Application for Training - National Laboratory Training Network Registration form

Attachment 3
National Laboratory Training Network Registration Form

NLTN
Data
Elements
Document

2013
Application for
Training

Table of Contents
Course Selection and Registration

3

Personal Information

4

Organization Information

5

Contact Information

6

Other Information

7

2

1. Course Selection and Registration

Figure 1A

Form Approved
OMB No. 0920-0017
Exp. Date: XX/XX/20XX

Public reporting burden of this collection of information is estimated to average 5 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 this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA(0920-0017).

3

2. Personal Information
Figure 2A

4

3. Organization Information

Figure 3A

5

4. Contact Information
Figure 4A

6

5. Other Information
Values Collected – Dropdown Lists on Create New Account Step 1 of 3

Occupation
Physician
Veterinarian
Laboratorian
Nursing Professional
Sanitarian
Administrator
Safety Professional
Educator
Epidemiologist
Environmental Scientist
Other

Employer Type
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

Education Level (Highest Completed)
Degree
Associate
Bachelor
Masters
Doctoral (M.D.)
Doctoral (Other than M.D.)
Technical/Hospital School
Some College
High School Graduate
Some High School
Other

7