WOSH Specialist Registration Form

PLEASE READ: This three-day program is appropriate for workers in entry level or professional positions in high hazardous industries (e.g., manufacturing, construction, agriculture, food services, warehousing and transportation). Union members and worker leaders are highly encouraged to attend. This training covers basic health and safety concepts. May not be appropriated for those in a supervisory or managerial position.

Contact Robin Dewey at rdewey@berkeley.edu should you have any questions.

Please complete this form to register for a WOSH Specialist training course.
More information at www.lohp.org/WOSHTEP

Course Information
Location of the course you are registering for:
(e.g. Sacramento, Modesto)
Your answer
Date of the course you are registering for:
*Select the first day of the three-day WOSH training*
MM
/
DD
/
YYYY
How did you hear about this course?
Check all that apply.
Required
Registrant Information
First and Last Name:
Enter your name as you would like it to appear on your Certificate of Completion.
Your answer
Email Address:
Your answer
Preferred Contact Phone Number:
Your answer
Preferred Mailing Address Line 1:
Include house number, street name, and apartment number (if applicable).
Your answer
City, State, and Zip Code
Your answer
Please tell us about yourself.
To which racial or ethnic group(s) do you most identify?
Check all that apply.
Required
What language(s) do you speak at home?
Check all that apply.
Required
What is your gender?
What is your age range?
Employment Information
Employer:
Your answer
Job Title/Occupation:
Your answer
Department:
Your answer
Work Street Address
Your answer
Work City, State, and Zip Code
Your answer
What is the main language(s) spoken at your workplace (or the workplace you represent)?
Check all that apply.
Required
Industry Information
Do you work in the private or public sector?
Select PUBLIC SECTOR industry and industry activity that best describes your company or organization.
If Industry or Industry Activity is not listed, select Other and you will have the opportunity to specify in the next question. Select N/A if not in public sector.
Select PRIVATE SECTOR industry and industry activity that best describes your company or organization.
If Industry or Industry Activity is not listed, select Other and you will have the opportunity to specify in the next question. Select N/A if not in private sector.
If INDUSTRY and/or INDUSTRY ACTIVITY is not listed, please specify here.
Please list in following order: 1. Industry 2. Industry activity. For example, "Construction - Roofing". If not known or not applicable, enter N/A.
Your answer
Union Information
Are there any unions representing workers in your workplace?
Are you a member of a union?
If YES, what union?
Your answer
Do you have a leadership role in your union? If YES, what is your title or job.
Your answer
Workplace Health and Safety
Have you attended any workplace health and safety training sessions in the past 5 years?
If you have attended a health and safety training before, on what topics?
Your answer
Do you currently have a health and safety leadership role at your workplace?
Is there a health and safety committee at your workplace (or the workplace you represent)?
Do you think your employer (or other sponsoring group) will support your efforts to improve workplace health and safety?
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