
HAZMAT EMPLOYEE TRAINING RECORD AND CERTIFICATION
EMPLOYEE NAME LAST FIRST MIDDLE EMPLOYER NAME
EMPLOYEE IDENTIFICATION NUMBER LOCATION STREET
POSITION/JOB DESCRIPTION CITY STATE ZIP CODE
ATTACH NECESSARY DOCUMENTATION TO
SUBSTANTIATE THE ABOVE TRAINING REQUIREMENTS
©
Copyright 2005 J. J. KELLER & ASSOCIATES, INC. 256-F 10614
Neenah, WI • USA • (800) 327-6868 • www.jjkeller.com
HAZMAT EMPLOYEE TRAINING REQUIRED
General Awareness
Function-specific
Safety Training
Security Awareness Training
In-Depth Security Training
Driver Training
REGULATIONS
§172.704(d) Recordkeeping. A record of current training, inclusive of the preceding three years, in accordance with this section
shall be created and retained by each hazmat employer for as long as that employee is employed by that employer as a hazmat
employee and for 90 days thereafter. The record shall include: (1) The hazmat employee's name; (2) The most recent training
completion date of the hazmat employee's training; (3) A description, copy, or the location of the training materials used to meet
the requirements in paragraph (a) of this section; (4) The name and address of the person providing the training; and (5)
Certification that the hazmat employee has been trained and tested, as required by this subpart.
§172.704(e) Limitation. A hazmat employee who repairs, modifies, reconditions, or tests packagings as qualified for use in the
transportation of hazardous materials, and who does not perform any other function subject to the requirements of this
subchapter, is not subject to the safety training requirement of paragraph (a)(3) of this section.
INSTRUCTIONS
The training requirements in §172.704 and 177.816 cover six areas of training for hazmat employees. Based on the training
required for the above named hazmat employee, provide the training and testing for compliance. Satisfy the recordkeeping
requirements in 172.704(d) by completing the information on this form.
SECTION 1 CURRENT TRAINING
COMPLETION DESCRIPTION OF TRAINING, COPY OR TRAINING AND TESTING
DATE LOCATION OF TRAINING MATERIALS USED
TRAINER/ADDRESS
CERTIFIED BY
DATE
SECTION 2 RELEVANT TRAINING
Provide information from previous hazmat employment training. Attach appropriate current records from the previous employer.
SECTION 3 RECURRENT TRAINING
COMPLETION DESCRIPTION OF TRAINING, COPY OR TRAINING AND TESTING
DATE LOCATION OF TRAINING MATERIALS USED
TRAINER/ADDRESS
CERTIFIED BY
DATE