Annual report

ATTACHMENT D

NIOSH Spirometry Training Program Annual Report

Form Approved

OMB NO. 0920-0138

Expiration Date: 11/30/20xx

NIOSH Spirometry Training Program Annual Report

Please submit this form to [email protected].

RE: NIOSH-APPROVED COURSE NO. __________

1. Conducting Courses ☐ Yes ☐ No

2. Initial Course

Course Location (state/country) Course Dates No. Students Trained

3. Refresher Course

Course Location (state/country) Course Dates No. Students Trained

4. Are any of the listed faculty members no longer teaching in your course? Faculty (lecturers and practicum instructors) must be approved by NIOSH. Please send NIOSH a request for approval and a current CV for prospective faculty members.

Faculty Member Name No Longer Teaching

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