Form assigned Att.1_National Laboratory Training Network-Paper

Form Approved

OMB No. 0920-0017

Exp. Date: 00/00/00

National Laboratory Training Network

Registration Form

(Please type or print.)

Training Event Title:

Event Code: Date: Location: (City, State)

and or Event Type: (e.g., teleconference, web-based, workshop)

S ite Facilitatior’s Information

(Dr./Mr./Miss/Ms./Mrs.)

Title: First Name: M.I. Last Name:

Position Title: State Licensure Number (If applicable):

Employer’s Name:

Mailing Address: (Please specify, Employer’s or your Home address?)

City: State/Country: Zip/Postal Code:

Work Phone Number: Work Fax Number:

E-mail Address: (E-mail future training event notifications? Please circle, YES or NO.)

(Please review all options in the three categories before circling the one most appropriate in each category.)

Occupation Type of Employer

Physician 01 Public Health Department (State or Territorial) 01

Veterinarian 02 Public Health Department (Local, City or County) 03

Laboratorian 04 Government (Other Local, not City or County) 04

Nursing Professional 05 Centers for Disease Control and Prevention 05

Sanitarian 06 U.S. Food and Drug Administration 09

Administrator 08 U.S. Department of Defense 11

Safety Professional 11 Veterans Administration Medical Center/Hospital 12

Educator 13 Other (Federal Employer) ___________________________ 15

Epidemiologist 14 Foreign 16

Environmental Scientist 15 College or University 19

Other ______________________ 12 Private Industry 21

Private Clinical Laboratory 23

Physician’s Office Laboratory/Group Practice 24

Hospital 33

Education Level (Highest Completed) Health Maintenance Organization 28

Degree Non-profit 31

Associate 04 Unemployed or Retired 32

Bachelor 05 Environmental Laboratory 34

Masters 06 Veterinary Laboratory 35

Doctoral (M.D.) 07 Agricultural Laboratory 36

Doctoral (Other than M.D.) 08 Other ___________________________________________ 30

Technical/Hospital School 09

Some College 03

High School Graduate 02

Some High School 01

Other ______________________ 10 Return form to:

The information requested on this form is collected under the authority _____________________________________

of 42 U.S.C., Section 243 (CDC). The requested information is used only

to process your training registration and will be disclosed only upon your

written request. Continuing education credit can only be provided when _____________________________________

all requested information is submitted. Furnishing the information

requested on this form is voluntary.

Public reporting burden for this collection of information is estimated to _____________________________________

average five minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining

the data needed, and completing and reviewing the collection of information. _____________________________________

An agency may not conduct or sponsor, and a person is not to respond to a

collection of information, unless it displays a currently valid OMB control

number. Send comments regarding this burden estimate or any other aspect _____________________________________

of this collection of information, including suggestions for reducing this burden

to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, N.E., MS D-24,

Atlanta, Georgia 30333; ATTN: PRA (0920-0017). CDC 32.1 (Rev. 05/10/2006)