Application for Training - National Laboratory Training Network Registration form (32.1)

National Laboratory Training Network

Form Approved
OMB No. 0920-0017
Exp. Date: 03/31/10

Registration Form

(Please type or print.)
Training Event Title:
Event Code:

Location: (City, State) or Event Type: (e.g., teleconference)

Date:

Applicant’s Information
Title:(Dr./Mr./Miss/Ms./Mrs.) 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:
Work Telephone Number:

State/Country:

Zip/Postal Code:
Work Fax Number:

E-mail Address: (Applicant must provide an e-mail address to receive an NLTN confirmation of registration.)
(To receive future training event notifications, please circle, YES.)

(Please review all options in the three categories before circling the one most appropriate in each category.)
Occupation
Physician
Veterinarian
Laboratorian
Nursing Professional
Sanitarian
Administrator
Safety Professional
Educator
Epidemiologist
Environmental Scientist
Other _____________________

01
02
04
05
06
08
11
13
14
15
12

Education Level (Highest Completed)
Degree
Associate
04
Bachelor
05
Masters
06
Doctoral (M.D.)
07
Doctoral (Other than M.D.)
08
Technical/Hospital School
09
Some College
03
High School Graduate
02
Some High School
01
Other _____________________ 10

Type of Employer
Public Health Department (State or Territorial)
Public Health Department (Local, City or County)
Government (Other Local, not City or County)
Centers for Disease Control and Prevention
U.S. Food and Drug Administration
U.S. Department of Defense
Veterans Administration Medical Center/Hospital
Other (Federal Employer) ____________________________
Foreign
College or University
Private Industry
Private Clinical Laboratory
Physician’s Office Laboratory/Group Practice
Hospital
Health Maintenance Organization
Non-profit
Unemployed or Retired
Environmental Laboratory
Veterinary Laboratory
Agricultural Laboratory
Other _________________________________________

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 information­requested­on­this­form­is­voluntary.
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.,
Mail Stop D24, Atlanta, GA 30333 ATTN: PRA (0920-0017).
CDC 32.1 (Rev. 03/14/2007)

Return form to

_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________

01
03
04
05
09
11
12
15
16
19
21
23
24
33
28
31
32
34
35
36
30