Safety Awareness Summary Form

Summary of Prior Learning - Safety Awareness

Students must consult with their mentor about the use of this summary form. This information provides the evaluator with an introduction to your learning. In the interview, the evaluator will ask you questions similar to those given in the Guide to Credit for Prior Learning. If necessary, you and the evaluator may agree on further methods of demonstrating your learning, including a written essay, a demonstration or performance, an examination or a sample of your work. Please attach appropriate documentation to this form.

You will be charged for your assessment of prior learning based on the IEF or IPLA fee structures as seen on If your first matriculated enrollment was the January 2012 term or later, you may incur additional charges for the submission of Individualized Prior Learning Assessments (IPLAs). If your first matriculated enrollment was prior to January 2012, you must have paid the Individual Evaluation Fee (IEF) before this request can be processed.

Please submit two copies of this form and two copies of any attached documentation to:
CDL Assessment Office, Empire State College, 113 West Avenue, Saratoga Springs, NY 12866.

Name:___________________________________________________________ESC ID:______________________


Phone (w)________________ (h)________________ Email Address:________


Please indicate if you are involved in any of the following CDL programs:

____AARP _____AT&T _____Lucent _____United Steelworkers

____Army _____Navy

Credits Requested:________ Level: Intro. or Advanced

Liberal Credit Requested:__________

Check the areas in which you believe you have competence. Identify whether you have an introductory or an advanced level of understanding.

Safety in the Workplace    
OSHA Required Training    
Hazard Awareness Training    
Industrial Hygiene    
Supervisor Safety Training    

1. List (or attach training documents for) any training programs you have taken in the area of safety awareness. Give the approximate dates and length of each workshop/class/seminar.

2. Please describe work experiences which have utilized your safety skills. Include names of businesses, agencies, organizations, positions held/tasks performed, time of involvement.

3. Define the following terms or programs:

  • Bloodborn Pathogen Program
  • Hazardous Communication Program
  • Lockout/Tagout
  • Job Safety Analysis
  • Personal Protective Equipment
  • Ergonomics
  • Americans with Disability Act
  • Noise and Hearing Conservation Program
  • Cumulative trauma disorders
  • Repetitive motion incidents
  • Indoor air quality programs
  • Right-to-know
  • Fire Brigades
  • Asbestos Abatement program