This registration information is required for any persons within the Manufacturers’ Health and Safety Association’s membership who are pursuing the Manufacturing Safety Officer (MSO) Certification. This registration form also tracks training accomplishments for the MSO Certification process. Once this form is completed, please send it into your regional MHSA office.

Please print the following information:

Last Name:______________________ First Name:_____________________ Initial:______

Company Name:___________________________________________________________

Company Address:_________________________________________________________

City:____________________ Province:___________ Postal Code:____________

Email Address:_____________________________ Fax:___________________________

Company Phone:________________________ Home Phone:_________________

Date of Registration:_____________________

The Participant must also submit a recommendation letter from their employer(s) verifying a minimum of three (3) years experience in the manufacturing industry. Certification will only be granted once the required courses are in place and test is completed.

MHSA Office Use Only:

Date Registration Received:______________________ MSO File #:____________

Registration Approved By:______________________________ Position:______________________________

Letter(s) of Employer Recommendation Received From:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

MSO Course Tracking Information

Compulsory Courses

Accident Investigation (1-Day) Date Completed:________________________

Back Injury Prevention (1/2- Day) Date Completed:________________________

Effective Disability Management (2-Day) Date Completed:________________________

Safety Basics (2-Day) Date Completed:________________________

Standard First Aid (2-Day) Date Completed:________________________

Substance Abuse Prevention Program (SAAP) (1-Day) Date Completed:________________________

Leadership for Safety Excellence (2-Day) Mark:____________ Date Completed:________________________

Workplace Hazardous Information System (1-Day) Date Completed:________________________ (WHMIS) Train the Trainer

General Safety Regulations Competency Mark:____________ Date Completed:________________________
Test (prepared by the MHSA)

Applicant Must Submit the Following:

Copy of Toolbox Meeting prepared and conducted by applicant Date Submitted:________________________

Copy of an Accident Investigation completed by applicant Date Submitted:________________________

Copy of a Company Hazard Assessment completed by applicant Date Submitted:________________________

Copy of a Company Worksite Safety Inspection completed by applicant Date Submitted:________________________

Elective Courses (any four of the following)

Basic Rigging (1-Day) Date Completed:________________________

Behaviour Based Safety Date Completed:________________________

Confined Space Awareness Date Completed:________________________

Driver Fatigue Management Date Completed:________________________

Emergency Planning Date Completed:________________________

Ergonomics Date Completed:________________________

Fall Protection Awareness (1-Day) Date Completed:________________________

Fire Safety Program Date Completed:________________________

Forklift Training (1-Day) Mark:____________ Date Completed:________________________

Health and Safety Committees (1/2-Day) Date Completed:________________________

Indoor Air Quality Date Completed:________________________

Industrial Hygiene Date Completed:________________________

Noise and Hearing Conservation Date Completed:________________________

Overhead Crane Train the Trainer (1-Day) Mark:____________ Date Completed:________________________

Respiratory Protective Equipment- Certified Fit Tester Date Completed:________________________

Safety Auditor Training and Certification Date of Peer Audit:____________________ Date Completed:________________________
(2-Day)

Transportation of Dangerous Goods (TDG) Train the Trainer Date Completed:________________________

Violence and Harassment in the Workplace Date Completed:________________________

Every two (2) years the Manufacturing Safety Officer must obtain a total of 8 credits.

2 Days = 4 Credits: 1 Day = 2 Credits: ½ Day = 1 Credit