Form 1 Annual Report

ATTACHMENT D

Annual Report

Form Approved

OMB NO. 0920-0138

Expiration Date: xx/xx/xxxx

Annual Reporting Form

RE: NIOSH-APPROVED COURSE NO. __________

1. Conducting Courses  Yes  No

2. Introductory Course

Course Location (state) Course Dates No. Students Trained

3. Refresher Course

4. Are any of the listed faculty members no longer teaching in your course? If you currently have faculty who are not listed below, please forward a request to NIOSH for their approval and include a current CV from that individual.

Faculty Member Name No Longer Teaching

Dr. AAA 

Dr. BBB 

Mr. CCC 

Ms. DDD 

By clicking on the submit button, you are effectively signing this form.

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-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Public reporting burden for this collection of information is estimated to average 30 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 required 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 the burden estimate to CDC/ASTDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0138)