Worker Occupational Safety and Health Specialist Training
*Interested participants will have to register first with LATTC. This is a mandatory first step!
Date of Class *
*Interested participants will have to register first with LATTC. This is a mandatory first step!
Required
Location of workshop you are registering for *
Name of city
Your answer
How did you hear about this training?
PARTICIPANT INFORMATION
First Name (as you would like it to appear on your certificate of completion) *
Your answer
Last 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 *
Your answer
City *
Your answer
State *
Your answer
ZIP Code *
Your answer
Racial or ethnic group(s) you identify as. Check all that apply.
What language(s) do you speak at home?
Gender
Age Range
Employment Information
Do you work for a private company or public agency (e.g. government, university, etc.)?
What is the name of your empoyer?
Your answer
What does your employer/agency do (e.g. hospital, grocery store, restaurant, manufacturing, construction company)?
Your answer
What is your job title/occupation?
Your answer
What department do you work in?
Your answer
Employer Address
(street, city, state, zip code)
Your answer
What is the main language(s) spoken at your workplace?
(Or, at the workplace you represent.)
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 role?
Your answer
County of your workplace:
(If known)
Your answer
Occupation, number of years with employer:
Your answer
Are there any unions representing workers in your workplace?
Does your union have its own health and safety committee?
Is there health and safety contract language at your workplace?
Who is sponsoring you to attend this course ?
(paying for your time, etc.,)
If a community group is sponsoring you, what is the name of the group?
Your answer
Do you think your employer (or other sponsoring group) will support your efforts to improve workplace health and safety?
Is worker health and safety training offered at your workplace?
Or the workplace you represent?
Have you attended any workplace health and safety training sessions in the past 5 years?
If Yes, please list some of the topics covered in these training sessions:
(For example, chemical safety, bloodborne pathogens)
Your answer
Please answer the following questions about your workplace:
(If you work for a union or a community organization, tell us instead about the workplace you mainly represent.)
Is there a designated person responsible for worker health and safety at your workplace?
(Or, the workplace you represent.)
Is there a health and safety committee at your workplace?
(Or, the workplace you represent.)
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