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SASH Registration Form
*Promoting Safe and Healthy Workplaces for California's School Employees*
This training is FREE for School District and County Office of Education employees.

Please complete this form to register for a SASH workshop.
Questions? Contact Sarah Jacobs at SJacobs@irle.ucla.edu. For more information, visit https://www.dir.ca.gov/chswc/SASH/index.htm
Date *
Location (City) of workshop you are registering for: *
First Name *
Please enter your name as you'd like it to appear on your certificate of completion.
Your answer
Last Name *
Your answer
Preferred email address: *
Your answer
Is this your work email? *
Preferred phone number: *
Your answer
Is this your work phone? *
Preferred Mailing Address Street *
Your answer
Preferred Mailing Address City *
Your answer
Preferred Mailing Address ZIP *
Your answer
State *
Your answer
Is this your work address? *
Employer: *
Your answer
Is your employer a: *
The county where you work: *
Your answer
If you work for a school or school district, what department do you work in? *
Your Job Title / Position *
Your answer
What language(s) do you speak at home? (Check all that apply) *
Required
Have you attended any prior health and safety training lasting more than 2 hours: *
Required
Are you a member of a union? *
If Yes, which union?
Your answer
If Yes, do you have a leadership role?
Your answer
Are you a manager or supervisor?
Is there a health and safety committee that includes a focus on employee health and safety? *
Are you responsible for carrying out health and safety activities at your workplace?
Are you responsible for writing your district's Injury and Illness Prevention Plan? *
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