
informa on provided on this applica on is material per nent only to my acceptance as an instructor, and
that any inaccuracy or misrepresenta on will be sufficient reason for suspension and/or revoca on of any
cer fica on issued in response to this applica on.
Signature: __________________________ Date: _____________________