Request edit access
40 Hour HAZWOPER Training Registration
Please register by completing and submitting the form below. After submitting your registration, you will receive a confirmation email and an invoice with payment instructions.
Date of Birth
Los Angeles, CA
Name of Course
March 26-30, 2018
July 16-20, 2018
Last name, first name, Middle Initial
Home Email Address
Contact for Payment
Please bring a check to the first class or pay by credit card prior to class.
Are you currently employed?
Temporary / Contract
SECTION A - WORKPLACE INFORMATION
Note: if you are currently employed, please complete SECTION A. If not, skip to SECTION C - Information About You
Name of Employer
Work Phone #
Work Email Address
What is your job title?
Please do not use abbreviations.
What type of employer do you work for?
Local / county government
Do you belong to a union?
If you belong to a union, please provide Union and Local
What best describes the type of industry where you work?
Please check ONE only. If working as a consultant or inspector, choose teh item that best describes your clients' or inspection industry.
Public Safety / Emergency Response
Waste Treatment, Storage or Disposal
SECTION B - WORKSITE HAZMAT ACTIVITIES
What best describes the type of hazardous waste/HAZMAT operations at your worksite?
If working as a consultant or inspector, choose the item that best describes your clients' or inspection sites.
Transportation of hazardous waste materials
Waste treatment, storage and disposal (TSD) facility
Generator of waste (for example, oil refinery, research lab, aircraft manufacturer, auto shop, etc.
What will be your routine job duties in the next 12 months?
Hazardous waste handling (for example, filtration unit, incinerator, etc.)
Hazardous waste manifesting
Field supervision of hazardous waste workers
Site assessment and investigation
Regulatory inspection of fixed facilities (for example, inspector for a regulatory agency)
Developing site health and safety plans
Supervising on-site regulatory compliance
Emergency HAZMAT response - offsite (for example, fire fighter, highway spill response, etc.)
Emergency HAZMAT response - onsite (for example, plant maintenance team, etc.)
SECTION C - INFORMATION ABOUT YOU
Our funders (NIEHS) have asked us to gather more information about the people we train so they can learn more about hazardous workers. We would appreciate your answers to the following questions:
What language do you speak at home?
What is your ethnic/racial background?
If multiple, please indicate the one you would prefer to report:
Asian/Asian American/Pacific Islander
American Indian/Native American
What is your age?
Under 18 years
Above 64 years
What is the highest level of education you have completed?
Junior High School
High School Graduate
Some College or Technical Training
Masters or Doctorate
How did you hear about our training?
Would you like to join our mailing list?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service